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Gulkas S, Aydin FO, Turhan SA, Toker AE. In vivo corneal confocal microscopy as a non-invasive test to assess obesity induced small fibre nerve damage and inflammation. Eye (Lond) 2023; 37:2226-2232. [PMID: 36443498 PMCID: PMC10366092 DOI: 10.1038/s41433-022-02321-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 10/20/2022] [Accepted: 11/15/2022] [Indexed: 11/29/2022] Open
Abstract
PURPOSE To investigate small nerve fibre damage and inflammation at the level of the sub-basal nerve plexus (SNP) of severe obese patients and compare the results with those of healthy subjects. METHODS This cross-sectional, observational study investigated the data of 28 patients (14 out of 28 prediabetic or diabetic) with severe obesity (Body Mass Index; BMI ≥ 40) and 20 healthy subjects. Corneal nerve fibre density (CNFD), branch density (CNBD), fibre length (CNFL), nerve fibre area (CNFA), nerve fibre width (CNFW), and nerve fractal dimension (CNFrD) and dendritic cell (DC) density were evaluated using in vivo confocal microscopy (IVCM, Heidelberg Retinal Tomograph III Rostock Cornea Module). Automatic CCMetrics software (University of Manchester, UK) was used for quantitative analysis of SNP. RESULTS Mean age was 48.4±7.4 and 45.1 ± 5.8 in the control and obese group, respectively (p = 0.09). Mean BMI were 49.1 ± 7.8 vs. 23.3 ± 1.4 in obese vs. control group, respectively (p < 0.001). Mean CNFD, CNBD, CNFL, CNFA, CNFW were significantly reduced in obese group compared with those in the control group (always p < 0.05, respectively). There were no significant differences in any ACCMetrics parameters between prediabetic/diabetic and non-diabetic obese patients. Increased DC densities were detected in obese group compared with those in control group (p < 0.0001). There were significant correlations between BMI scores and SNP parameters. CONCLUSION Imaging with IVCM is a feasible, non-invasive method to detect and quantify occult corneal nerve damage and increased inflammation in patients with obesity. This study suggests that obesity may be a separate risk factor for peripheral neuropathy regardless of DM.
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Affiliation(s)
- Samet Gulkas
- Department of Ophthalmology, Abdulkadir Yuksel State Hospital, Gaziantep, Turkey.
| | - Fahri Onur Aydin
- Department of Ophthalmology, University of Health Sciences, Basaksehir Cam and Sakura City Hospital, Istanbul, Turkey
| | - Semra Akkaya Turhan
- Department of Ophthalmology, Marmara University School of Medicine, Pendik Training and Research Hospital, Istanbul, Turkey
| | - Ayse Ebru Toker
- Department of Ophthalmology and Visual Sciences, West Virginia University Eye Institute, Morgantown, WV, USA
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Matuszewska-Iwanicka A, Stratmann B, Stachs O, Allgeier S, Bartschat A, Winter K, Guthoff R, Tschoepe D, Hettlich HJ. Mosaic vs. Single Image Analysis with Confocal Microscopy of the Corneal Nerve Plexus for Diagnosis of Early Diabetic Peripheral Neuropathy. Ophthalmol Ther 2022; 11:2211-2223. [PMID: 36184730 DOI: 10.1007/s40123-022-00574-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 09/09/2022] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION The assessment of the corneal nerve fibre plexus with corneal confocal microscopy (CCM) is an upcoming but still experimental method in the diagnosis of early stage diabetic peripheral neuropathy (DPN). Using an innovative imaging technique-Heidelberg Retina Tomograph equipped with the Rostock Cornea Module (HRT-RCM) and EyeGuidance module (EG)-we were able to look at greater areas of subbasal nerve plexus (SNP) in order to increase the diagnostic accuracy. The aim of our study was to evaluate the usefulness of EG instead of single image analysis in diagnosis of early stage DPN. METHODS This prospective study was performed on 60 patients with type 2 diabetes mellitus, classified equally into two subgroups based on neuropathy deficient score (NDS): patients without DPN (group 1) or with mild DPN (group 2). The following parameters were analysed in the two subgroups: corneal nerve fibre length (CNFL; mm/mm2), corneal nerve fibre density (CNFD; no./mm2), corneal nerve branch density (CNBD; no./mm2). Furthermore, we compared the data calculated with the novel mosaic, EG-based method with those received from single image analysis using different quantification tools. RESULTS Using EG we did not find a significant difference between group 1 and group 2: CNFL (16.81 ± 5.87 mm/mm2 vs. 17.19 ± 7.19 mm/mm2, p = 0.895), CNFD (254.05 ± 115.36 no./mm2 vs. 265.91 ± 161.63 no./mm2, p = 0.732) and CNBD (102.68 ± 62.28 no./mm2 vs. 115.38 ± 96.91 no./mm2, p = 0.541). No significant difference between the EG method of analysing the SNP and the single image analysis of 10 images per patient was detected. CONCLUSION On the basis of our results it was not possible to differentiate between early stages of large nerve fibre DPN in patients with type 2 diabetes mellitus via SNP analysis. To improve sensitivity and specificity of this method newer technologies are under current evaluation. TRIAL REGISTRATION ClinicalTrials.gov Identifier NCT05326958.
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Affiliation(s)
- Aleksandra Matuszewska-Iwanicka
- Eye Clinic Johannes Wesling Hospital, Ruhr Universität Bochum, Augen-Praxisklinik Minden, Königstraße 120, 32427, Minden, Germany.
| | - Bernd Stratmann
- Herz- und Diabeteszentrum NRW, Diabeteszentrum, Ruhr Universität Bochum, Bad Oeynhausen, Germany
| | - Oliver Stachs
- Department of Ophthalmology, Rostock University Medical Center, Rostock, Germany
| | - Stephan Allgeier
- Institute for Automation and Applied Informatics, Karlsruhe Institute of Technology (KIT), Karlsruhe, Germany
| | - Andreas Bartschat
- Institute for Automation and Applied Informatics, Karlsruhe Institute of Technology (KIT), Karlsruhe, Germany
| | - Karsten Winter
- Institute of Anatomy, University of Leipzig, Leipzig, Germany
| | - Rudolf Guthoff
- Department of Ophthalmology, Rostock University Medical Center, Rostock, Germany
| | - Diethelm Tschoepe
- Herz- und Diabeteszentrum NRW, Diabeteszentrum, Ruhr Universität Bochum, Bad Oeynhausen, Germany
- Stiftung DHD (Der herzkranke Diabetiker) Stiftung in der Deutschen Diabetes-Stiftung, Bad Oeynhausen, Germany
| | - Hans-Joachim Hettlich
- Eye Clinic Johannes Wesling Hospital, Ruhr Universität Bochum, Augen-Praxisklinik Minden, Königstraße 120, 32427, Minden, Germany
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Tyler EF, McGhee CNJ, Lawrence B, Braatvedt GD, Mankowski JL, Oakley JD, Sethi S, Misra SL. Corneal Nerve Changes Observed by In Vivo Confocal Microscopy in Patients Receiving Oxaliplatin for Colorectal Cancer: The COCO Study. J Clin Med 2022; 11:jcm11164770. [PMID: 36013010 PMCID: PMC9409896 DOI: 10.3390/jcm11164770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 08/08/2022] [Accepted: 08/08/2022] [Indexed: 11/24/2022] Open
Abstract
An objective method of early identification of people at risk of chemotherapy-induced peripheral neuropathy is needed to minimize long-term toxicity and maximize dose intensity. The aims of the study were to observe corneal nerve microstructure and corneal sensitivity changes and peripheral neuropathy in patients receiving oxaliplatin, and to determine its association with corneal parameters at different stages of treatment and assess utility as non-invasive markers to detect and monitor peripheral neuropathy. Twenty-three patients scheduled to receive oxaliplatin chemotherapy with intravenous 5-FU for gastro-intestinal cancer were recruited and followed up with for 12 months. Ocular examinations including corneal and retinal evaluations, alongside peripheral neuropathy assessment, were performed. The corneal nerve density did not show significant change after chemotherapy when measured with a widely used semi-automated program or an automated analysis technique. Macula and optic nerve function did not change during or after oxaliplatin chemotherapy. However, the corneal nerve density modestly correlated with clinical peripheral neuropathy after 20 weeks of chemotherapy (r = 0.61, p = 0.01) when peripheral neuropathy is typical most profound, and corneal nerve sensitivity correlated with neuropathy at 12 (r = 0.55, p = 0.01) and 20 weeks (r = 0.64, p = 0.006). In conclusion, corneal changes detected on confocal microscopy show moderate association with peripheral neuropathy, indicating their potential to identify the development of oxaliplatin-induced peripheral neuropathy. However, further studies are required to confirm these findings.
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Affiliation(s)
- Ellen F. Tyler
- Department of Ophthalmology, New Zealand National Eye Centre, Faculty of Medical and Health Sciences, The University of Auckland, Auckland 1142, New Zealand
| | - Charles N. J. McGhee
- Department of Ophthalmology, New Zealand National Eye Centre, Faculty of Medical and Health Sciences, The University of Auckland, Auckland 1142, New Zealand
| | - Benjamin Lawrence
- Department of Oncology, The University of Auckland, Auckland 1142, New Zealand
| | - Geoffrey D. Braatvedt
- Department of Endocrinology, Greenlane Clinical Centre, Auckland District Health Board, Auckland 1051, New Zealand
| | - Joseph L. Mankowski
- Department of Molecular and Comparative Pathobiology, Johns Hopkins University, Baltimore, MD 21205, USA
| | | | - Sargun Sethi
- Department of Ophthalmology, New Zealand National Eye Centre, Faculty of Medical and Health Sciences, The University of Auckland, Auckland 1142, New Zealand
| | - Stuti L. Misra
- Department of Ophthalmology, New Zealand National Eye Centre, Faculty of Medical and Health Sciences, The University of Auckland, Auckland 1142, New Zealand
- Correspondence:
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4
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Yu FSX, Lee PSY, Yang L, Gao N, Zhang Y, Ljubimov AV, Yang E, Zhou Q, Xie L. The impact of sensory neuropathy and inflammation on epithelial wound healing in diabetic corneas. Prog Retin Eye Res 2022; 89:101039. [PMID: 34991965 PMCID: PMC9250553 DOI: 10.1016/j.preteyeres.2021.101039] [Citation(s) in RCA: 49] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 12/10/2021] [Accepted: 12/20/2021] [Indexed: 02/08/2023]
Abstract
Diabetic peripheral neuropathy (DPN) is the most common complication of diabetes, with several underlying pathophysiological mechanisms, some of which are still uncertain. The cornea is an avascular tissue and sensitive to hyperglycemia, resulting in several diabetic corneal complications including delayed epithelial wound healing, recurrent erosions, neuropathy, loss of sensitivity, and tear film changes. The manifestation of DPN in the cornea is referred to as diabetic neurotrophic keratopathy (DNK). Recent studies have revealed that disturbed epithelial-neural-immune cell interactions are a major cause of DNK. The epithelium is supplied by a dense network of sensory nerve endings and dendritic cell processes, and it secretes growth/neurotrophic factors and cytokines to nourish these neighboring cells. In turn, sensory nerve endings release neuropeptides to suppress inflammation and promote epithelial wound healing, while resident immune cells provide neurotrophic and growth factors to support neuronal and epithelial cells, respectively. Diabetes greatly perturbs these interdependencies, resulting in suppressed epithelial proliferation, sensory neuropathy, and a decreased density of dendritic cells. Clinically, this results in a markedly delayed wound healing and impaired sensory nerve regeneration in response to insult and injury. Current treatments for DPN and DNK largely focus on managing the severe complications of the disease. Cell-based therapies hold promise for providing more effective treatment for diabetic keratopathy and corneal ulcers.
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Affiliation(s)
- Fu-Shin X Yu
- Departments of Ophthalmology and Anatomy and Cell Biology, Wayne State University School of Medicine, Detroit, MI, 48201, USA.
| | - Patrick S Y Lee
- Departments of Ophthalmology and Anatomy and Cell Biology, Wayne State University School of Medicine, Detroit, MI, 48201, USA
| | - Lingling Yang
- State Key Laboratory Cultivation Base, Shandong Provincial Key Laboratory of Ophthalmology, Shandong Eye Institute, Shandong First Medical University & Shandong Academy of Medical Sciences, Qingdao, China
| | - Nan Gao
- Departments of Ophthalmology and Anatomy and Cell Biology, Wayne State University School of Medicine, Detroit, MI, 48201, USA
| | - Yangyang Zhang
- State Key Laboratory Cultivation Base, Shandong Provincial Key Laboratory of Ophthalmology, Shandong Eye Institute, Shandong First Medical University & Shandong Academy of Medical Sciences, Qingdao, China
| | - Alexander V Ljubimov
- Departments of Biomedical Sciences and Neurosurgery, Cedars-Sinai Medical Center, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Ellen Yang
- Chicago Medical School, Rosalind Franklin University of Medicine and Science, North Chicago, IL, 60064, USA
| | - Qingjun Zhou
- State Key Laboratory Cultivation Base, Shandong Provincial Key Laboratory of Ophthalmology, Shandong Eye Institute, Shandong First Medical University & Shandong Academy of Medical Sciences, Qingdao, China
| | - Lixin Xie
- State Key Laboratory Cultivation Base, Shandong Provincial Key Laboratory of Ophthalmology, Shandong Eye Institute, Shandong First Medical University & Shandong Academy of Medical Sciences, Qingdao, China.
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5
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Wu H, Fang X, Luo S, Shang X, Xie Z, Dong N, Xiao X, Lin Z, Liu Z. Meibomian Glands and Tear Film Findings in Type 2 Diabetic Patients: A Cross-Sectional Study. Front Med (Lausanne) 2022; 9:762493. [PMID: 35479935 PMCID: PMC9037095 DOI: 10.3389/fmed.2022.762493] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Accepted: 03/03/2022] [Indexed: 11/16/2022] Open
Abstract
Background The characteristics of the meibomian gland and tear film in patients with type 2 diabetes (T2D) with different glycemic control levels and diabetic durations remain largely unexplored. This study aimed to identify the association of dry eye and meibomian gland dysfunction (MGD) in T2D. Materials and Methods Ninety-nine patients with type 2 diabetes mellitus (DM group), 33 dry eye patients without diabetes mellitus (DE group), and 40 normal subjects (NC group) were recruited for this study. Participants were evaluated with an Ocular Surface Disease Index (OSDI) questionnaire, tear film breakup time (BUT), the Schirmer I test (SIT), corneal fluorescein staining (FL), lipid layer thickness (LLT), and MGD parameters. Glycosylated hemoglobin (HbA1c) and duration of diabetes were recorded. Results The SIT value in the DM group was higher than that of the DE group (p < 0.05). The BUT and LLT were lower, and MGD parameters were higher in the DM group than those of the DE and NC groups (p < 0.05). In the DM group, 47 patients were diagnosed with dry eye (DM + DE group), whereas 40 patients without dry eye were categorized as the DM − DE group. The SIT, BUT, and LLT values in the DM − DE group were higher (p < 0.01), and MGD parameters were lower (p < 0.01) in the DM − DE group than those of the DM + DE group. The MGD parameters were higher in the DM − DE group than those in the NC group (p < 0.05). The HbA1c levels were correlated with OSDI, BUT, LLT, FL, and MGD parameters (p < 0.001) in the DM group. However, in patients with low HbA1c, normal SIT value, and low OSDI, the MGD parameters were higher than those in the NC group (p < 0.05). The duration of diabetes positively correlated with MGD parameters (p < 0.001). Conclusion Asymptomatic MGD may be an early sign of dry eye and ocular discomfort in T2D. The MGD parameters were associated with the HbA1c level and diabetic duration.
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Affiliation(s)
- Huping Wu
- Eye Institute and Affiliated Xiamen Eye Center of Xiamen University, School of Medicine, Xiamen University, Xiamen, China.,Fujian Provincial Key Laboratory of Ophthalmology and Visual Science, Xiamen, China.,Fujian Key Laboratory of Ocular Surface and Corneal Diseases, Affiliated Xiamen Eye Center of Xiamen University, Xiamen, China
| | - Xie Fang
- Eye Institute and Affiliated Xiamen Eye Center of Xiamen University, School of Medicine, Xiamen University, Xiamen, China.,Fujian Key Laboratory of Ocular Surface and Corneal Diseases, Affiliated Xiamen Eye Center of Xiamen University, Xiamen, China
| | - Shunrong Luo
- Eye Institute and Affiliated Xiamen Eye Center of Xiamen University, School of Medicine, Xiamen University, Xiamen, China.,Fujian Key Laboratory of Ocular Surface and Corneal Diseases, Affiliated Xiamen Eye Center of Xiamen University, Xiamen, China
| | - Xumin Shang
- Eye Institute and Affiliated Xiamen Eye Center of Xiamen University, School of Medicine, Xiamen University, Xiamen, China.,Fujian Key Laboratory of Ocular Surface and Corneal Diseases, Affiliated Xiamen Eye Center of Xiamen University, Xiamen, China
| | - Zhiwen Xie
- Eye Institute and Affiliated Xiamen Eye Center of Xiamen University, School of Medicine, Xiamen University, Xiamen, China.,Fujian Key Laboratory of Ocular Surface and Corneal Diseases, Affiliated Xiamen Eye Center of Xiamen University, Xiamen, China
| | - Nuo Dong
- Eye Institute and Affiliated Xiamen Eye Center of Xiamen University, School of Medicine, Xiamen University, Xiamen, China.,Fujian Key Laboratory of Ocular Surface and Corneal Diseases, Affiliated Xiamen Eye Center of Xiamen University, Xiamen, China
| | - Xianwen Xiao
- Eye Institute and Affiliated Xiamen Eye Center of Xiamen University, School of Medicine, Xiamen University, Xiamen, China.,Fujian Key Laboratory of Ocular Surface and Corneal Diseases, Affiliated Xiamen Eye Center of Xiamen University, Xiamen, China
| | - Zhirong Lin
- Eye Institute and Affiliated Xiamen Eye Center of Xiamen University, School of Medicine, Xiamen University, Xiamen, China.,Fujian Provincial Key Laboratory of Ophthalmology and Visual Science, Xiamen, China.,Fujian Key Laboratory of Ocular Surface and Corneal Diseases, Affiliated Xiamen Eye Center of Xiamen University, Xiamen, China
| | - Zuguo Liu
- Eye Institute and Affiliated Xiamen Eye Center of Xiamen University, School of Medicine, Xiamen University, Xiamen, China.,Fujian Provincial Key Laboratory of Ophthalmology and Visual Science, Xiamen, China
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6
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Strand N, Wie C, Peck J, Maita M, Singh N, Dumbroff J, Tieppo Francio V, Murphy M, Chang K, Dickerson DM, Maloney J. Small Fiber Neuropathy. Curr Pain Headache Rep 2022; 26:429-438. [PMID: 35384587 DOI: 10.1007/s11916-022-01044-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/28/2022] [Indexed: 12/20/2022]
Abstract
PURPOSE OF REVIEW This narrative review aims to summarize advances in the field of small fiber neuropathy made over the last decade, with emphasis on novel research highlighting the distinctive features of SFN. RECENT FINDINGS While the management of SFNs is ideally aimed at treating the underlying cause, most patients will require pain control via multiple, concurrent therapies. Herein, we highlight the most up-to-date information for diagnosis, medication management, interventional management, and novel therapies on the horizon. Despite the prevalence of small fiber neuropathies, there is no clear consensus on guidelines specific for the treatment of SFN. Despite the lack of specific guidelines for SFN treatment, the most recent general neuropathic pain guidelines are based on Cochrane studies and randomized controlled trials (RCTs) which have individually examined therapies used for the more commonly studied SFNs, such as painful diabetic neuropathy and HIV neuropathy. The recommendations from current guidelines are based on variables such as number needed to treat (NNT), safety, ease of use, and effect on quality of life.
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Affiliation(s)
- N Strand
- Division of Pain Medicine, Mayo Clinic Hospital, Phoenix, AZ, USA.
| | - C Wie
- Division of Pain Medicine, Mayo Clinic Hospital, Phoenix, AZ, USA
| | - J Peck
- Performing Arts Medicine Department, Shenandoah University, Winchester, USA
| | - M Maita
- Division of Pain Medicine, Mayo Clinic Hospital, Phoenix, AZ, USA
| | - N Singh
- OrthoAlabama Spine and Sports, Birmingham, AL, USA
| | - J Dumbroff
- Mount Sinai Morningside and West Department of Anesthesiology, New York, NY, USA
| | - V Tieppo Francio
- Department of Rehabilitation on Medicine, The University of Kansas Medical Center, Kansas City, KS, USA
| | - M Murphy
- Department of Rehabilitation on Medicine, The University of Kansas Medical Center, Kansas City, KS, USA
| | - K Chang
- Department of Anesthesiology and Critical Care, Emory University, Atlanta, GA, USA
| | - D M Dickerson
- NorthShore University HealthSystem, Evanston, IL, USA
- University of Chicago Medicine, Chicago,, IL, USA
| | - J Maloney
- Division of Pain Medicine, Mayo Clinic Hospital, Phoenix, AZ, USA
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7
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Gu Y, Liu X, Yu X, Qin Q, Yu N, Ke W, Wang K, Chen M. Corneal in vivo Confocal Microscopy for Assessment of Non-Neurological Autoimmune Diseases: A Meta-Analysis. Front Med (Lausanne) 2022; 9:809164. [PMID: 35372389 PMCID: PMC8965464 DOI: 10.3389/fmed.2022.809164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 02/07/2022] [Indexed: 11/24/2022] Open
Abstract
Purpose This study aimed to evaluate the features of corneal nerve with in vivo confocal microscopy (IVCM) among patients with non-neurological autoimmune (NNAI) diseases. Methods We systematically searched PubMed, Web of Science, and Cochrane Central Register of Controlled Trials for studies published until May 2021. The weighted mean differences (WMDs) of corneal nerve fiber length (CNFL), corneal nerve fiber density (CNFD), corneal nerve branch density (CNBD), tortuosity, reflectivity, and beadings per 100 μm with a 95% CI between NNAI and control group were analyzed using a random-effects model. Results The results showed 37 studies involving collective totals of 1,423 patients and 1,059 healthy controls were ultimately included in this meta-analysis. The pooled results manifested significantly decreased CNFL (WMD: −3.94, 95% CI: −4.77–−3.12), CNFD (WMD: −6.62, 95% CI: −8.4–−4.85), and CNBD (WMD: −9.89, 95% CI: −14–−5.79) in NNAI patients. In addition, the NNAI group showed more tortuous corneal nerve (WMD: 1.19, 95% CI:0.57–1.81). The comparison between NNAI patients and healthy controls in beadings per 100 μm corneal nerve length was inconsistent. No significant difference was found in the corneal nerve fiber reflectivity between NNAI and the control group (WMD: −0.21, 95% CI: −0.65–0.24, P = 0.361). Conclusions The parameters and morphology of corneal nerves observed by IVCM proved to be different in NNAI patients from healthy controls, suggesting that IVCM may be a non-invasive technique for identification and surveillance of NNAI diseases.
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Affiliation(s)
- Yuxiang Gu
- Eye Center of the Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Zhejiang Provincial Key Lab of Ophthalmology, Hangzhou, China
| | - Xin Liu
- Eye Center of the Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Zhejiang Provincial Key Lab of Ophthalmology, Hangzhou, China
| | - Xiaoning Yu
- Eye Center of the Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Zhejiang Provincial Key Lab of Ophthalmology, Hangzhou, China
| | - Qiyu Qin
- Eye Center of the Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Zhejiang Provincial Key Lab of Ophthalmology, Hangzhou, China
| | - Naiji Yu
- Eye Center of the Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Zhejiang Provincial Key Lab of Ophthalmology, Hangzhou, China
| | - Weishaer Ke
- Eye Center of the Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Zhejiang Provincial Key Lab of Ophthalmology, Hangzhou, China
| | - Kaijun Wang
- Eye Center of the Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Zhejiang Provincial Key Lab of Ophthalmology, Hangzhou, China
| | - Min Chen
- Eye Center of the Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China.,Zhejiang Provincial Key Lab of Ophthalmology, Hangzhou, China
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8
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Newlin Lew K, Arnold T, Cantelmo C, Jacque F, Posada-Quintero H, Luthra P, Chon KH. Diabetes Distal Peripheral Neuropathy: Subtypes and Diagnostic and Screening Technologies. J Diabetes Sci Technol 2022; 16:295-320. [PMID: 34994241 PMCID: PMC8861801 DOI: 10.1177/19322968211035375] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Diabetes distal symmetrical peripheral neuropathy (DSPN) is the most prevalent form of neuropathy in industrialized countries, substantially increasing risk for morbidity and pre-mature mortality. DSPN may manifest with small-fiber disease, large-fiber disease, or a combination of both. This review summarizes: (1) DSPN subtypes (small- and large-fiber disease) with attention to clinical signs and patient symptoms; and (2) technological diagnosis and screening for large- and small-fiber disease with inclusion of a comprehensive literature review of published studies from 2015-present (N = 66). Review findings, informed by the most up-to-date research, advance critical understanding of DSPN large- and small-fiber screening technologies, including those designed for point-of-care use in primary care and endocrinology practices.
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Affiliation(s)
- Kelley Newlin Lew
- School of Nursing, University of
Connecticut (UConn), Storrs, CT, USA
- Kelley Newlin Lew, School of Nursing,
University of Connecticut (UConn), 231 Glenbrook Road, Storrs, CT 06269, USA.
| | - Tracey Arnold
- School of Nursing, University of
Connecticut (UConn), Storrs, CT, USA
| | | | - Francky Jacque
- Hispanic Alliance of Southeastern
Connecticut, New London, CT, USA
| | - Hugo Posada-Quintero
- Biomedical Engineering Department,
University of Connecticut (UConn), Storrs, CT, USA
| | - Pooja Luthra
- Division of Endocrinology and
Metabolism, UConn Health, Farmington, CT, USA
| | - Ki H. Chon
- Biomedical Engineering Department,
University of Connecticut (UConn), Storrs, CT, USA
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9
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Zhou Q, Yang L, Wang Q, Li Y, Wei C, Xie L. Mechanistic investigations of diabetic ocular surface diseases. Front Endocrinol (Lausanne) 2022; 13:1079541. [PMID: 36589805 PMCID: PMC9800783 DOI: 10.3389/fendo.2022.1079541] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 12/02/2022] [Indexed: 12/23/2022] Open
Abstract
With the global prevalence of diabetes mellitus over recent decades, more patients suffered from various diabetic complications, including diabetic ocular surface diseases that may seriously affect the quality of life and even vision sight. The major diabetic ocular surface diseases include diabetic keratopathy and dry eye. Diabetic keratopathy is characterized with the delayed corneal epithelial wound healing, reduced corneal nerve density, decreased corneal sensation and feeling of burning or dryness. Diabetic dry eye is manifested as the reduction of tear secretion accompanied with the ocular discomfort. The early clinical symptoms include dry eye and corneal nerve degeneration, suggesting the early diagnosis should be focused on the examination of confocal microscopy and dry eye symptoms. The pathogenesis of diabetic keratopathy involves the accumulation of advanced glycation end-products, impaired neurotrophic innervations and limbal stem cell function, and dysregulated growth factor signaling, and inflammation alterations. Diabetic dry eye may be associated with the abnormal mitochondrial metabolism of lacrimal gland caused by the overactivation of sympathetic nervous system. Considering the important roles of the dense innervations in the homeostatic maintenance of cornea and lacrimal gland, further studies on the neuroepithelial and neuroimmune interactions will reveal the predominant pathogenic mechanisms and develop the targeting intervention strategies of diabetic ocular surface complications.
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Affiliation(s)
- Qingjun Zhou
- State Key Laboratory Cultivation Base, Eye Institute of Shandong First Medical University, Qingdao, China
- Shandong Provincial Key Laboratory of Ophthalmology, Eye Institute of Shandong First Medical University, Qingdao, China
| | - Lingling Yang
- State Key Laboratory Cultivation Base, Eye Institute of Shandong First Medical University, Qingdao, China
- Shandong Provincial Key Laboratory of Ophthalmology, Eye Institute of Shandong First Medical University, Qingdao, China
| | - Qun Wang
- State Key Laboratory Cultivation Base, Eye Institute of Shandong First Medical University, Qingdao, China
- Shandong Provincial Key Laboratory of Ophthalmology, Eye Institute of Shandong First Medical University, Qingdao, China
| | - Ya Li
- State Key Laboratory Cultivation Base, Eye Institute of Shandong First Medical University, Qingdao, China
- Shandong Provincial Key Laboratory of Ophthalmology, Eye Institute of Shandong First Medical University, Qingdao, China
| | - Chao Wei
- State Key Laboratory Cultivation Base, Eye Institute of Shandong First Medical University, Qingdao, China
- Shandong Provincial Key Laboratory of Ophthalmology, Eye Institute of Shandong First Medical University, Qingdao, China
| | - Lixin Xie
- State Key Laboratory Cultivation Base, Eye Institute of Shandong First Medical University, Qingdao, China
- Shandong Provincial Key Laboratory of Ophthalmology, Eye Institute of Shandong First Medical University, Qingdao, China
- *Correspondence: Lixin Xie,
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10
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Wide-field mosaics of the corneal subbasal nerve plexus in Parkinson's disease using in vivo confocal microscopy. Sci Data 2021; 8:306. [PMID: 34836991 PMCID: PMC8626466 DOI: 10.1038/s41597-021-01087-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 10/28/2021] [Indexed: 11/09/2022] Open
Abstract
In vivo confocal microscopy (IVCM) is a non-invasive imaging technique facilitating real-time acquisition of images from the live cornea and its layers with high resolution (1-2 µm) and high magnification (600 to 800-fold). IVCM is extensively used to examine the cornea at a cellular level, including the subbasal nerve plexus (SBNP). IVCM of the cornea has thus gained intense interest for probing ophthalmic and systemic diseases affecting peripheral nerves. One of the main drawbacks, however, is the small field of view of IVCM, preventing an overview of SBNP architecture and necessitating subjective image sampling of small areas of the SBNP for analysis. Here, we provide a high-quality dataset of the corneal SBNP reconstructed by automated mosaicking, with an average mosaic image size corresponding to 48 individual IVCM fields of view. The mosaic dataset represents a group of 42 individuals with Parkinson's disease (PD) with and without concurrent restless leg syndrome. Additionally, mosaics from a control group (n = 13) without PD are also provided, along with clinical data for all included participants.
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11
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Gemignani F, Bellanova MF, Saccani E, Pavesi G. Non-length-dependent small fiber neuropathy: Not a matter of stockings and gloves. Muscle Nerve 2021; 65:10-28. [PMID: 34374103 DOI: 10.1002/mus.27379] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Revised: 07/11/2021] [Accepted: 07/18/2021] [Indexed: 12/17/2022]
Abstract
The clinical spectrum of small fiber neuropathy (SFN) encompasses manifestations related to the involvement of thinly myelinated A-delta and unmyelinated C fibers, including not only the classical distal phenotype, but also a non-length-dependent (NLD) presentation that can be patchy, asymmetrical, upper limb-predominant, or diffuse. This narrative review is focused on NLD-SFN. The diagnosis of NLD-SFN can be problematic, due to its varied and often atypical presentation, and diagnostic criteria developed for distal SFN are not suitable for NLD-SFN. The topographic pattern of NLD-SFN is likely related to ganglionopathy restricted to the small neurons of dorsal root ganglia. It is often associated with systemic diseases, but about half the time is idiopathic. In comparison with distal SFN, immune-mediated diseases are more common than dysmetabolic conditions. Treatment is usually based on the management of neuropathic pain. Disease-modifying therapy, including immunotherapy, may be effective in patients with identified causes. Future research on NLD-SFN is expected to further clarify the interconnected aspects of phenotypic characterization, diagnostic criteria, and pathophysiology.
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Affiliation(s)
- Franco Gemignani
- Neurology Unit, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Maria F Bellanova
- Laboratory of Neuromuscular Histopathology, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Elena Saccani
- Neurology Unit, Department of Specialized Medicine, University Hospital of Parma, Parma, Italy
| | - Giovanni Pavesi
- Neurology Unit, Department of Medicine and Surgery, University of Parma, Parma, Italy
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12
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Bondugulapati LNR, Narayen N. Corneal confocal microscopy: potential usage in the context of diabetes mellitus. PRACTICAL DIABETES 2021. [DOI: 10.1002/pdi.2328] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- LN Rao Bondugulapati
- Consultant Physician in Diabetes & Endocrinology, Endocrine Unit, Maelor Hospital, Wrexham, UK
| | - Nitesh Narayen
- Consultant Ophthalmologist, Cataract, Cornea and Refractive Surgeon, Director – Nvision Eye Care, Hyderabad, India
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Revisiting the Corneal and Blink Reflexes for Primary and Secondary Trigeminal Facial Pain Differentiation. Pain Res Manag 2021; 2021:6664736. [PMID: 33628353 PMCID: PMC7886525 DOI: 10.1155/2021/6664736] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Accepted: 02/01/2021] [Indexed: 11/25/2022]
Abstract
Trigeminal neuralgia is often misdiagnosed at initial presentation due to close connotation with dental pain and is often over diagnosed for the very same reasons leading to numerous unnecessary surgical procedures such as peripheral neurectomy and alcohol injections, while the actual cause may remain elusive for decades. Evaluation of the neurosensory system may disclose the correct anatomical location of the etiology. The neurological examination may be clouded by the sensory deficits subsequent to previous peripheral surgical procedures. The corneal and blink reflexes are integral measures of the trigeminal and facial neurosensory assessment, and their abnormal function may facilitate the identification of intrinsic disease of the brain stem. These reflexes can be employed to discover pathological lesions including intracranial space-occupying trigeminal, lateral medullary, cerebral hemispheric lesions, and degenerative diseases of the central nervous system. Dental surgeons and oral and maxillofacial surgeons should consider corneal reflex in neurological assessment of patient presenting with trigeminal neuralgia-like symptoms. Failure to evaluate corneal sensitivity may lead to delayed or inaccurate diagnosis and unsuitable or redundant treatment interventions. This simple noninvasive reflex can be performed by chair-side and may provide significant information regarding the origin of facial pain and is an invaluable part of clinical methods especially in remote and peripheral healthcare center practitioners where sophisticated radiographic investigations such as computed tomography and magnetic resonance imaging may not be available.
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Abstract
BACKGROUND Diabetic neuropathy is a multifaceted condition affecting up to 50% of individuals with long standing diabetes. The most common presentation is peripheral diabetic sensory neuropathy (DPN). METHODS We carried out a systematic review of papers dealing with diabetic neuropathy on Pubmed in addition to a targeted Google search.Search terms included small fiber neuropathy,diffuse peripheral neuropathy, quantitative sensory testing, nerve conduction testing, intra-epidermal nerve fiber density, corneal confocal reflectance microscopy, aldose reductase inhbitors, nerve growth factor, alpha-lipoic acid, ruboxistaurin, nerve growth factor antibody, and cibinetide. RESULTS Over the past half century, there have been a number of agents undergoing unsuccessful trials for treatment of DPN.There are several approved agents for relief of pain caused by diabetic neuropathy, but these do not affect the pathologic process. EXPERT OPINION The failure to find treatments for diabetic neuropathy can be ascribed to (1) the complexity of design of studies and (2) the slow progression of the condition, necessitating long duration trials to prove efficacy.We propose a modification of the regulatory process to permit early introduction of agents with demonstrated safety and suggestion of benefit as well as prolongation of marketing exclusivity while long term trials are in progress to prove efficacy.
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Affiliation(s)
- Marc S Rendell
- The Association for Diabetes Investigators , Newport Coast, California. USA
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15
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Carmichael J, Fadavi H, Ishibashi F, Shore AC, Tavakoli M. Advances in Screening, Early Diagnosis and Accurate Staging of Diabetic Neuropathy. Front Endocrinol (Lausanne) 2021; 12:671257. [PMID: 34122344 PMCID: PMC8188984 DOI: 10.3389/fendo.2021.671257] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 03/17/2021] [Indexed: 12/14/2022] Open
Abstract
The incidence of both type 1 and type 2 diabetes is increasing worldwide. Diabetic peripheral neuropathy (DPN) is among the most distressing and costly of all the chronic complications of diabetes and is a cause of significant disability and poor quality of life. This incurs a significant burden on health care costs and society, especially as these young people enter their peak working and earning capacity at the time when diabetes-related complications most often first occur. DPN is often asymptomatic during the early stages; however, once symptoms and overt deficits have developed, it cannot be reversed. Therefore, early diagnosis and timely intervention are essential to prevent the development and progression of diabetic neuropathy. The diagnosis of DPN, the determination of the global prevalence, and incidence rates of DPN remain challenging. The opinions vary about the effectiveness of the expansion of screenings to enable early diagnosis and treatment initiation before disease onset and progression. Although research has evolved over the years, DPN still represents an enormous burden for clinicians and health systems worldwide due to its difficult diagnosis, high costs related to treatment, and the multidisciplinary approach required for effective management. Therefore, there is an unmet need for reliable surrogate biomarkers to monitor the onset and progression of early neuropathic changes in DPN and facilitate drug discovery. In this review paper, the aim was to assess the currently available tests for DPN's sensitivity and performance.
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Affiliation(s)
- Josie Carmichael
- Diabetes and Vascular Research Centre, National Institute for Health Research, Exeter Clinical Research Facility, University of Exeter Medical School, Exeter, United Kingdom
| | - Hassan Fadavi
- Peripheral Neuropathy Group, Imperial College, London, United Kingdom
| | - Fukashi Ishibashi
- Internal Medicine, Ishibashi Medical and Diabetes Centre, Hiroshima, Japan
| | - Angela C Shore
- Diabetes and Vascular Research Centre, National Institute for Health Research, Exeter Clinical Research Facility, University of Exeter Medical School, Exeter, United Kingdom
| | - Mitra Tavakoli
- Diabetes and Vascular Research Centre, National Institute for Health Research, Exeter Clinical Research Facility, University of Exeter Medical School, Exeter, United Kingdom
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16
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Performance analysis of noninvasive electrophysiological methods for the assessment of diabetic sensorimotor polyneuropathy in clinical research: a systematic review and meta-analysis with trial sequential analysis. Sci Rep 2020; 10:21770. [PMID: 33303857 PMCID: PMC7730399 DOI: 10.1038/s41598-020-78787-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 11/12/2020] [Indexed: 12/13/2022] Open
Abstract
Despite the availability of various clinical trials that used different diagnostic methods to identify diabetic sensorimotor polyneuropathy (DSPN), no reliable studies that prove the associations among diagnostic parameters from two different methods are available. Statistically significant diagnostic parameters from various methods can help determine if two different methods can be incorporated together for diagnosing DSPN. In this study, a systematic review, meta-analysis, and trial sequential analysis (TSA) were performed to determine the associations among the different parameters from the most commonly used electrophysiological screening methods in clinical research for DSPN, namely, nerve conduction study (NCS), corneal confocal microscopy (CCM), and electromyography (EMG), for different experimental groups. Electronic databases (e.g., Web of Science, PubMed, and Google Scholar) were searched systematically for articles reporting different screening tools for diabetic peripheral neuropathy. A total of 22 studies involving 2394 participants (801 patients with DSPN, 702 controls, and 891 non-DSPN patients) were reviewed systematically. Meta-analysis was performed to determine statistical significance of difference among four NCS parameters, i.e., peroneal motor nerve conduction velocity, peroneal motor nerve amplitude, sural sensory nerve conduction velocity, and sural sensory nerve amplitude (all p < 0.001); among three CCM parameters, including nerve fiber density, nerve branch density, and nerve fiber length (all p < 0.001); and among four EMG parameters, namely, time to peak occurrence (from 0 to 100% of the stance phase) of four lower limb muscles, including the vastus lateralis (p < 0.001), tibialis anterior (p = 0.63), lateral gastrocnemius (p = 0.01), and gastrocnemius medialis (p = 0.004), and the vibration perception threshold (p < 0.001). Moreover, TSA was conducted to estimate the robustness of the meta-analysis. Most of the parameters showed statistical significance between each other, whereas some were statistically nonsignificant. This meta-analysis and TSA concluded that studies including NCS and CCM parameters were conclusive and robust. However, the included studies on EMG were inconclusive, and additional clinical trials are required.
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17
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Gad H, Saraswathi S, Al-Jarrah B, Petropoulos IN, Ponirakis G, Khan A, Singh P, Al Khodor S, Elawad M, Almasri W, Abdelrahman H, Hussain K, Hendaus MA, Al-Mudahka F, Abouhazima K, McGrogan P, Malik RA, Akobeng AK. Corneal confocal microscopy demonstrates minimal evidence of distal neuropathy in children with celiac disease. PLoS One 2020; 15:e0238859. [PMID: 32956371 PMCID: PMC7505458 DOI: 10.1371/journal.pone.0238859] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 08/25/2020] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVES The aim of this study was to utilise corneal confocal microscopy to quantify corneal nerve morphology and establish the presence of sub-clinical small fibre damage and peripheral neuropathy in children with celiac disease. METHODS This is a cross-sectional cohort study of twenty children with celiac disease and 20 healthy controls who underwent clinical and laboratory assessments and corneal confocal microscopy. Corneal nerve fiber density (no.mm2), corneal nerve branch density (no.mm2), corneal nerve fiber length (mm.mm2), corneal nerve fiber tortuosity and inferior whorl length (mm.mm2) were quantified manually. RESULTS Corneal nerve fiber density (34.7±8.6 vs. 32.9±8.6; P = 0.5), corneal nerve branch density (47.2±24.5 vs. 47.3±20.0; P = 0.1) and corneal nerve fiber length (20.0±5.1 vs. 19.5±4.5; P = 0.8) did not differ between children with celiac disease and healthy controls. Corneal nerve fiber tortuosity (11.4±1.9 vs 13.5±3.0; P = 0.01) was significantly lower and inferior whorl length (20.0±5.5 vs 23.0±3.8; P = 0.06) showed a non-significant reduction in children with celiac disease compared to healthy controls. Inferior whorl length correlated significantly with corneal nerve fiber density (P = 0.005), corneal nerve branch density (P = 0.04), and corneal nerve fiber length (P = 0.002). CONCLUSION Corneal confocal microscopy demonstrates minimal evidence of neuropathy in children with celiac disease.
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Affiliation(s)
- Hoda Gad
- Department Medicine, Weill Cornell Medicine-Qatar, Doha, Qatar
| | - Saras Saraswathi
- Division of Gastroenterology, Hepatology, and Nutrition, Sidra Medicine, Doha, Qatar
| | - Bara Al-Jarrah
- Division of Gastroenterology, Hepatology, and Nutrition, Sidra Medicine, Doha, Qatar
| | | | | | - Adnan Khan
- Department Medicine, Weill Cornell Medicine-Qatar, Doha, Qatar
| | - Parul Singh
- Research Department, Sidra Medicine, Doha, Qatar
| | | | - Mamoun Elawad
- Division of Gastroenterology, Hepatology, and Nutrition, Sidra Medicine, Doha, Qatar
| | - Wesam Almasri
- Division of Gastroenterology, Hepatology, and Nutrition, Sidra Medicine, Doha, Qatar
| | - Hatim Abdelrahman
- Division of Gastroenterology, Hepatology, and Nutrition, Sidra Medicine, Doha, Qatar
| | | | | | - Fatma Al-Mudahka
- Division of Gastroenterology, Hepatology, and Nutrition, Sidra Medicine, Doha, Qatar
| | - Khaled Abouhazima
- Division of Gastroenterology, Hepatology, and Nutrition, Sidra Medicine, Doha, Qatar
| | - Paraic McGrogan
- Division of Gastroenterology, Hepatology, and Nutrition, Sidra Medicine, Doha, Qatar
| | - Rayaz A. Malik
- Department Medicine, Weill Cornell Medicine-Qatar, Doha, Qatar
- Institute of Cardiovascular Medicine, University of Manchester, Manchester, United Kingdom
| | - Anthony K. Akobeng
- Division of Gastroenterology, Hepatology, and Nutrition, Sidra Medicine, Doha, Qatar
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18
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Hargrave A, Courson JA, Pham V, Landry P, Magadi S, Shankar P, Hanlon S, Das A, Rumbaut RE, Smith CW, Burns AR. Corneal dysfunction precedes the onset of hyperglycemia in a mouse model of diet-induced obesity. PLoS One 2020; 15:e0238750. [PMID: 32886728 PMCID: PMC7473521 DOI: 10.1371/journal.pone.0238750] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 08/21/2020] [Indexed: 01/23/2023] Open
Abstract
PURPOSE The purpose of this study was to use a mouse model of diet-induced obesity to determine if corneal dysfunction begins prior to the onset of sustained hyperglycemia and if the dysfunction is ameliorated by diet reversal. METHODS Six-week-old male C57BL/6 mice were fed a high fat diet (HFD) or a normal diet (ND) for 5-15 weeks. Diet reversal (DiR) mice were fed a HFD for 5 weeks, followed by a ND for 5 or 10 weeks. Corneal sensitivity was determined using aesthesiometry. Corneal cytokine expression was analyzed using a 32-plex Luminex assay. Excised corneas were prepared for immunofluorescence microscopy to evaluate diet-induced changes and wound healing. For wounding studies, mice were fed a HFD or a ND for 10 days prior to receiving a central 2mm corneal abrasion. RESULTS After 10 days of HFD consumption, corneal sensitivity declined. By 10 weeks, expression of corneal inflammatory mediators increased and nerve density declined. While diet reversal restored nerve density and sensitivity, the corneas remained in a heightened inflammatory state. After 10 days on the HFD, corneal circadian rhythms (limbal neutrophil accumulation, epithelial cell division and Rev-erbα expression) were blunted. Similarly, leukocyte recruitment after wounding was dysregulated and accompanied by delays in wound closure and nerve recovery. CONCLUSION In the mouse, obesogenic diet consumption results in corneal dysfunction that precedes the onset of sustained hyperglycemia. Diet reversal only partially ameliorated this dysfunction, suggesting a HFD diet may have a lasting negative impact on corneal health that is resistant to dietary therapeutic intervention.
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Affiliation(s)
- Aubrey Hargrave
- College of Optometry, University of Houston, Houston, Texas, United States of America
| | - Justin A Courson
- College of Optometry, University of Houston, Houston, Texas, United States of America
| | - Vanna Pham
- College of Optometry, University of Houston, Houston, Texas, United States of America
| | - Paul Landry
- College of Optometry, University of Houston, Houston, Texas, United States of America
| | - Sri Magadi
- College of Optometry, University of Houston, Houston, Texas, United States of America
| | - Pooja Shankar
- College of Optometry, University of Houston, Houston, Texas, United States of America
| | - Sam Hanlon
- College of Optometry, University of Houston, Houston, Texas, United States of America
| | - Apoorva Das
- College of Optometry, University of Houston, Houston, Texas, United States of America
| | - Rolando E Rumbaut
- Children's Nutrition Research Center, Baylor College of Medicine, Houston, Texas, United States of America
- Center for Translational Research on Inflammatory Diseases (CTRID), Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, United States of America
| | - C Wayne Smith
- Center for Translational Research on Inflammatory Diseases (CTRID), Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, United States of America
| | - Alan R Burns
- College of Optometry, University of Houston, Houston, Texas, United States of America
- Children's Nutrition Research Center, Baylor College of Medicine, Houston, Texas, United States of America
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Understanding Diabetic Neuropathy: Focus on Oxidative Stress. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2020; 2020:9524635. [PMID: 32832011 PMCID: PMC7422494 DOI: 10.1155/2020/9524635] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Accepted: 07/22/2020] [Indexed: 02/06/2023]
Abstract
Diabetic neuropathy is one of the clinical syndromes characterized by pain and substantial morbidity primarily due to a lesion of the somatosensory nervous system. The burden of diabetic neuropathy is related not only to the complexity of diabetes but also to the poor outcomes and difficult treatment options. There is no specific treatment for diabetic neuropathy other than glycemic control and diligent foot care. Although various metabolic pathways are impaired in diabetic neuropathy, enhanced cellular oxidative stress is proposed as a common initiator. A mechanism-based treatment of diabetic neuropathy is challenging; a better understanding of the pathophysiology of diabetic neuropathy will help to develop strategies for the new and correct diagnostic procedures and personalized interventions. Thus, we review the current knowledge of the pathophysiology in diabetic neuropathy. We focus on discussing how the defects in metabolic and vascular pathways converge to enhance oxidative stress and how they produce the onset and progression of nerve injury present in diabetic neuropathy. We discuss if the mechanisms underlying neuropathy are similarly operated in type I and type II diabetes and the progression of antioxidants in treating diabetic neuropathy.
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20
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Gad H, Al-Jarrah B, Saraswathi S, Petropoulos IN, Ponirakis G, Khan A, Singh P, Al Khodor S, Elawad M, Almasri W, Abdelrahman H, Elawwa A, Khalifa A, Shamekh A, Al-Khalaf F, Petrovski G, Al Zyoud M, Al Maadheed M, Hendaus MA, Hussain K, Akobeng AK, Malik RA. Corneal nerve loss in children with type 1 diabetes mellitus without retinopathy or microalbuminuria. J Diabetes Investig 2020; 11:1594-1601. [PMID: 32491258 PMCID: PMC7610109 DOI: 10.1111/jdi.13313] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 05/18/2020] [Accepted: 05/28/2020] [Indexed: 12/12/2022] Open
Abstract
Aims/Introduction Corneal confocal microscopy is a rapid, non‐invasive ophthalmic technique to identify subclinical neuropathy. The aim of this study was to quantify corneal nerve morphology in children with type 1 diabetes mellitus compared with age‐matched healthy controls using corneal confocal microscopy. Materials and Methods A total of 20 participants with type 1 diabetes mellitus (age 14 ± 2 years, diabetes duration 4.08 ± 2.91 years, glycated hemoglobin 9.3 ± 2.1%) without retinopathy or microalbuminuria and 20 healthy controls were recruited from outpatient clinics. Corneal confocal microscopy was undertaken, and corneal nerve fiber density (n/mm2), corneal nerve branch density (n/mm2), corneal nerve fiber length (mm/mm2), corneal nerve fiber tortuosity and inferior whorl length (mm/mm2) were quantified manually. Results Corneal nerve fiber density (22.73 ± 8.84 vs 32.92 ± 8.59; P < 0.001), corneal nerve branch density (26.19 ± 14.64 vs 47.34 ± 20.01; P < 0.001), corneal nerve fiber length (13.26 ± 4.06 vs 19.52 ± 4.54; P < 0.001) and inferior whorl length (15.50 ± 5.48 vs 23.42 ± 3.94; P < 0.0001) were significantly lower, whereas corneal nerve fiber tortuosity (14.88 ± 5.28 vs 13.52 ± 3.01; P = 0.323) did not differ between children with type 1 diabetes mellitus and controls. Glycated hemoglobin correlated with corneal nerve fiber tortuosity (P < 0.006) and aspartate aminotransferase correlated with corneal nerve fiber density (P = 0.039), corneal nerve branch density (P = 0.003) and corneal nerve fiber length (P = 0.037). Conclusion Corneal confocal microscopy identifies significant subclinical corneal nerve loss, especially in the inferior whorl of children with type 1 diabetes mellitus without retinopathy or microalbuminuria.
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Affiliation(s)
- Hoda Gad
- Medicine Department, Weill Cornell Medicine-Qatar, Doha, Qatar
| | - Bara Al-Jarrah
- Gastroenterology Department, Sidra Medicine, Doha, Qatar
| | | | | | | | - Adnan Khan
- Medicine Department, Weill Cornell Medicine-Qatar, Doha, Qatar
| | - Parul Singh
- Research Department, Sidra Medicine, Doha, Qatar
| | | | - Mamoun Elawad
- Gastroenterology Department, Sidra Medicine, Doha, Qatar
| | - Wesam Almasri
- Gastroenterology Department, Sidra Medicine, Doha, Qatar
| | | | - Ahmed Elawwa
- Endocrinology Department, Sidra Medicine, Doha, Qatar
| | - Amel Khalifa
- Endocrinology Department, Sidra Medicine, Doha, Qatar
| | - Ahmed Shamekh
- Endocrinology Department, Sidra Medicine, Doha, Qatar
| | | | | | | | | | | | | | | | - Rayaz A Malik
- Medicine Department, Weill Cornell Medicine-Qatar, Doha, Qatar.,Institute of Cardiovascular Medicine, University of Manchester, Manchester, UK
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21
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Tear Levels of IGFBP-3: A Potential Biomarker for Diabetic Nerve Changes in the Cornea. Eye Contact Lens 2020; 46:319-325. [DOI: 10.1097/icl.0000000000000700] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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22
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Williams SM, Eleftheriadou A, Alam U, Cuthbertson DJ, Wilding JPH. Cardiac Autonomic Neuropathy in Obesity, the Metabolic Syndrome and Prediabetes: A Narrative Review. Diabetes Ther 2019; 10:1995-2021. [PMID: 31552598 PMCID: PMC6848658 DOI: 10.1007/s13300-019-00693-0] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Indexed: 12/19/2022] Open
Abstract
Cardiac autonomic neuropathy (CAN) is a major complication of type 1 and type 2 diabetes mellitus (T1DM and T2DM). The increased morbidity, cardiovascular and all-cause mortality associated with CAN is established from numerous epidemiological studies. However, CAN is increasingly recognised in people with prediabetes (pre-DM) and the metabolic syndrome (MetS) with a reported prevalence up to 11% and 24% respectively. CAN is associated with components of MetS including hypertension and obesity, predating hyperglycaemia. The aetiology of CAN is multifactorial and there is a reciprocal relationship with insulin resistance and MetS. Obstructive sleep apnoea (OSA) is also associated with CAN possibly through MetS and an independent mechanism. An estimated global prevalence of the impaired glucose tolerance (IGT) form of pre-DM of 587 million people by 2045 means CAN will become a major clinical problem. CAN is independently associated with silent myocardial ischaemia, major cardiovascular events, myocardial dysfunction and cardiovascular mortality. Screening for CAN in pre-DM using risk scores with analysis of heart rate variability (HRV) or Sudoscan is important to allow earlier treatment at a reversible stage. The link between obesity and CAN highlights the therapeutic potential of lifestyle interventions including diet and physical activity to reverse MetS and prevent CAN. Weight loss achieved using these dietary and exercise lifestyle interventions improves the sympathetic and parasympathetic HRV indices of cardiac autonomic function. Further research is needed to identify high-risk populations of people with pre-DM or obesity that might benefit from targeted pharmacotherapy including metformin, sodium/glucose cotransporter 2 (SGLT2) inhibitors and glucagon-like peptide 1 (GLP-1) analogues. Bariatric surgery also improves HRV through weight loss which might also prevent CAN in severe obesity. This article reviews the literature on CAN in obesity, pre-DM and MetS, to help determine a rationale for screening, early intervention treatment and formulate future research questions in this highly prevalent condition.
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Affiliation(s)
| | | | - Uazman Alam
- Diabetes and Neuropathy Research, Department of Eye and Vision Sciences and Pain Research Institute, Institute of Ageing and Chronic Disease, University of Liverpool and Aintree University Hospital NHS Foundation Trust, Liverpool, UK
- Royal Liverpool and Broadgreen University NHS Hospital Trust, Liverpool, UK
- Division of Endocrinology, Diabetes and Gastroenterology, University of Manchester, Manchester, UK
| | - Daniel J Cuthbertson
- Obesity and Endocrinology Research, Institute of Ageing and Chronic Disease, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
| | - John P H Wilding
- Obesity and Endocrinology Research, Institute of Ageing and Chronic Disease, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
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Vitoux MA, Kessal K, Melik Parsadaniantz S, Claret M, Guerin C, Baudouin C, Brignole-Baudouin F, Réaux-Le Goazigo A. Benzalkonium chloride-induced direct and indirect toxicity on corneal epithelial and trigeminal neuronal cells: proinflammatory and apoptotic responses in vitro. Toxicol Lett 2019; 319:74-84. [PMID: 31707104 DOI: 10.1016/j.toxlet.2019.10.014] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 10/03/2019] [Accepted: 10/18/2019] [Indexed: 11/17/2022]
Abstract
Benzalkonium chloride (BAK), a quaternary ammonium compound widely used as disinfecting agent as well as preservative in eye drops is known to induce toxic effects on the ocular surface with inflammation and corneal nerve damage leading to dry eye disease (DED) in the medium-to-long term. The aim of this study was to evaluate in vitro the toxicity of a conditioned medium produced by corneal epithelial cells previously exposed to BAK (BAK-CM) on trigeminal neuronal cells. A human corneal epithelial (HCE) cell line was exposed to 5.10-3% BAK (i.e. 0.005% BAK) for 15 min and let recover for 5 h to prepare a BAK-CM. This BAK concentration is the lowest one found in eye drops. After this recovery period, BAK effect on HCE cells displayed cytotoxicity, morphological alteration, apoptosis, oxidative stress, ATP release, CCL2 and IL6 gene induction, as well as an increase in CCL2, IL-6 and MIF release. Next, a mouse trigeminal ganglion primary culture was exposed to the BAK-CM for 2 h, 4 h or 24 h. Whereas BAK-CM did not alter neuronal cell morphology, or induced neuronal cytotoxicity or oxidative stress, BAK-CM induced gene expression of Fos (neuronal activation marker), Atf3 (neuronal injury marker), Ccl2 and Il6 (inflammatory markers). Two and 4 h BAK-CM exposure promoted a neuronal damage (ATF-3, phospho-p38 increases; phospho-Stat3 decreases) while 24 h-BAK-CM exposure initiated a prosurvival pathway activation (phospho-p44/42, phospho-Akt increases; ATF-3, GADD153, active Caspase-3 decreases). In conclusion, this in vitro model, simulating paracrine mechanisms, represents an interesting tool to highlight the indirect toxic effects of BAK or any other xenobiotic on corneal trigeminal neurons and may help to better understand the cellular mechanisms that occur during DED pathophysiology.
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Affiliation(s)
- Michael-Adrien Vitoux
- Sorbonne Université, INSERM, CNRS, IHU Foresight, Institut de la Vision, F-75012 Paris, France; HORUS PHARMA, F-06700 Saint-Laurent-du-Var, France
| | - Karima Kessal
- Sorbonne Université, INSERM, CNRS, IHU Foresight, Institut de la Vision, F-75012 Paris, France; Centre Hospitalier National d'Ophtalmologie des Quinze-Vingts, INSERM-DGOS CIC 1423, IHU Foresight, F-75012 Paris, France
| | | | | | | | - Christophe Baudouin
- Sorbonne Université, INSERM, CNRS, IHU Foresight, Institut de la Vision, F-75012 Paris, France; Centre Hospitalier National d'Ophtalmologie des Quinze-Vingts, INSERM-DGOS CIC 1423, IHU Foresight, F-75012 Paris, France; Université Versailles-Saint-Quentin-en-Yvelines, Hôpital Ambroise Paré, APHP, F-92100 Boulogne-Billancourt, France
| | - Françoise Brignole-Baudouin
- Sorbonne Université, INSERM, CNRS, IHU Foresight, Institut de la Vision, F-75012 Paris, France; Centre Hospitalier National d'Ophtalmologie des Quinze-Vingts, INSERM-DGOS CIC 1423, IHU Foresight, F-75012 Paris, France; Université de Paris, Faculté de Pharmacie de Paris, F-75006 Paris, France
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Ozaki K, Terayama Y, Matsuura T. Hyperglycemia Suppresses Age-Related Increases in Corneal Peripheral Sensory Nerves in Wistar Bon Kobori (WBN/Kob) Rats. Invest Ophthalmol Vis Sci 2019; 60:4151-4158. [PMID: 31598626 DOI: 10.1167/iovs.19-28060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Purpose Nerve fiber density in the cornea is an alternative marker for diabetic peripheral neuropathy combined with intraepidermal nerve fiber density (IENFD). Recent studies investigated corneal nerves using rodent models of diabetes. Male Wistar Bon Kobori (WBN/Kob) rats spontaneously develop long-lasting diabetes and human-like diabetic peripheral neuropathy with vascular lesions. This study investigated corneal nerve fiber density and IENFD in diabetic male WBN/Kob rats as morphological markers of diabetic peripheral neuropathy. Methods Male WBN/Kob rats exhibit abnormal glucose tolerance and diabetes at approximately 30 weeks of age, which progresses until approximately 90 weeks of age. Male WBN/Kob rats aged 36 and 90 weeks were therefore used for histological investigations and compared with age-matched nondiabetic female rats. Results Terminal epithelial nerve density and subbasal nerve plexus density in the central cornea were significantly greater in nondiabetic female rats aged 90 weeks when compared with nondiabetic female rats aged 36 weeks. However, terminal epithelial nerve density and subbasal nerve plexus density did not increase with age in diabetic male WBN/Kob rats, instead lowering by up to 40%, relative to measurements in nondiabetic female rats aged 90 weeks. However, this difference was not statistically significant. IENFD was significantly lower in diabetic male rats aged 90 weeks than in male rats aged 36 weeks, but did not differ between diabetic male rats and nondiabetic female rats aged 90 weeks. Conclusions In WBN/Kob rats, hyperglycemia suppresses an age-related increase in peripheral sensory corneal nerve density; therefore, corneal sensory nerves may be important morphological markers of diabetic peripheral sensory neuropathy.
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Affiliation(s)
- Kiyokazu Ozaki
- Laboratory of Pathology, Faculty of Pharmaceutical Science, Setsunan University, Hirakata, Osaka, Japan
| | - Yui Terayama
- Laboratory of Pathology, Faculty of Pharmaceutical Science, Setsunan University, Hirakata, Osaka, Japan
| | - Tetsuro Matsuura
- Laboratory of Pathology, Faculty of Pharmaceutical Science, Setsunan University, Hirakata, Osaka, Japan
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Ozaki K, Terayama Y, Matsuura T. Extended Duration of Hyperglycemia Result in Human-Like Corneal Nerve Lesions in Mice With Alloxan- and Streptozotocin-Induced Type 1 Diabetes. Invest Ophthalmol Vis Sci 2019; 59:5868-5875. [PMID: 30550618 DOI: 10.1167/iovs.18-25693] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Purpose Previous experimental studies assessing corneal nerves as a measure of the severity of diabetic peripheral neuropathy have yielded discordant results; this may have been due to the effect of the short duration of the induced diabetes. We investigated whether increases in the duration of hyperglycemia result in the development of corneal lesions in a mouse model of alloxan (AL)- or streptozotocin (STZ)-induced type 1 diabetes. We further determined whether corneal nerve fiber density, intraepidermal nerve fiber density (IENFD), and sural nerve morphology can be used as morphologic markers of diabetic peripheral neuropathy in rodent models. Methods A total of 30 female ICR mice were divided into three groups: those with STZ-induced (STZ group) and AL-induced (AL group) diabetes, and a control group. Hyperglycemia was maintained in diabetic mice for 35 weeks. Animals were euthanized at 41 weeks of age. Results Subbasal nerve plexus density (SBNPD) and terminal epithelial nerve density (TEND) in the cornea, as well as IENFD, were significantly lower, and mean sural nerve axon sizes were smaller in mice in the STZ and AL groups than in the control group. There were significant correlations between IENFD and SBNPD, and between IENFD and TEND. Conclusions These results indicate that the TEND and SBNTD of the cornea may be useful morphologic markers for diabetic peripheral neuropathy.
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Affiliation(s)
- Kiyokazu Ozaki
- Laboratory of Pathology, Faculty of Pharmaceutical Science, Setsunan University, Osaka, Japan
| | - Yui Terayama
- Laboratory of Pathology, Faculty of Pharmaceutical Science, Setsunan University, Osaka, Japan
| | - Tetsuro Matsuura
- Laboratory of Pathology, Faculty of Pharmaceutical Science, Setsunan University, Osaka, Japan
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Aghanoori MR, Smith DR, Shariati-Ievari S, Ajisebutu A, Nguyen A, Desmond F, Jesus CHA, Zhou X, Calcutt NA, Aliani M, Fernyhough P. Insulin-like growth factor-1 activates AMPK to augment mitochondrial function and correct neuronal metabolism in sensory neurons in type 1 diabetes. Mol Metab 2019; 20:149-165. [PMID: 30545741 PMCID: PMC6358538 DOI: 10.1016/j.molmet.2018.11.008] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 11/20/2018] [Accepted: 11/23/2018] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE Diabetic sensorimotor polyneuropathy (DSPN) affects approximately half of diabetic patients leading to significant morbidity. There is impaired neurotrophic growth factor signaling, AMP-activated protein kinase (AMPK) activity and mitochondrial function in dorsal root ganglia (DRG) of animal models of type 1 and type 2 diabetes. We hypothesized that sub-optimal insulin-like growth factor 1 (IGF-1) signaling in diabetes drives loss of AMPK activity and mitochondrial function, both contributing to development of DSPN. METHODS Age-matched control Sprague-Dawley rats and streptozotocin (STZ)-induced type 1 diabetic rats with/without IGF-1 therapy were used for in vivo studies. For in vitro studies, DRG neurons from control and STZ-diabetic rats were cultured and treated with/without IGF-1 in the presence or absence of inhibitors or siRNAs. RESULTS Dysregulation of mRNAs for IGF-1, AMPKα2, ATP5a1 (subunit of ATPase), and PGC-1β occurred in DRG of diabetic vs. control rats. IGF-1 up-regulated mRNA levels of these genes in cultured DRGs from control or diabetic rats. IGF-1 treatment of DRG cultures significantly (P < 0.05) increased phosphorylation of Akt, P70S6K, AMPK and acetyl-CoA carboxylase (ACC). Mitochondrial gene expression and oxygen consumption rate (spare respiratory capacity), ATP production, mtDNA/nDNA ratio and neurite outgrowth were augmented (P < 0.05). AMPK inhibitor, Compound C, or AMPKα1-specific siRNA suppressed IGF-1 elevation of mitochondrial function, mtDNA and neurite outgrowth. Diabetic rats treated with IGF-1 exhibited reversal of thermal hypoalgesia and, in a separate study, reversed the deficit in corneal nerve profiles. In diabetic rats, IGF-1 elevated the levels of AMPK and P70S6K phosphorylation, raised Complex IV-MTCO1 and Complex V-ATP5a protein expression, and restored the enzyme activities of Complex IV and I in the DRG. IGF-1 prevented TCA metabolite build-up in nerve. CONCLUSIONS In DRG neuron cultures IGF-1 signals via AMPK to elevate mitochondrial function and drive axonal outgrowth. We propose that this signaling axis mediates IGF-1-dependent protection from distal dying-back of fibers in diabetic neuropathy.
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Affiliation(s)
- Mohamad-Reza Aghanoori
- Division of Neurodegenerative Disorders, St Boniface Hospital Albrechtsen Research Centre, Winnipeg, MB, Canada; Department of Pharmacology and Therapeutics, University of Manitoba, Winnipeg, MB, Canada
| | - Darrell R Smith
- Division of Neurodegenerative Disorders, St Boniface Hospital Albrechtsen Research Centre, Winnipeg, MB, Canada
| | - Shiva Shariati-Ievari
- Canadian Centre for Agri-Food Research in Health and Medicine, St. Boniface Hospital Albrechtsen Research Centre, Winnipeg, Canada
| | - Andrew Ajisebutu
- Division of Neurodegenerative Disorders, St Boniface Hospital Albrechtsen Research Centre, Winnipeg, MB, Canada
| | - Annee Nguyen
- Department of Pathology, University of California San Diego, La Jolla, CA, USA
| | - Fiona Desmond
- Department of Pathology, University of California San Diego, La Jolla, CA, USA
| | - Carlos H A Jesus
- Department of Pathology, University of California San Diego, La Jolla, CA, USA
| | - Xiajun Zhou
- Department of Pathology, University of California San Diego, La Jolla, CA, USA
| | - Nigel A Calcutt
- Department of Pathology, University of California San Diego, La Jolla, CA, USA
| | - Michel Aliani
- Department of Human Nutritional Sciences, University of Manitoba, Winnipeg, MB, Canada; Canadian Centre for Agri-Food Research in Health and Medicine, St. Boniface Hospital Albrechtsen Research Centre, Winnipeg, Canada; Department of Physiology and Pathophysiology, University of Manitoba, Winnipeg, Canada
| | - Paul Fernyhough
- Division of Neurodegenerative Disorders, St Boniface Hospital Albrechtsen Research Centre, Winnipeg, MB, Canada; Department of Pharmacology and Therapeutics, University of Manitoba, Winnipeg, MB, Canada.
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Bussan KA, Robertson DM. Contact lens wear and the diabetic corneal epithelium: A happy or disastrous marriage? J Diabetes Complications 2019; 33:75-83. [PMID: 30391097 PMCID: PMC7364814 DOI: 10.1016/j.jdiacomp.2018.09.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Revised: 09/10/2018] [Accepted: 09/23/2018] [Indexed: 12/11/2022]
Abstract
Diabetes mellitus is an epidemic in the US and abroad. With the advent of new contact lens technology, the use of contact lenses as glucose sensors in lieu of the traditional finger stick is quickly becoming realized. This has the potential to rapidly expand the contact lens market into this growing patient population. The independent cellular and physiological effects of contact lens wear and diabetes on the corneal epithelium have been described. However, little evidence exists to date to support whether there is increased risk associated with contact lens wear in diabetes. The focus of this review is to discuss what is known about the cellular effects of contact lenses on the corneal epithelium, the pathophysiological changes in the corneal epithelium that occur in diabetes, and whether an increased risk for corneal epithelial damage and/or infection may negatively impact safety in diabetic contact lens wearers. Available data indicates that there are inherent risks associated with contact lens wear in diabetics. Importantly, eye care practitioners fitting contact lenses in the diabetic patient need to carefully consider the duration of disease, the level of glycemic control, the presence of retinopathy, and the patient's overall health.
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Affiliation(s)
- Katherine A Bussan
- The Department of Ophthalmology, The University of Texas Southwestern Medical Center, United States of America
| | - Danielle M Robertson
- The Department of Ophthalmology, The University of Texas Southwestern Medical Center, United States of America.
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ČESKÁ BURDOVÁ M, KULICH M, DOTŘELOVÁ D, MAHELKOVÁ G. Effect of Diabetes Mellitus Type 1 Diagnosis on the Corneal Cell Densities and Nerve Fibers. Physiol Res 2018; 67:963-974. [DOI: 10.33549/physiolres.933899] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Relation of diabetes mellitus (DM) to the various stages of corneal nerve fiber damage is well accepted. A possible association between changes in the cornea of diabetic patients and diabetic retinopathy (DR), DM duration, and age at the time of DM diagnosis were evaluated. The study included 60 patients with DM type 1 (DM1) and 20 healthy control subjects. The density of basal epithelial cells, keratocytes and endothelial cells, and the status of the subbasal nerve fibers were evaluated using in vivo corneal confocal microscopy. Basal epithelial cell density increased with age (p=0.026), while stromal and endothelial cell density decreased with age (p=0.003, p=0.0005, p<0.0001). After the DM1 diagnosis was established, this association with age weaken. We showed nerve fiber damage in DM1 patients (p˂0.0001). The damage correlated with the degree of DR. DM1 patients with higher age at DM1 diagnosis had a higher nerve fiber density (p=0.0021). These results indicated that age at DM1 diagnosis potentially has an important effect on final nerve fiber and corneal cell density.
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Affiliation(s)
| | | | | | - G. MAHELKOVÁ
- Department of Ophthalmology, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
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Andersen ST, Grosen K, Tankisi H, Charles M, Andersen NT, Andersen H, Petropoulos IN, Malik RA, Jensen TS, Karlsson P. Corneal confocal microscopy as a tool for detecting diabetic polyneuropathy in a cohort with screen-detected type 2 diabetes: ADDITION-Denmark. J Diabetes Complications 2018; 32:1153-1159. [PMID: 30309785 DOI: 10.1016/j.jdiacomp.2018.09.016] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Revised: 09/10/2018] [Accepted: 09/26/2018] [Indexed: 12/26/2022]
Abstract
AIMS In this cross-sectional study, we explored the utility of corneal confocal microscopy (CCM) measures for detecting diabetic polyneuropathy (DPN) and their association with clinical variables, in a cohort with type 2 diabetes. METHODS CCM, nerve conduction studies, and assessment of symptoms and clinical deficits of DPN were undertaken in 144 participants with type 2 diabetes and 25 controls. DPN was defined according to the Toronto criteria for confirmed DPN. RESULTS Corneal nerve fiber density (CNFD) was lower both in participants with confirmed DPN (n = 27) and in participants without confirmed DPN (n = 117) compared with controls (P = 0.04 and P = 0.01, respectively). No differences were observed for CNFD (P = 0.98) between participants with and without DPN. There were no differences in CNFL and CNBD between groups (P = 0.06 and P = 0.29, respectively). CNFD was associated with age, height, total- and LDL cholesterol. CONCLUSIONS CCM could not distinguish patients with and without neuropathy, but CNFD was lower in patients with type 2 diabetes compared to controls. Age may influence the level of CCM measures.
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Affiliation(s)
- Signe T Andersen
- Research Unit for General Practice & Section for General Medical Practice, Department of Public Health, Aarhus University, Aarhus, Denmark
| | - Kasper Grosen
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Hatice Tankisi
- Department of Clinical Neurophysiology, Aarhus University Hospital, Aarhus, Denmark
| | - Morten Charles
- Research Unit for General Practice & Section for General Medical Practice, Department of Public Health, Aarhus University, Aarhus, Denmark
| | - Niels T Andersen
- Department of Public Health, Section for Biostatistics, Aarhus University, Aarhus, Denmark
| | - Henning Andersen
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Ioannis N Petropoulos
- Weill Cornell Medicine-Qatar, Education City, Doha, Qatar; Central Manchester University Hospitals Foundation Trust, Manchester, UK
| | - Rayaz A Malik
- Weill Cornell Medicine-Qatar, Education City, Doha, Qatar; Central Manchester University Hospitals Foundation Trust, Manchester, UK
| | - Troels S Jensen
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Pall Karlsson
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.
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Chen X, Graham J, Petropoulos IN, Ponirakis G, Asghar O, Alam U, Marshall A, Ferdousi M, Azmi S, Efron N, Malik RA. Corneal Nerve Fractal Dimension: A Novel Corneal Nerve Metric for the Diagnosis of Diabetic Sensorimotor Polyneuropathy. Invest Ophthalmol Vis Sci 2018; 59:1113-1118. [PMID: 29490348 PMCID: PMC5830988 DOI: 10.1167/iovs.17-23342] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Objective Corneal confocal microscopy (CCM), an in vivo ophthalmic imaging modality, is a noninvasive and objective imaging biomarker for identifying small nerve fiber damage. We have evaluated the diagnostic performance of previously established CCM parameters to a novel automated measure of corneal nerve complexity called the corneal nerve fiber fractal dimension (ACNFrD). Methods A total of 176 subjects (84 controls and 92 patients with type 1 diabetes) with and without diabetic sensorimotor polyneuropathy (DSPN) underwent CCM. Fractal dimension analysis was performed on CCM images using purpose-built corneal nerve analysis software, and compared with previously established manual and automated corneal nerve fiber measurements. Results Manual and automated subbasal corneal nerve fiber density (CNFD) (P < 0.0001), length (CNFL) (P < 0.0001), branch density (CNBD) (P < 0.05), and ACNFrD (P < 0.0001) were significantly reduced in patients with DSPN compared to patients without DSPN. The areas under the receiver operating characteristic curves for identifying DSPN were comparable: 0.77 for automated CNFD, 0.74 for automated CNFL, 0.69 for automated CNBD, and 0.74 for automated ACNFrD. Conclusions ACNFrD shows comparable diagnostic efficiency to identify diabetic patients with and without DSPN.
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Affiliation(s)
- Xin Chen
- School of Computer Science, University of Nottingham, Nottingham, United Kingdom
| | - Jim Graham
- Centre for Imaging Sciences, Institute of Population Health, University of Manchester, Manchester, United Kingdom
| | | | | | - Omar Asghar
- Cardiovascular Sciences, Institute of Cardiovascular Sciences, University of Manchester, Manchester, United Kingdom
| | - Uazman Alam
- Department of Eye and Vision Sciences, Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, United Kingdom.,Diabetes and Endocrinology Research, Clinical Sciences Centre, Aintree University Hospital, Liverpool, United Kingdom
| | - Andrew Marshall
- Department of Clinical Neurophysiology, Central Manchester NHS Foundation Trust, Manchester, United Kingdom
| | - Maryam Ferdousi
- Cardiovascular Sciences, Institute of Cardiovascular Sciences, University of Manchester, Manchester, United Kingdom
| | - Shazli Azmi
- Cardiovascular Sciences, Institute of Cardiovascular Sciences, University of Manchester, Manchester, United Kingdom
| | - Nathan Efron
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Australia
| | - Rayaz A Malik
- Weill Cornell Medicine-Qatar, Division of Medicine, Doha, Qatar.,Cardiovascular Sciences, Institute of Cardiovascular Sciences, University of Manchester, Manchester, United Kingdom
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Mahelková G, Burdová MC, Malá Š, Hoskovcová L, Dotrelová D, Štechová K. Higher Total Insulin Dose Has Positive Effect on Corneal Nerve Fibers in DM1 Patients. ACTA ACUST UNITED AC 2018; 59:3800-3807. [DOI: 10.1167/iovs.18-24265] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Gabriela Mahelková
- Department of Ophthalmology, Charles University, 2nd Faculty of Medicine, Motol University Hospital, Prague, Czech Republic
- Department of Physiology, Charles University, 2nd Faculty of Medicine, Prague, Czech Republic
| | - Marie Ceská Burdová
- Department of Ophthalmology, Charles University, 2nd Faculty of Medicine, Motol University Hospital, Prague, Czech Republic
- Department of Physiology, Charles University, 2nd Faculty of Medicine, Prague, Czech Republic
| | - Šárka Malá
- Department of Internal Medicine, Charles University, 2nd Faculty of Medicine, Motol University Hospital, Prague, Czech Republic
| | - Lucie Hoskovcová
- Department of Internal Medicine, Charles University, 2nd Faculty of Medicine, Motol University Hospital, Prague, Czech Republic
| | - Dagmar Dotrelová
- Department of Ophthalmology, Charles University, 2nd Faculty of Medicine, Motol University Hospital, Prague, Czech Republic
| | - Katerina Štechová
- Department of Internal Medicine, Charles University, 2nd Faculty of Medicine, Motol University Hospital, Prague, Czech Republic
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Yang AY, Chow J, Liu J. Corneal Innervation and Sensation: The Eye and Beyond. THE YALE JOURNAL OF BIOLOGY AND MEDICINE 2018; 91:13-21. [PMID: 29599653 PMCID: PMC5872636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The cornea is one of the most densely innervated and sensitive tissues in the body. In addition to their important sensory functions, corneal nerves induce reflex tear production, blinking, and the release of trophic factors - all of which combined help to maintain the structural and functional integrity of the surface of the eye. Consequently, damage to corneal nerves as a result of disease, surgery, or trauma can lead to diminished corneal sensitivity, epithelial defects, and possible blindness. In this review, we describe commonly used tools that have provided considerable new information on corneal architecture and sensation in healthy and diseased corneas, with special emphasis on changes seen in herpes zoster ophthalmicus, corneal and other therapeutic ocular procedures, antiglaucoma medical therapy, aging, and diabetes. With its potential applications ranging from managing ocular-specific to systemic diseases, the study of corneal innervation has implications for future therapies extending beyond just the eye itself.
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Affiliation(s)
| | | | - Ji Liu
- To whom all correspondence should be addressed: Ji Liu, MD, 40 Temple St. Department of Ophthalmology and Visual Science, Yale School of Medicine, New Haven, CT 06510; Tel: 203-785-2020, Fax: 203-785-7090,
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Herlyn A, Prakasam RK, Peschel S, Allgeier S, Köhler B, Winter K, Guthoff RF, Mittlmeier T, Stachs O. Corneal Subbasal Nerve Plexus Changes in Severe Diabetic Charcot Foot Deformity: A Pilot Study in Search for a DNOAP Biomarker. J Diabetes Res 2018; 2018:5910639. [PMID: 30525053 PMCID: PMC6247393 DOI: 10.1155/2018/5910639] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Revised: 08/31/2018] [Accepted: 09/26/2018] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Diabetic neuroosteoarthropathy (DNOAP) early symptoms are unspecific, mimicking general infectious symptoms and rendering a diagnosis challenging. Consequently, unfavourable outcomes occur frequently, with recurrent foot ulceration, infectious complications, and eventually amputation. Corneal confocal microscopy (CCM) of the subbasal nerve plexus (SNP) is used to detect early peripheral neuropathy in diabetic patients without diabetic retinopathy. This pilot study was designed to determine if specific SNP changes manifest in severe DNOAP in comparison to a healthy control group. METHODS This pilot study utilized a matched-pair analysis to investigate SNP changes by in vivo CCM for 26 patients (mean patient age 63.7 years, range 27 to 78) with severe DNOAP defined by condition after the need for reconstructive foot surgery (n = 13) and a healthy control group (n = 13). Corneal nerve fibre length (CNFL), nerve fibre density (CNFD), nerve branch density (CNBD), average weighted corneal nerve fibre thickness (CNFTh), nerve connecting points (CNCP), and average weighted corneal nerve fibre tortuosity (CNFTo) were assessed as well as the general clinical status, diabetic status, and ophthalmologic basic criteria. RESULTS In vivo CCM revealed significantly reduced SNP parameters in the DNOAP group for CNFL (p = 0.010), CNFD (p = 0.037), CNBD (p = 0.049), and CNCP (p = 0.012) when compared to the healthy control group. Six patients (46%) of the DNOAP group suffered from diabetic retinopathy and none of the control group. CONCLUSIONS This pilot study revealed a rarefication of SNP in all measured parameters in patients with severe DNOAP. We see a potential value of CCM providing a SNP-based biomarker for early stages of DNOAP prior to the development of any foot deformities that needs to be evaluated in further studies. This trial is registered with German Clinical Trials Register (DKRS) DRKS00007537.
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Affiliation(s)
- Anica Herlyn
- Department of Trauma, Hand and Reconstructive Surgery, Rostock University Medical Center, Schillingallee 35, 18057 Rostock, Germany
| | - Ruby Kala Prakasam
- Department of Ophthalmology, Rostock University Medical Center, Doberaner Straße 140, 18057 Rostock, Germany
| | - Sabine Peschel
- Department of Ophthalmology, Rostock University Medical Center, Doberaner Straße 140, 18057 Rostock, Germany
| | - Stephan Allgeier
- Institute for Automation and Applied Informatics, Karlsruhe Institute of Technology (KIT), Hermann-von-Helmholtz-Platz 1, 76344 Eggenstein-Leopoldshafen, Germany
| | - Bernd Köhler
- Institute for Automation and Applied Informatics, Karlsruhe Institute of Technology (KIT), Hermann-von-Helmholtz-Platz 1, 76344 Eggenstein-Leopoldshafen, Germany
| | - Karsten Winter
- Institute of Anatomy, University of Leipzig, Liebigstrasse 13, 04103 Leipzig, Germany
| | - Rudolf F. Guthoff
- Department of Ophthalmology, Rostock University Medical Center, Doberaner Straße 140, 18057 Rostock, Germany
| | - Thomas Mittlmeier
- Department of Trauma, Hand and Reconstructive Surgery, Rostock University Medical Center, Schillingallee 35, 18057 Rostock, Germany
| | - Oliver Stachs
- Department of Ophthalmology, Rostock University Medical Center, Doberaner Straße 140, 18057 Rostock, Germany
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Ishibashi F, Tavakoli M. Impact of Normoglycemia in Reducing Microvascular Complications in Patients with Type 2 Diabetes: A Follow-Up Study. Front Endocrinol (Lausanne) 2018; 9:52. [PMID: 29545773 PMCID: PMC5838016 DOI: 10.3389/fendo.2018.00052] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Accepted: 02/05/2018] [Indexed: 01/15/2023] Open
Abstract
AIMS Hyperglycemia is associated with an increased risk of microvascular complications in patients with type 2 diabetes. The aim of the present study was to investigate whether the reduction of the levels of HbA1c by tight glycemic control (GC) decreases the rate of microvascular complications and improves the neurological measures in patients with type 2 diabetes. METHODS Detailed clinical and neurological examinations including corneal confocal microscopy (CCM) were performed in 141 Japanese patients with type 2 diabetes and 60 age-matched control subjects at baseline and follow-up with GC for 4 years. Patients were stratified according to the mean HbA1c level during follow-up into good (HbA1c < 53.0 mmol/mol, mean; 47.5 mmol/mol), fair (53.0 mmol/mol ≤HbA1c < 58.5 mmol/mol, mean; 55.6 mmol/mol), and poor (HbA1c ≥ 58.5 mmol/mol, mean; 68.9 mmol/mol) GC groups with similar HbA1c levels at baseline (84.5-88.2 mmol/mol). RESULTS At baseline, CCM revealed significant nerve fiber damage in all patients compared to that in controls. The interval changes in most corneal nerve fiber (CNF) parameters and neurophysiological functions were significantly related with the mean HbA1c levels during follow-up. Interestingly, the baseline HbA1c level did not impact on neurological functions at follow-up. Interval changes in neuropathy outcomes were associated with mean clinical factors during follow-up and hypoglycemic strategies. Good GC improved all nerve functions, including CNF branch density and bead, but not the length and main fiber density. Fair GC deteriorated some nerve functions. Poor GC compromised all neuropathy outcomes. Irrespective of GC levels, retinopathy increased after follow-up period, while nephropathy decreased. CONCLUSION This study showed that tight GC was beneficial just for nephropathy among microvascular complications. Despite strict GC, the retinopathy progressed in patients with type 2 diabetes. Glucose control did not improve neurophysiological and corneal nerve measurements unless near-normoglycemia was reached.
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Affiliation(s)
| | - Mitra Tavakoli
- University of Exeter Medical School, Exeter, United Kingdom
- *Correspondence: Mitra Tavakoli,
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Patients With Dry Eye Disease and Low Subbasal Nerve Density Are at High Risk for Accelerated Corneal Endothelial Cell Loss. Cornea 2017; 36:196-201. [PMID: 28060067 DOI: 10.1097/ico.0000000000001057] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE To evaluate changes in corneal endothelial cell density over time in patients with dry eye disease (DED) and to correlate endothelial cell loss with corneal subbasal nerve density. METHODS This retrospective study included 40 eyes of 20 patients with DED. Laser in vivo confocal microscopy had been performed in the central cornea of both eyes at an initial visit and repeated after a mean follow-up of 33.2 ± 10.2 months. The densities of corneal endothelial cells and subbasal nerves were measured in both visits and compared with 13 eyes of 13 normal age-matched controls. RESULTS At the initial visit, the DED group had lower densities of corneal endothelial cells (2620 ± 386 cells/mm) and subbasal nerves (17.8 ± 7.5 mm/mm) compared with the control group (2861 ± 292 cells/mm and 22.8 ± 3.0 mm/mm, with P = 0.08 and P = 0.01, respectively). At the end of follow-up, although there was no significant change in subbasal nerve density (16.7 ± 7.2 mm/mm, P = 0.43), the mean corneal endothelial cell density significantly decreased to 2465 ± 391 cells/mm (P = 0.01), with a mean corneal endothelial cell loss of 2.1 ± 3.6% per year. The endothelial cell loss showed a statistically significant negative correlation with the initial subbasal nerve density (Rs = -0.55, P = 0.02). CONCLUSIONS Patients with DED have an accelerated corneal endothelial cell loss compared with that reported in the literature for normal aging. Those with lower subbasal nerve density, in particular, are at a higher risk for endothelial cell loss over time.
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Parasoglou P, Rao S, Slade JM. Declining Skeletal Muscle Function in Diabetic Peripheral Neuropathy. Clin Ther 2017; 39:1085-1103. [PMID: 28571613 PMCID: PMC5503477 DOI: 10.1016/j.clinthera.2017.05.001] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Revised: 04/27/2017] [Accepted: 05/01/2017] [Indexed: 12/25/2022]
Abstract
PURPOSE The present review highlights current concepts regarding the effects of diabetic peripheral neuropathy (DPN) in skeletal muscle. It discusses the lack of effective pharmacologic treatments and the role of physical exercise intervention in limb protection and symptom reversal. It also highlights the importance of magnetic resonance imaging (MRI) techniques in providing a mechanistic understanding of the disease and helping develop targeted treatments. METHODS This review provides a comprehensive reporting on the effects of DPN in the skeletal muscle of patients with diabetes. It also provides an update on the most recent trials of exercise intervention targeting DPN pathology. Lastly, we report on emerging MRI techniques that have shown promise in providing a mechanistic understanding of DPN and can help improve the design and implementation of clinical trials in the future. FINDINGS Impairments in lower limb muscles reduce functional capacity and contribute to altered gait, increased fall risk, and impaired balance in patients with DPN. This finding is an important concern for patients with DPN because their falls are likely to be injurious and lead to bone fractures, poorly healing wounds, and chronic infections that may require amputation. Preliminary studies have shown that moderate-intensity exercise programs are well tolerated by patients with DPN. They can improve their cardiorespiratory function and partially reverse some of the symptoms of DPN. MRI has the potential to bring new mechanistic insights into the effects of DPN as well as to objectively measure small changes in DPN pathology as a result of intervention. IMPLICATIONS Noninvasive exercise intervention is particularly valuable in DPN because of its safety, low cost, and potential to augment pharmacologic interventions. As we gain a better mechanistic understanding of the disease, more targeted and effective interventions can be designed.
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Affiliation(s)
- Prodromos Parasoglou
- Bernard and Irene Schwartz Center for Biomedical Imaging, Department of Radiology, New York University School of Medicine, New York, New York; Center for Advanced Imaging Innovation and Research (CAI(2)R), Department of Radiology, New York University School of Medicine, New York, New York.
| | - Smita Rao
- Department of Physical Therapy, New York University, New York, New York
| | - Jill M Slade
- Department of Radiology, Michigan State University, East Lansing, Michigan; Biomedical Imaging Research Center, Michigan State University, East Lansing, Michigan
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Sankaranarayanan A, Malik RA. Can corneal confocal microscopy help in early detection of neuronal damage and cognitive dysfunction as a consequence of metabolic syndrome in schizophrenia? Early Interv Psychiatry 2017; 11:271-274. [PMID: 26177108 DOI: 10.1111/eip.12258] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2015] [Accepted: 06/08/2015] [Indexed: 12/13/2022]
Affiliation(s)
| | - Rayaz A Malik
- Weill Cornell Medical College in Qatar, Qatar Foundation, Education City, Doha, Qatar
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A systematic review on the impact of diabetes mellitus on the ocular surface. Nutr Diabetes 2017; 7:e251. [PMID: 28319106 PMCID: PMC5380897 DOI: 10.1038/nutd.2017.4] [Citation(s) in RCA: 111] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Revised: 11/10/2016] [Accepted: 11/14/2016] [Indexed: 12/27/2022] Open
Abstract
Diabetes mellitus is associated with extensive morbidity and mortality in any human community. It is well understood that the burden of diabetes is attributed to chronic progressive damage in major end-organs, but it is underappreciated that the most superficial and transparent organ affected by diabetes is the cornea. Different corneal components (epithelium, nerves, immune cells and endothelium) underpin specific systemic complications of diabetes. Just as diabetic retinopathy is a marker of more generalized microvascular disease, corneal nerve changes can predict peripheral and autonomic neuropathy, providing a window of opportunity for early treatment. In addition, alterations of immune cells in corneas suggest an inflammatory component in diabetic complications. Furthermore, impaired corneal epithelial wound healing may also imply more widespread disease. The non-invasiveness and improvement in imaging technology facilitates the emergence of new screening tools. Systemic control of diabetes can improve ocular surface health, possibly aided by anti-inflammatory and vasoprotective agents.
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Sassani JW, Mc Laughlin PJ, Zagon IS. The Yin and Yang of the Opioid Growth Regulatory System: Focus on Diabetes-The Lorenz E. Zimmerman Tribute Lecture. J Diabetes Res 2016; 2016:9703729. [PMID: 27703986 PMCID: PMC5039296 DOI: 10.1155/2016/9703729] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Accepted: 04/24/2016] [Indexed: 12/16/2022] Open
Abstract
The Opioid Growth Regulatory System consists of opioid growth factor (OGF), [Met5]-enkephalin, and its unique receptor (OGFr). OGF inhibits cell division when bound to OGFr. Conversely, blockade of the interaction of OGF and OGFr, using the potent, long-acting opioid receptor antagonist, naltrexone (NTX), results in increased DNA synthesis and cell division. The authors have demonstrated both in vitro and in vivo that the addition of exogenous OGF or an increase in available OGFr decreases corneal epithelial cell division and wound healing. Conversely, blockade of the OGF-OGFr interaction by NTX or a decrease in the production of the OGFr increases corneal epithelial cell division and facilitates corneal epithelial wound healing. The authors also have demonstrated that depressed corneal and cutaneous wound healing, dry eye, and abnormal corneal sensitivity in type 1 and type 2 diabetes in animals can be reversed by OGF-OGFr blockade by NTX. Thus, the function of the Opioid Growth Regulatory System appears to be disordered in diabetic animals, and its function can be restored with NTX treatment. These studies suggest a fundamental role for the Opioid Growth Regulatory System in the pathobiology of diabetic complications and a need for studies to elucidate this role further.
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Affiliation(s)
- Joseph W. Sassani
- Departments of Ophthalmology and Pathology, Penn State Milton S. Hershey Medical Center, Hershey, PA 17033, USA
| | - Patricia J. Mc Laughlin
- Department of Neural and Behavioral Sciences, The Penn State University College of Medicine, Hershey, PA 17033, USA
| | - Ian S. Zagon
- Department of Neural and Behavioral Sciences, The Penn State University College of Medicine, Hershey, PA 17033, USA
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Petropoulos IN, Javed S, Azmi S, Khan A, Ponirakis G, Malik RA. Diabetic neuropathy and painful diabetic neuropathy in the Middle East and North Africa (MENA) region: Much work needs to be done. J Taibah Univ Med Sci 2016. [DOI: 10.1016/j.jtumed.2016.06.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
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Pereira MP, Mühl S, Ständer S. Kleinfaserneuropathie als mögliche Ursache für chronischen Pruritus. Hautarzt 2016; 67:615-21. [DOI: 10.1007/s00105-016-3817-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Salvi L, Plateroti P, Balducci S, Bollanti L, Conti FG, Vitale M, Recupero SM, Enrici MM, Fenicia V, Pugliese G. Abnormalities of retinal ganglion cell complex at optical coherence tomography in patients with type 2 diabetes: a sign of diabetic polyneuropathy, not retinopathy. J Diabetes Complications 2016; 30:469-76. [PMID: 26809902 DOI: 10.1016/j.jdiacomp.2015.12.025] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2015] [Revised: 12/23/2015] [Accepted: 12/28/2015] [Indexed: 01/19/2023]
Abstract
AIMS To compare optical coherence tomography (OCT)-derived neuro-retinal parameters in patients with type 2 diabetes and non-diabetic controls and to evaluate their correlation with diabetic retinopathy (DR) and polyneuropathy (DPN). METHODS One-hundred consecutive patients with type 2 diabetes were examined by spectral-domain (SD) OCT for evaluating ganglion cell complex (GCC) and retinal nerve fibre layer (RNFL) thickness and two new pattern-based quantitative measures of GCC damage, global and focal loss volume (GLV and FLV). Fifty sex- and age-matched non-diabetic subjects served as control. RESULTS RNFL thickness (101.0±10.6 vs. 106.4±10.3 μm, P=0.003) was significantly lower and GLV (6.58±4.98 vs. 4.52±3.10 %, P=0.008) and FLV (1.90±1.97 vs. 0.89±0.84 %, P<0.0001) were significantly higher in diabetic versus control subjects. The OCT parameters did not differ significantly according to DR grade. Conversely, RNFL thickness was lower and GLV and FLV were higher in patients with versus those without DPN, and the extent of changes increased significantly with quartiles of DPN score. At both bivariate and multivariate analysis, OCT parameters, especially FLV, correlated significantly with DPN measures. CONCLUSIONS The GCC is significantly affected in patients with type 2 diabetes and SD-OCT might represent a useful tool to detect DPN, but not DR in these individuals.
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Affiliation(s)
- Laura Salvi
- Department of Clinical and Molecular Medicine, "La Sapienza" University, Via di Grottarossa, 1035-1039 - 00189, Rome, Italy; Diabetes Unit, Sant'Andrea Hospital, Via di Grottarossa, 1035-1039 - 00189, Rome, Italy
| | - Pasquale Plateroti
- Department of NESMOS, "La Sapienza" University, Via di Grottarossa, 1035-1039 - 00189, Rome, Italy; Vitreo-Retinal Unit, Sant'Andrea Hospital, Via di Grottarossa, 1035-1039 - 00189, Rome, Italy
| | - Stefano Balducci
- Department of Clinical and Molecular Medicine, "La Sapienza" University, Via di Grottarossa, 1035-1039 - 00189, Rome, Italy; Diabetes Unit, Sant'Andrea Hospital, Via di Grottarossa, 1035-1039 - 00189, Rome, Italy; Metabolic Fitness Association, Via Nomentana, 27 - 00015 Monterotondo Scalo Rome, Italy
| | - Lucilla Bollanti
- Department of Clinical and Molecular Medicine, "La Sapienza" University, Via di Grottarossa, 1035-1039 - 00189, Rome, Italy; Diabetes Unit, Sant'Andrea Hospital, Via di Grottarossa, 1035-1039 - 00189, Rome, Italy
| | - Francesco G Conti
- Department of Clinical and Molecular Medicine, "La Sapienza" University, Via di Grottarossa, 1035-1039 - 00189, Rome, Italy; Diabetes Unit, Sant'Andrea Hospital, Via di Grottarossa, 1035-1039 - 00189, Rome, Italy
| | - Martina Vitale
- Department of Clinical and Molecular Medicine, "La Sapienza" University, Via di Grottarossa, 1035-1039 - 00189, Rome, Italy; Diabetes Unit, Sant'Andrea Hospital, Via di Grottarossa, 1035-1039 - 00189, Rome, Italy
| | - Santi Maria Recupero
- Department of NESMOS, "La Sapienza" University, Via di Grottarossa, 1035-1039 - 00189, Rome, Italy; Ophthalmology Unit, Sant'Andrea Hospital, Via di Grottarossa, 1035-1039 - 00189, Rome, Italy
| | - Maurizio Maurizi Enrici
- Department of NESMOS, "La Sapienza" University, Via di Grottarossa, 1035-1039 - 00189, Rome, Italy; Vitreo-Retinal Unit, Sant'Andrea Hospital, Via di Grottarossa, 1035-1039 - 00189, Rome, Italy
| | - Vito Fenicia
- Department of NESMOS, "La Sapienza" University, Via di Grottarossa, 1035-1039 - 00189, Rome, Italy; Vitreo-Retinal Unit, Sant'Andrea Hospital, Via di Grottarossa, 1035-1039 - 00189, Rome, Italy
| | - Giuseppe Pugliese
- Department of Clinical and Molecular Medicine, "La Sapienza" University, Via di Grottarossa, 1035-1039 - 00189, Rome, Italy; Diabetes Unit, Sant'Andrea Hospital, Via di Grottarossa, 1035-1039 - 00189, Rome, Italy.
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Ehmke T, Leckelt J, Reichard M, Weiss H, Hovakimyan M, Heisterkamp A, Stachs O, Baltrusch S. In vivo nonlinear imaging of corneal structures with special focus on BALB/c and streptozotocin-diabetic Thy1-YFP mice. Exp Eye Res 2015; 146:137-144. [PMID: 26677758 DOI: 10.1016/j.exer.2015.11.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Revised: 11/25/2015] [Accepted: 11/30/2015] [Indexed: 01/09/2023]
Abstract
Two-photon microscopy (TPM) allows high contrast imaging at a subcellular resolution scale. In this work, the microscopy technique was applied to visualize corneal structures in two mouse models (BALB/c and B6.Cg-Tg(Thy1-YFP)16Jrs/J) in vivo. In particular, the transgenic Thy1-YFP mice expressing the yellow fluorescent protein (YFP) in all motor and sensory neurons had been used for investigating the nerve fiber density in healthy and streptozotocin-diabetic mice. This model is clinically relevant since patients suffering from diabetes mellitus have a high risk to develop small fiber neuropathy. Nonlinear laser scanning microscopy displayed a reduction of nerve fiber density in streptozotocin-diabetic versus healthy mice and confirmed data obtained by confocal laser scanning microscopy (CLSM). In recent years, corneal CLSM was proved to be an appropriate non-invasive tool for an early diagnosis of diabetic neuropathy. Nevertheless, validation of the CLSM method for the clinical routine is currently a matter of investigation and requires confirmation by further studies and complementary techniques. Thus, the present study provides further evidence of corneal confocal microscopy as a promising technique for non-invasive detection of diabetic neuropathy. Information derived from these experiments may become clinically relevant and help to develop new drugs for treatment of diabetic neuropathy.
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Affiliation(s)
- Tobias Ehmke
- Laser Zentrum Hannover e.V., Hollerithallee 8, 30419, Hannover, Germany.
| | - Janine Leckelt
- Institute of Medical Biochemistry and Molecular Biology, Schillingallee 70, University of Rostock, 18057, Rostock, Germany
| | - Maria Reichard
- Department of Ophthalmology, Doberaner Str. 140, University of Rostock, 18057, Rostock, Germany
| | - Heike Weiss
- Institute of Medical Biochemistry and Molecular Biology, Schillingallee 70, University of Rostock, 18057, Rostock, Germany
| | - Marina Hovakimyan
- Institute for Biomedical Engineering, F.-Barnewitz Strasse 4, Rostock University Medical Center, 18119, Rostock, Germany
| | - Alexander Heisterkamp
- Laser Zentrum Hannover e.V., Hollerithallee 8, 30419, Hannover, Germany; Institute of Quantum Optics, Welfengarten 1, Leibniz University Hannover, 30167, Hannover, Germany
| | - Oliver Stachs
- Department of Ophthalmology, Doberaner Str. 140, University of Rostock, 18057, Rostock, Germany
| | - Simone Baltrusch
- Institute of Medical Biochemistry and Molecular Biology, Schillingallee 70, University of Rostock, 18057, Rostock, Germany
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Reichard M, Weiss H, Poletti E, Ruggeri A, Guthoff RF, Stachs O, Baltrusch S. Age-Related Changes in Murine Corneal Nerves. Curr Eye Res 2015; 41:1021-1028. [PMID: 26642890 DOI: 10.3109/02713683.2015.1088952] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
PURPOSE The aim of this study is to determine age-related morphological changes in the corneal subbasal nerve plexus (SNP) in two inbred mouse strains. MATERIALS AND METHODS The corneal SNP was investigated by in vivo confocal laser scanning microscopy (CLSM) in 0.5-, 1-, 1.5-, and 2-year-old C57BL/6J mice and in 0.5- and 1-year-old BALB/c mice (n = 4 per age category and strain; 10 images per mouse). Fixed corneal samples from C57BL/6J mice were also analyzed after PGP9.5 staining. Nerve fiber density (NFD) was determined using the semi-automated NeuronJ program. In addition, a new custom-designed, fully automated computerized technique based on oriented multiscale matched filtering was tested to objectify and accelerate image analysis. RESULTS C57BL/6J mice showed low NFD (11.7 ± 0.5 mm/mm2). Aging from 0.5 to 1, 1.5, and 2 years resulted in significant reductions in subbasal NFD by 34%, 49%, and 66%, respectively. The decline in nerve fibers revealed by in vivo CLSM together with NeuronJ quantification was confirmed by ex vivo immunohistochemical analyses. Subbasal NFD in BALB/c mice (30.0 ± 1.4 mm/mm2) was 3-fold higher than in C57BL/6J mice. Aging from 0.5 to 1 year resulted in a significant 17% reduction in NFD. With the automated approach, NFD of 22.6 ± 2.9 mm/mm2 and a 45% reduction during aging was determined from the same images. CONCLUSIONS An age-related reduction in subbasal corneal nerve fibers was observed. The differing extent of reduction in the two mouse strains may be accounted for by genetic factors. Automated NFD quantification of corneal nerve fibers in mice appears to be a useful, reliable, objective, and time-saving tool.
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Affiliation(s)
- Maria Reichard
- a Department of Ophthalmology , University of Rostock , Rostock , Germany
| | - Heike Weiss
- b Institute of Medical Biochemistry and Molecular Biology , University of Rostock , Rostock , Germany
| | - Enea Poletti
- c Department of Information Engineering , University of Padua , Padua , Italy
| | - Alfredo Ruggeri
- c Department of Information Engineering , University of Padua , Padua , Italy
| | - Rudolf F Guthoff
- a Department of Ophthalmology , University of Rostock , Rostock , Germany
| | - Oliver Stachs
- a Department of Ophthalmology , University of Rostock , Rostock , Germany
| | - Simone Baltrusch
- b Institute of Medical Biochemistry and Molecular Biology , University of Rostock , Rostock , Germany
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In Vivo Confocal Microscopy of the Human Cornea in the Assessment of Peripheral Neuropathy and Systemic Diseases. BIOMED RESEARCH INTERNATIONAL 2015; 2015:951081. [PMID: 26770980 PMCID: PMC4685107 DOI: 10.1155/2015/951081] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/29/2015] [Accepted: 11/22/2015] [Indexed: 12/13/2022]
Abstract
In vivo confocal microscopy (IVCM) of the living human cornea offers the ability to perform repeated imaging without tissue damage. Studies using corneal IVCM have led to significant contributions to scientific and clinical knowledge of the living cornea in health and pathological states. Recently the application of corneal IVCM beyond ophthalmology to wider clinical and research fields has been demonstrated. Abnormalities of the corneal subbasal nerve plexus have been associated with many forms of peripheral neuropathy and Langerhans cells correlate with systemic inflammatory states. There is a rapidly growing evidence base investigating the use of corneal IVCM in many systemic conditions and a well-established evidence base for IVCM imaging of the corneal subbasal plexus in diabetic peripheral neuropathy. This paper reviews the potential use of corneal IVCM in general clinical practice as a noninvasive method of assessing peripheral neuropathies, monitoring inflammatory states and clinical therapeutic response.
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Javed S, Alam U, Malik RA. Burning through the pain: treatments for diabetic neuropathy. Diabetes Obes Metab 2015; 17:1115-25. [PMID: 26179288 DOI: 10.1111/dom.12535] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2015] [Revised: 07/02/2015] [Accepted: 07/05/2015] [Indexed: 01/17/2023]
Abstract
The rise in the global burden of diabetes is spurring an increase in the prevalence of its complications. Diabetic peripheral neuropathy (DPN) is a common and devastating complication of diabetes, with multiple clinical manifestations. The most common is a symmetrical length-dependent dysfunction and damage of peripheral nerves. The management of DPN rests on three tenets: intensive glycaemic control, even though the evidence of benefit is questionable in people with type 2 diabetes; pathogenetic therapies; and symptomatic treatment. A number of pathogenetic treatments have been evaluated in phase III clinical trials, including α-lipoic acid (stems reactive oxygen species formation), benfotiamine (prevents vascular damage) and aldose-reductase inhibitors (reduce flux through the polyol pathway), protein kinase C inhibitors (prevent hyperglycaemia-induced activation of protein kinase C), nerve growth factors (stimulate nerve regeneration) and Actovegin® (improves tissue glucose and oxygen uptake). However, none have gained US Food and Drug Administration or European Medicines Agency (EMA) approval, questioning the validity of current trial designs and the endpoints deployed to define efficacy. For painful diabetic neuropathy, clinical guidelines recommend: atypical analgesics for pain relief, including duloxetine and amitriptyline; the γ-aminobutyric acid analogues gabapentin and pregabalin; opioids, including Tapentadol; and topical agents such as lidocaine and capsaicin. No single effective treatment exists for painful DPN, highlighting a growing need for studies to evaluate more potent and targeted drugs, as well as combinations. A number of novel potential candidates, including erythropoietin analogues and angiotensin II type 2 receptor anatagonists are currently being evaluated in phase II clinical trials.
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Affiliation(s)
- S Javed
- Centre for Endocrinology and Diabetes, Institute of Human Development, University of Manchester, Manchester, UK
| | - U Alam
- Central Manchester University Hospitals, Manchester, UK
| | - R A Malik
- Centre for Endocrinology and Diabetes, Institute of Human Development, University of Manchester, Manchester, UK
- Weill-Cornell Medical College-Qatar, Doha, Qatar
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Javed S, Alam U, Malik RA. Treating Diabetic Neuropathy: Present Strategies and Emerging Solutions. Rev Diabet Stud 2015; 12:63-83. [PMID: 26676662 DOI: 10.1900/rds.2015.12.63] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Diabetic peripheral neuropathies (DPN) are a heterogeneous group of disorders caused by neuronal dysfunction in patients with diabetes. They have differing clinical courses, distributions, fiber involvement (large or small), and pathophysiology. These complications are associated with increased morbidity, distress, and healthcare costs. Approximately 50% of patients with diabetes develop peripheral neuropathy, and the projected rise in the global burden of diabetes is spurring an increase in neuropathy. Distal symmetrical polyneuropathy (DSPN) with painful diabetic neuropathy, occurring in around 20% of diabetes patients, and diabetic autonomic neuropathy (DAN) are the most common manifestations of DPN. Optimal glucose control represents the only broadly accepted therapeutic option though evidence of its benefit in type 2 diabetes is unclear. A number of symptomatic treatments are recommended in clinical guidelines for the management of painful DPN, including antidepressants such as amitriptyline and duloxetine, the γ-aminobutyric acid analogues gabapentin and pregabalin, opioids, and topical agents such as capsaicin. However, monotherapy is frequently not effective in achieving complete resolution of pain in DPN. There is a growing need for head-to-head studies of different single-drug and combination pharmacotherapies. Due to the ubiquity of autonomic innervation in the body, DAN causes a plethora of symptoms and signs affecting cardiovascular, urogenital, gastrointestinal, pupillomotor, thermoregulatory, and sudomotor systems. The current treatment of DAN is largely symptomatic, and does not correct the underlying autonomic nerve deficit. A number of novel potential candidates, including erythropoietin analogues, angiotensin II receptor type 2 antagonists, and sodium channel blockers are currently being evaluated in phase II clinical trials.
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Affiliation(s)
- Saad Javed
- Centre for Endocrinology and Diabetes, Institute of Human Development, Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK
| | - Uazman Alam
- Centre for Endocrinology and Diabetes, Institute of Human Development, Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK
| | - Rayaz A Malik
- Centre for Endocrinology and Diabetes, Institute of Human Development, Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK
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