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1 From the Ocular Research Center, New England College of Optometry, Boston, Massachusetts; and the 2 Harvard School of Public Health; Boston, Massachusetts.
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Abstract |
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METHODS. Insulin eye drops (
15 µL: 0.75% porcine insulin + 0.5%
permeation enhancer) were applied to the eyes of normal and
diabetic rats. The rats were killed at various intervals up to 16
hours, and the retinas and optic nerves from both eyes were analyzed
for the presence of insulin in an ELISA. The extent to which
systemically absorbed insulin accounted for the findings of insulin in
the retina was explored by examining the effects of intravenously
injected insulin on retinal insulin levels and by examining the effects
of eye drop administration in decapitated rats.
RESULTS. Insulin levels rose significantly and peaked in the retina of normal rats 20 minutes after eye drop application (0.7 pg/µg; P < 0.00001). Levels in diabetic retinas peaked at 60 minutes (0.66 pg/µg; P < 0.004) and remained elevated for a longer period than in normal rats. The contralateral retina showed delayed accumulation of lesser amounts of insulin in both normal and diabetic rats. Significant elevations also occurred in the optic nerves in normal and diabetic rats, with concentrations reaching 13 pg/µg in normal rats at 20 minutes and 26 pg/µg in diabetic rats at 5 hours. Topical insulin application resulted in a decrease in serum glucose concomitant with an increase in serum porcine insulin. It did not appear, however, that the systemic absorption of insulin contributed to the accumulation of insulin in the ipsilateral retinas, for two reasons: The intravenous injection of a high concentration of insulin did not appreciably influence retinal insulin levels, and the application of insulin eye drops to decapitated rats still resulted in the accumulation of insulin in the retina.
CONCLUSIONS. These results led to the conclusion that topically applied insulin accumulates in the retina and optic nerve in normal and diabetic rats, with levels remaining elevated longer in diabetic animals. It did not appear that systemically absorbed insulin, resulting from ocular drainage, contributed to this effect.
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Introduction |
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It was demonstrated sometime ago that the noncorneal absorption route also contributes to drug penetration into intraocular tissues.6 Specifically, it was demonstrated in rabbits that topical inulin (molecular weight [MW]: 5000) reaches intraocular tissues by way of the sclera if the corneal absorption route is blocked with a glass cylinder glued to the cornea. These investigators reported a significant concentration of inulin in the vitreous after the topical application of a 0.65% solution.
The revelation that a molecule with an MW of 5000 could accumulate in the vitreous after topical application led us to speculate that a molecule with only a somewhat larger size, insulin (MW: 5802), might similarly concentrate in the retina after topical application. It was theorized that the topical application of insulin to the eye may be potentially beneficial in preventing and possibly reversing diabetic retinopathy, even in the presence of sustained hyperglycemia, through its localized induction of nitric oxide and Na,K-adenosine triphosphatase (ATPase) production, among other mechanisms.7 Insulin receptors are nearly ubiquitous in the retina, being present not only on the retinal microvasculature but in nearly all cellular layers of the retina,8 9 10 suggesting an important role for insulin in retinal function and further supporting this hypothesis.
As a first step toward determining whether topical insulin administration is advantageous in the treatment of diabetic retinopathy, in this study we investigated the pharmacokinetics of topical insulin applied in Lewis rats, with specific attention given to retinal and optic nerve accumulation.
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Methods |
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Insulin Eye Drop Administration
Both normal and diabetic rats received insulin eye drops. The
insulin used was porcine derived (Sigma Chemical Co.) and was
reconstituted in an isotonic bicarbonate (0.75% solution) buffer
containing 0.5% of the permeation enhancer, polyoxyethylene-20-stearyl
ether (Brij-78; Sigma Chemical Co.). An insulin drop (approximately 15
µL) was applied to the left eye of unanesthetized rats and the lids
spread apart and opened wide for 1 to 2 seconds before the eye was held
closed for 30 seconds. This approach routinely resulted in some
overflow (suggesting that a relatively uniform volume was retained in
each animal), and was followed in an attempt to prevent the rapid
drainage of fluid into the lacrimal drainage system.
Quantifying Insulin Levels in the Retina and Optic Nerve
At various time points after topical insulin administration,
rats were killed by decapitation, blood collected, and serum prepared
by centrifugation. The eyes (both the treated ipsilateral eye and the
untreated contralateral eye) were removed using curved, serrated
scissors in a manner that preserved approximately a 3- to 5-mm section
of the optic nerve. The optic nerves were then sliced off at the
posterior pole and pulled from surrounding tissue before being placed
in 100 µL of assay buffer in 0.5 mL microfuge tubes (Kontes,
Vineland, NJ) on ice. The posterior segments were then sliced away from
the anterior segments with a pair of curved scissors, and the retinas
scraped from the choroid and sclera with the aid of a dissecting scope.
Confirmation that this technique yielded retinal tissue alone was
assessed morphologically early in the study. The retinas were similarly
placed in 100 µL of buffer in 0.5-mL microfuge tubes on ice.
The optic nerves and retinas were homogenized using a battery-powered, handheld homogenizer (Kontes) on ice and spun down in a microfuge (Beckman Instruments, Berkeley, CA), and the supernatants were transferred to separate microfuge tubes on ice. A porcine insulin ELISA (ALPCO, Windham, NH) was used to quantify porcine insulin levels. This assay has minimal cross-reactivity to rat insulin and does not cross-react with either insulin-like growth factor (IGF)-1 or -2 (Kim Tilly at ALPCO, personal communication, January 2000). The final colorimetric readings were obtained using a microtiter plate reader (absorbance at 450 nm; model EL310; Bio-Tek, Burlington, VT).
The pellets were resuspended in 100 µL deionized water, washed two more times in 500 mL water, and resuspended in 1 M NaOH. After the tissue pellets had fully solubilized (2–3 days later), their total protein content was analyzed in a protein assay (absorbance at 595 nm; Bio-Rad, Richmond, CA).
Special care was taken to ensure that no cross-contamination of samples occurred during the isolation and homogenization process. This was accomplished by extensive and repeated washing of the instruments and dissecting microscope stage between samples. Eyes were not washed before isolation, however, because our early empiric measurements assured us that such a practice was not necessary.
Experimental Design
Pharmacokinetics.
Baseline porcine insulin levels were measured and compared in normal
and diabetic rats. (As expected, these levels were quite low and only
registered a reading at all because of minimal cross-reactivity to rat
insulin.) In normal rats, porcine retinal and optic nerve insulin
levels were additionally assessed 10, 15, 20, 30, and 60 minutes after
eye drop administration. In diabetic rats in which there were sustained
elevations in retinal porcine insulin for longer periods, retinal and
optic nerve insulin levels were assessed at 10 (except in contralateral
nerves), 15, 20, 30, 60, 90, 180, 300, 480, and 960 minutes after
porcine insulin eye drop administration. Porcine insulin levels in the
aqueous humor of treated eyes only were also quantified, but only at 20
minutes after eye drop administration in diabetic rats.
Effects of Topical Insulin Administration on Systemic Insulin and
Glucose Levels.
A proportion of topically applied insulin enters the systemic
circulation and can affect blood glucose levels. The degree to which
this occurs was assessed in diabetic rats. Serum samples were obtained
from these animals after decapitation, up to 210 minutes after topical
insulin was applied, and were analyzed for their levels of porcine
insulin using the porcine-insulin–specific ELISA; serum glucose was
measured using a Beckman glucose analyzer.
Role of Systemic Uptake in Accumulation of Porcine Insulin in the
Retina and Optic Nerve.
Two experiments were performed to determine to what extent, if any,
systemic uptake contributed to our findings of porcine insulin in both
the ipsilateral and contralateral retinas and optic nerves. In the
first, 0.25 µg porcine insulin in 100 µL was injected intravenously
into diabetic rats, some of which were then killed 3, 12, 20, 30, 45,
and 60 minutes later. Serum and retinal porcine insulin levels were
then assessed as described, and baseline samples were also obtained. In
the second, the left eye of intact and decapitated diabetic rats was
removed 20 minutes after the application of an insulin eye drop. Only
the retinas were assessed in these animals.
Statistics
For each experiment, the differences between baseline
measurements and the measurements taken at later time points were
tested by a nonparametric statistical method, the Wilcoxon rank sum
test. This test is nonparametric in the sense that no distributional
assumptions regarding the data have to be made. Because of the small
sample sizes, exact probabilities were computed using
StatExact.11
A Bonferroni correction was applied to the
test results because of the multiple within-experiment tests performed.
The correction involves multiplying the probability (P) of
the Wilcoxon test statistic by the number of time points tested for a
particular experiment.
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Results |
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Effects of Topical Insulin on Serum Insulin and Glucose Levels
Serum glucose levels decreased by 30 minutes after eye drop
administration, and remained approximately 20% suppressed for 120
minutes (Fig. 5) . Because baseline glucose levels varied somewhat between animals,
these data were expressed as the percentage of baseline levels. The
decline in serum glucose corresponded with an increase in serum insulin
(Fig. 6)
, with levels reaching the initial peak of 0.52 pg/µg at 20 minutes
and remaining elevated for 90 minutes.
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Discussion |
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Our data showed that the topical application of a high concentration of porcine insulin to the rat eye resulted in its accumulation in the retina. In both normal and diabetic rats, it took insulin approximately 20 minutes to reach the retina. The route taken by insulin to the retina has not yet been thoroughly explored. In experiments in rabbits in which the corneal route was blocked, topical timolol and insulin were shown to penetrate the sclera to enter the intraocular tissues. This occurred as a result of entry of the drug into the conjunctiva, followed by its diffusion into the sclera.6 23 It has been reported that the conjunctival epithelium, because of its higher membrane permeability and larger absorptive and intercellular space, was the most viable route for the ocular delivery of peptides and oligonucleotides.24 However, our data showing high levels of insulin in the aqueous humor at the 20-minute time point, support a role, in part, for transcorneal diffusion.
A more prolonged accumulation of insulin was demonstrated in the retina and optic nerve in diabetic than in normal rats. The most characteristic functional alteration in the diabetic vasculature, whether human or rat, is an increased vascular permeability resulting in the development of microangiopathy.25 26 27 28 29 30 At first thought, it seemed reasonable to speculate that increased vascular permeability, and perhaps increased blood flow, may have resulted in the prolonged deposition of insulin in the back of the eye. However, it is not immediately clear how these vascular changes could affect retinal insulin levels. Furthermore, in our decapitation study, we were able to show that an intact vasculature was not necessary for insulin absorption to occur in the retina. An alternate possibility is that the insulin was derived from the aqueous humor, which served as a temporary sink for the peptide, or from conjunctival or scleral areas that similarly concentrated the insulin and through which it leached across connective tissue and epithelial barriers into the retina. However, these still do not explain the differences between diabetic and nondiabetic animals.
Because the RPE barrier is thought to restrict only molecules with an MW of 20,000 or more, it is reasonable to speculate that a transscleral route of entry may play a role in retinal insulin accumulation in both normal and diabetic rats. In support of this route of entry are data that show that large molecules, such as IgG (MW, 150,000), diffuse across the sclera intact, in a manner consistent with diffusion through a fiber matrix.31 Certainly, in this potential pathway to the retina, as well as through the cornea, important impediments to retinal delivery persist, not the least of which is the long diffusional path length. Furthermore, a counterdirectional intraocular convection in aqueous humor and in the flow of retinal fluid toward the choriocapillaris are also obstacles to retinal absorption.3 32
Extreme care was taken to prevent the contamination of retinas and optic nerves with insulin derived from previous samples during harvesting. As a matter of course, we opted not to wash the eyes before harvesting, because we were unsure whether such treatment might unnaturally redistribute any remaining surface insulin. However, in a separate experiment, we washed several eyes before harvesting and were able to show levels of insulin in the retina and optic nerve that were comparable to those reported in this study (data not shown).
As expected, the topical application of insulin resulted in its partial systemic absorption, affecting serum glucose levels. The ability of topical insulin to be absorbed into the blood has led others to the exploration of this approach as an alternative to insulin injection in diabetes.33 34 35 36 37 It has been reported that the long-term application of insulin to the eyes of both humans36 and animals38 was well tolerated, and, in the rabbit, in which the permeation enhancer Brij 78 was used (as in this study), resulted in no adverse corneal effects for up to 3 months of use.38
Although it is clear that insulin applied topically enters the blood, it did not appear that systemic absorption of porcine insulin contributed significantly to levels in the retina. This conclusion was supported by the data showing porcine insulin in the retinas of rats that received topical porcine insulin after they were decapitated, as well as by the finding that the intravenous injection of a high concentration of insulin did not appreciably elevate retinal insulin levels. Although not explicitly stated previously, both the normal and diabetic rat retinas contain a small amount of rat insulin (data not shown). This is perhaps analogous to the comparable baseline serum insulin levels that are present in normal rats and those with type 2 diabetes. It is possible that, with time, the levels of insulin in the diabetic retina decrease; this is currently under investigation.
It is not immediately clear whether the accumulation of insulin in the contralateral retina and optic nerve was due to systemic uptake or to some diffusional mechanism from the treated eye. Our data show that the intravenous injection of a dose of insulin in diabetic rats that was roughly comparable to the amount contained within an eye drop resulted in a very slight increase in retinal insulin levels that was similar to the increase seen in the contralateral retina of eye drop–treated animals. However, we did not examine the optic nerves in these animals. That both optic nerves showed very high levels of insulin after eye drop administration to the left eye, suggests that, at the very least, nonvascular mechanisms may play a role in the accumulation of insulin in the contralateral optic nerve, if not in the retina.
In conclusion, these data support the hypothesis that topically applied insulin can accumulate in the retina and optic nerve. It appears that this effect was not influenced by systemic insulin levels. The route taken by insulin to the back of the eye remains to be investigated, although high levels in the aqueous humor after application suggest at least a partial role for transcorneal migration.
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Acknowledgements |
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Footnotes |
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Submitted for publication August 14, 2001; revised October 19, 2001; accepted November 13, 2001.
Commercial relationships policy: N.
The publication costs of this article were defrayed in part by page
charge payment. This article must therefore be marked
"advertisement" in accordance with 18 U.S.C. 
1734
solely to indicate this fact.
Corresponding author: Steven B. Koevary, Ocular Research Center, New England College of Optometry, 424 Beacon Street, Boston, MA 02115; koevarys{at}ne-optometry.edu
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