脉络膜上腔注射酮咯酸氨丁三醇后神经节细胞的变化

doi:10.3969/j.issn.1673-5374.2012.35.004

摘要/Abstract

Abstract:

Rabbit right eyes were injected with 3 or 6 mg ketorolac tromethamine into the suprachoroidal space. Electroretinography results demonstrated no abnormal changes in rod cell response, maximum rod cell or cone cell mixing reaction, oscillation potential, cone cell response, waveform, amplitude, and potential of 30 Hz scintillation response in right eyes before injection, and at 1, 2, and 4 weeks after injection. There was no difference between left (control) and right eyes. Under light microscopy, the histomorphology of cells in each retinal layer was normal at 4 weeks following 6 mg ketorolac tromethamine administration. These results indicate that a single suprachoroidal injection of 3 or 6 mg ketorolac tromethamine into rabbits was safe. Suprachoroidal space injection appears to be safe.

Key words: nonsteroidal anti-inflammatory drug, ketorolac tromethamine, segment disease, retina, suprachoroidal space, retinal toxicity, electroretinography, pharmacology, regeneration, neural regeneration

. 脉络膜上腔注射酮咯酸氨丁三醇后神经节细胞的变化[J]. 中国神经再生研究(英文版), 2012, 7(35): 2770-2777.

Sumeng Liu, Wu Liu, Yaling Ma, Kegao Liu, Meizi Wang. Suprachoroidal injection of ketorolac tromethamine does not cause retinal damage[J]. Neural Regeneration Research, 2012, 7(35): 2770-2777.

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引言

材料方法

讨论

文章快阅

延伸阅读

1 中文摘要

目的：探讨正常兔眼脉络膜上腔注射不同剂量酮咯酸氨丁三醇的视网膜毒性。实验方法：新西兰大白兔12只，随机分为A和B两组，每只兔子右眼脉络膜上腔注射不同剂量的酮咯酸氨丁三醇（A组：3000μg/0.05mL，B组：6000μg/0.05mL），左眼全部注射生理盐水作为对照。注射前和注射后1，2，4周每只眼进行闪光全视网膜电图检测，4周后所有动物处死摘除眼球做病理切片，在光学显微镜下分析视网膜组织结构改变。结果：兔眼脉络膜上腔注射酮咯酸氨丁三醇前及注射后1，2，4周，实验眼（右眼）和对照眼（左眼）视网膜电图视杆细胞反应、视杆-视锥细胞最大混合反应、振荡电位、视锥细胞反应和30Hz闪烁反应的波形均正常，振幅和潜伏期均未出现异常改变，经过统计学分析实验眼与对照眼没有差异（P>0.05）。光学显微镜下观察视网膜组织结构，各组实验眼和对照眼视网膜各层组织形态学表现均正常，细胞排列紧密整齐，未见异形细胞、炎症反应以及视网膜出血等结构异常。结论：兔眼脉络膜上腔注射酮咯酸氨丁三醇3000和6000μg后，视网膜功能，组织形态未见异常。这个剂量在兔眼脉络膜上腔注射是安全的。另外可以证明，脉络膜上腔注射的给药方式也是安全的。关键词：酮咯酸氨丁三醇，视网膜毒性，闪光全视野视网膜电图，光学显微镜

2 主要内容及构思创新

新生血管性疾病和黄斑水肿是严重影响视力的眼底疾病，其发病原因的多元化和治疗方法的缺乏导致其发病率在世界范围呈上升趋势。酮咯酸氨丁三醇作为一种非甾体抗炎药已在临床有广泛用途，但多是用于滴眼给药方式用于镇痛消炎，基于大量研究表明其有抗新生血管抗增殖的作用，在眼底疾病如脉络膜新生血管、视网膜新生血管、糖尿病视网膜眼底病变及黄斑囊样水肿的治疗应用上给予了很大的期待。以上论述的目前广泛应用的眼底给药方式有诸多局限，研究多使用玻璃体腔注射，因此我们考虑可否使用脉络膜上腔注射使药物更好进入眼内到达视网膜和脉络膜。本研究通过正常兔眼脉络膜上腔注射不同剂量的酮咯酸氨丁三醇，给药后采用视网膜电图和光学显微镜观察，对视网膜功能和组织形态进行分析研究，探讨脉络膜上腔注射酮咯酸氨丁三醇的视网膜毒性反应。

对于此药国外有报道用于兔眼内玻璃体腔注射来观察视网膜毒性的文献，但是尚无脉络膜上腔注射的相关报道，本实验设计者大量翻阅国内外文献，玻璃体腔内注射酮咯酸氨丁三醇表现出视网膜电图和病理变化的剂量为6000μg，故本实验设计最高剂量为6000μg，经过标准视网膜电图和光镜下视网膜结构的观察没有发现毒性证据，证明这个剂量的酮咯酸氨丁三醇在脉络膜上腔注射是安全的。本实验打药方式和实验结果具有临床指导意义。

3 外审专家意见及作者答复

问题1：在本研究中用的药物浓度是否可达到临床治疗眼部疾病的有效浓度？

回复：此药临床治疗特定眼底疾病的疗效尚未得到有效证明，在讨论部分加了脉络膜上腔注射的药代学文献，本文献所使用的浓度是参考国外文献在玻璃体腔注射引起毒性的浓度，有文献使用酮咯酸氨丁三醇玻璃体腔注射在3000μg时显示出视网膜电图改变，6000μg时显示出病理变化。本实验在6000μg酮咯酸氨丁三醇脉络膜上腔注射没有显示明显的毒性。

问题2：何证明所给的药进入的脉络膜上腔而不是其他地方，例如超声检查或者是其他的组织学染色检查等。

回复：在讨论里引用了刚发表的一篇文献，关于酮咯酸氨丁三醇脉络膜上腔注射的药代动力学的报道，证明在脉络膜上腔注射酮咯酸氨丁三醇250μg/0.05mL后0.5h的视网膜浓度为56.71 ± 22.64 μg/g（讨论里）。药物注射由经验丰富的眼底专家操作，注射后眼底镜观察眼底状况。

问题3：多大剂量的药物才能起作用即引起视网膜电图和形态学的改变，什么时间起作用。为什么选择1，2，4周作为观察点；

回复：因为根据药代学报道，酮咯酸氨丁三醇于脉络膜上腔注射24h后视网膜浓度即为零，但是国外分别有文献报道玻璃体腔注射3000μg的浓度有延迟毒性，2周后视网膜电图 b波增强，6000μg4周后视网膜电图振幅下降10%。关于引起毒性的药物剂量，其一由于条件和时间限制，没有继续往更大浓度做；其二市售滴眼液剂量为5mg/mL，远远低于本实验给的剂量6000μg/0.05mL（120mg/mL）。

问题4：脉络膜上腔注射和玻璃体眼内注射的优劣是什么？

回复：玻璃体上腔注射容易引起玻璃体紊乱，玻璃体注射易导致视网膜的毒性，所以限制了药物使用的剂量，影响疾病治疗效果。脉络膜上腔注射由药代学文献证明其起药时间快，迅速达到有效浓度，本实验证明，在相同浓度玻璃体注射能够导致视网膜毒性而脉络膜上腔注射则不导致毒性，因此这个部位注射可以考虑加大药物剂量更好治疗眼底疾病。但是脉络膜上腔注射对操作性要求较高。

问题5：本研究是采用市售酮咯酸氨丁三醇粉，用生理盐水稀释，脉络膜上腔注射。若与市售该药品注射剂比较，制剂辅料不同，市售该药品注射剂一般含有乙醇，禁用于鞘内或硬膜外给药；若与市售滴眼液比较，本研究又为注射观察毒性。所以，本研究的立题依据不清楚，是证实本品无毒？还是证实本品生理盐水溶解无毒？担心本文的结果，会误导认为市售制剂亦可用于脉络膜上腔注射。

回复：本文想证明脉络膜上腔注射酮咯酸氨丁三醇到6000μg的视网膜毒性，与市场销售滴眼液无关，原料药加生理盐水的配制是查阅文献所得，大量文献研究也有报道认为酮咯酸氨丁三醇有治疗眼底疾病的作用，具体某种疾病的疗效浓度和作用效果尚未有实验证明，本实验只是一个初步的实验。

问题6：3. 本研究所用药剂量来源根据？如果该剂量“6000μg/0.05mL”给予兔，是出于与人用药剂量的转换还是其他来源？选择该剂量的标准没有标明。一般市售滴眼液浓度为0.5%，相当于5mg/mL，而本研究给予的量为注射剂量12μg/mL，远远低于正常制剂给药量400多倍，如何观察毒性？即使无毒，也不能说明按照市售药物的给药量亦无毒

回复：6000μg/0.05mL是120mg/mL，远远高于市售剂量。实验设计者认为酮咯酸氨丁三醇有治疗眼底疾病的价值这是本实验的出发点，国外也有文献做酮咯酸氨丁三醇于玻璃体腔注射，也选用自己配比的剂型或无防腐剂剂型，本实验未考虑和市售滴眼液作对比一是滴眼液含防腐剂及其他制品，不容易判别酮咯酸氨丁三醇药物本身对视网膜造成的毒性，另外与国外几篇文章报道玻璃体上腔注射酮咯酸氨丁三醇3000μg和6000μg造成的不同毒性相比，想证明这个剂量用脉络膜上腔注射没有引起毒性，区别两种注射方法，对于临床使用阶段的参考仍处于非常初步的阶段，谢谢专家指点，文章讨论部分会就此做修改注明。