Search

Background: The choroidal vasculature, including the choriocapillaris and vortex veins, is essential for providing nutrients to the metabolically demanding photoreceptors and retinal pigment epithelium. Choroidal vascular dysfunction leads to vision loss and is associated with age-related macular degeneration and the poorly understood pachychoroid diseases including central serous chorioretinopathy and polypoidal choroidal vasculopathy that are characterized by formation of dilated pachyvessels throughout the choroid. Methods: Using neural crest-specific Angpt1 knockout mice, we show that Angiopoietin 1, a ligand of the endothelial receptor TEK (also known as Tie2) is essential for choriocapillaris development and vortex vein patterning. Results: Lacking choroidal ANGPT1, neural crest-specific Angpt1 knockout eyes exhibited marked choriocapillaris attenuation and 50% reduction in number of vortex veins, with only 2 vortex veins present in the majority of eyes. Shortly after birth, dilated choroidal vessels resembling human pachyvessels were observed extending from the remaining vortex veins and displacing the choriocapillaris, leading to retinal pigment epithelium dysfunction and subretinal neovascularization similar to that seen in pachychoroid disease. Conclusions: Together, these findings identify a new role for ANGPT1 in ocular vascular development and demonstrate a clear link between vortex vein dysfunction, pachyvessel formation, and disease.

PURPOSE: To describe the utility of fundus autofluorescence (FAF) for detection and monitoring of acute regional outer retinopathy in punctate inner choroidopathy (PIC). DESIGN: Multimodal imaging case series METHODS: Patients with PIC and acute regional hyperautofluorescence were identified. Multimodal imaging, treatment, and clinical course were reviewed. RESULTS: Six eyes of five patients were included (5 women, mean age 39 years, range 28–69). All endorsed new symptoms. Short-wave blue FAF revealed regional hyperautofluorescence in the symptomatic eye, corresponding to ellipsoid zone (EZ) loss on optical coherence tomography (OCT). All patients were treated with local or systemic corticosteroids or immunosuppression, with resolution of symptoms and acute imaging abnormalities. CONCLUSIONS: Symptomatic acute regional outer retinopathy in PIC, manifesting as hyperautofluorescence and EZ loss, is easily identifiable using widefield FAF imaging. Treatment resulted in resolution of symptoms and imaging findings in our cohort, and should be considered in this patient population.

Age-related macular degeneration (AMD) is genetically associated with complement. Dendritic cells (DCs) play key roles during innate and adaptive immunity, and express complement components and their receptors. We investigated ocular DC heterogeneity and the role of DCs in the laser-induced choroidal neovascularization (CNV) model. In order to determine the function of DCs, we used two models of DC deficiency: the Flt3−/− and Flt3l−/− mouse. We identified three types of ocular DCs: plasmacytoid DC, classical DC-1, and classical DC-2. At steady-state, classical DCs were found in the iris and choroid but were not detectable in the retina. Plasmacytoid DCs existed at very low levels in iris, choroid, and retina. After laser injury, the number of each DC subset was up-regulated in the choroid and retina. In Flt3−/− mice, we found reduced numbers of classical DCs at steady-state, but each DC subset equally increased after laser injury between wildtype and Flt3−/− mice. In Flt3l−/− mice, each DC subsets was severely reduced after laser injury. Neither Flt3−/− or Flt3l−/− mice demonstrated reduced CNV area compared to wildtype mice. DCs do not play any significant role during the laser-induced CNV model of neovascular AMD.

PURPOSE To report the multimodal imaging findings of immune recovery uveitis mimicking recurrent T-cell lymphoma after autologous bone marrow transplant therapy. METHODS A 71-year-old man presented with posterior uveitis 6 weeks after chemotherapy and autologous bone marrow transplant for angioimmunoblastic T-cell lymphoma. Multimodal imaging included fluorescein angiography, fundus autofluorescence, and optical coherence tomography. Diagnostic testing included ocular polymerase chain reaction and diagnostic vitrectomy. RESULTS Clinical examination demonstrated vitritis and perivascular deep retinal whitening. Imaging of the retinal whitening showed late hyperfluorescence on fluorescein angiography, hyperautofluorescence on fundus autofluorescence, and ellipsoid zone loss on optical coherence tomography without infiltrative lesions. Testing was negative for syphilis, herpes simplex virus, varicella-zoster virus, and cytomegalovirus. After no clinical improvement with valacyclovir and intravitreal foscarnet treatment, diagnostic vitrectomy was performed. Bacterial and fungal cultures were negative, and herpes simplex virus, varicella-zoster virus, and cytomegalovirus were not detected by polymerase chain reaction. Cytopathology showed mature small nonneoplastic lymphocytes, macrophages, and monocytes. Flow cytometry demonstrated a reactive T-cell population. The patient demonstrated clinical improvement over time with spontaneous resolution of all retinal findings. CONCLUSION This case most likely represents immune recovery uveitis-like syndrome. Diagnostic vitrectomy is highly valuable when the differential includes inflammatory, infectious, and neoplastic processes.

This prospective, observational cohort study of 116 patients found that residents could participate in ∼40% of vitreoretinal surgery cases with good visual and anatomical outcomes. Ophthalmology residents can participate in vitreoretinal surgery with appropriate supervision. Surgical training is a key component of ophthalmology residency. For a variety of extraocular and anterior segment procedures, studies evaluating outcomes and complications in resident-performed surgeries have found equivalent outcomes to attending-performed surgeries, 1 , 2 , 3 except resident cases have longer operative times. 4 In vitreoretinal surgery (VRS), however, only survey results exist. One report showed that, by the end of their residency, over 30% of residents reported performing a pars plana vitrectomy (PPV) as the primary surgeon. 5 A second study reported that 60% of surveyed residents had performed at least 1 primary PPV. 6 Thus, a significant gap exists in the VRS education literature regarding resident involvement, surgical outcomes, operative time, and safety.

Purpose Optic pit maculopathy (OPM) is an uncommon cause of vision loss with no standard surgical treatment. Surgical treatment involves pars plana vitrectomy (PPV), often combined with adjunctive procedures. Large studies comparing outcomes of these approaches are lacking because of low disease incidence. Therefore, we conducted a meta-analysis of PPV without or with adjunctive procedures. Design Meta-analysis and systematic literature review. Methods We conducted a literature search to identify clinical studies and case series of surgically managed OPM. Inclusion criteria were: (1) more than 2 patients, (2) treatment with PPV, and (3) reporting of preoperative and postoperative visual acuity data. We excluded review articles and studies not available in English. Results were analyzed using a 1-way analysis of variance, Pearson’s chi-square test, and simple linear regression. Publication bias was modeled using funnel plots. Main Outcome Measures Visual acuity changes, resolution rate, resolution time, and change in OCT thickness. Results We identified 26 studies, encompassing 27 years and 342 patients. We identified 6 commonly reported techniques: PPV alone (92 patients), PPV plus juxtapapillary laser treatment (JPL; 146 patients), PPV plus internal limiting membrane peeling (ILMP; 50 patients), PPV plus both ILMP and JPL (16 patients), PPV plus inner retinal fenestration (18 patients), and PPV plus autologous platelet concentrate (22 patients). All groups demonstrated improved best-corrected visual acuity (BCVA; average, 0.46 logarithm of the minimum angle of resolution [logMAR]; 95% confidence interval [CI], 0.41–0.51 logMAR) compared with baseline, with no differences between groups (P = 0.11). The average OPM resolution rate was 70% among all groups (range, 56%–100%), and the average time to resolution was 8.4 months for all groups (95% CI, 7.2–9.6 months). Central macular thickness was reduced in all groups with no differences between groups (P = 0.15). Tamponade had no effect on outcomes. Linear regression analysis demonstrated significant correlations between preoperative BCVA and above outcome measures. Funnel plots demonstrated positive publication bias in PPV and PPV plus JPL groups. Conclusions We did not identify any significant differences in outcomes among 6 different surgical techniques. This study is limited by its inclusion of primarily retrospective studies and positive publication bias.

Macrophage-like cells (MLCs) are an emerging retinal biomarker. MLCs are increased in retinal vein occlusion (RVO) eyes, but their predictive value is unknown. This study investigated if MLCs can predict meaningful clinical outcomes. This prospective, cross-sectional study involved 46 eyes from 23 patients with unilateral RVO. Patients’ unaffected eyes were used as matched controls. MLCs were quantified to determine MLC density and percent image area. We collected demographic, clinical, ocular, and imaging characteristics at the time of MLC imaging. We additionally recorded best corrected visual acuity (BCVA) and number of intravitreal injections at 6 months and 12 months post-imaging. MLC density and percent area increased by 1.86 (p = 0.0266)- and 1.94 (p = 0.0415)-fold in RVO compared to control eyes. We found no significant correlation between MLC parameters and any baseline characteristic. MLC density was positively correlated with the number of intravitreal injections at 6 months (n = 12, r = 0.62, p = 0.03) and 12 months (n = 9, r = 0.80, p = 0.009) post-imaging. MLC percent area was correlated with LogMAR BCVA change over 12 months (n = 17, r = 0.57, p = 0.02). High MLC counts correlated with more future intravitreal injections and worse visual acuity outcomes, suggesting that MLCs are a biomarker for treatment resistant RVO eyes.

Neovascular age-related macular degeneration (nAMD) commonly causes vision loss from aberrant angiogenesis, termed choroidal neovascularization (CNV). Interleukin-6 (IL6) is a pro-inflammatory and pro-angiogenic cytokine that is correlated with AMD progression and nAMD activity. We hypothesize that anti-IL6 therapy is a potential nAMD therapeutic. We found that IL6 levels were increased after laser injury and expressed by macrophages. Il6-deficiency decreased laser-induced CNV area and exogenous IL6 addition increased choroidal sprouting angiogenesis. Il6-null mice demonstrated equally increased macrophage numbers as wildtype mice. At steady state, IL6R expression was detected on peripheral blood and ocular monocytes. After laser injury, the number of IL6R+Ly6C+ monocytes in blood and IL6R+ macrophages in the eye were increased. In human choroid, macrophages expressed IL6, IL6R, and IL6ST. Furthermore, IL6R+ macrophages displayed a transcriptional profile consistent with STAT3 (signal transducer and activator of transcription 3) activation and angiogenesis. Our data show that IL6 is both necessary and sufficient for choroidal angiogenesis. Macrophage-derived IL6 may stimulate choroidal angiogenesis via classical activation of IL6R+ macrophages, which then stimulate angiogenesis. Targeting IL6 or the IL6R could be an effective adjunctive therapy for treatment-resistant nAMD patients.

Purpose To report a case of an opacified scleral-sutured Akreos intraocular lens (IOL) and discuss the technique for surgical removal. Methods A 27-year-old man presented with blurry vision in the right eye 1 year after trauma, pars plana vitrectomy, glaucoma tube shunt surgery, and a scleral-sutured Akreos AO60 IOL. Examination demonstrated a visual acuity of 20/300, a persistently dilated pupil, 360° of peripheral anterior synechiae, and an opacified IOL. The patient underwent IOL explantation. Results Owing to the expected granulation of the Gore-Tex suture, an external approach for suture ligation was not attempted. The suture was identified and ligated nasally with forceps and IOL cutting scissors. The Gore-Tex suture was granulated into the ciliary body temporally and was unable to be identified. The eyelets of the Akreos IOL were ligated to remove the IOL. Conclusion Granulation of the Gore-Tex suture into the ciliary body and sclera requires an internal approach for ligation of the suture or eyelets to remove an opacified scleral-sutured Akreos IOL.

BackgroundOcriplasmin is approved for the treatment of symptomatic vitreomacular traction (VMT). However, several retrospective reports have identified ellipsoid zone (EZ) alterations on spectral domain optical coherence tomography (SDOCT) after ocriplasmin injection. This report quantitatively analysed outer retinal changes after intravitreal ocriplasmin.MethodsOcriplasmin Research to Better Inform Treatment is a prospective, observational phase IV clinical study where subjects received a single intravitreal injection of ocriplasmin for symptomatic VMT. Macular cube scans were imported into a semiautomated EZ mapping and fluid feature extraction software for SDOCT analysis. Change in visual acuity, VMT release, macular hole (MH) closure, EZ integrity/volume and subretinal fluid (SRF) volume on SDOCT macular cube scans were recorded and analysed.ResultsThis analysis included 55 participants with 6 months of follow-up. Intravitreal ocriplasmin injection caused VMT release in 67% and MH closure in 82% of participants. Visual acuity improved by 4.5 letters (pConclusionOcriplasmin treatment resulted in VMT release, MH closure and visual acuity gains in a significant portion of eyes. EZ volume was significantly reduced at week 1, but recovered to baseline levels by final follow-up and was not associated with final visual acuity.

Purpose Beta-adrenergic receptor (AR) antagonists, like propranolol, inhibit angiogenesis in multiple ocular conditions through an unknown mechanism. We previously showed that propranolol reduces choroidal neovascularization (CNV) by decreasing interleukin-6 levels. Since macrophages are one of the central producers of interleukin-6, we examined whether macrophages are required for propranolol-driven inhibition of choroidal angiogenesis. Methods We tested the anti-angiogenic properties of propranolol in the choroidal sprouting assay and the laser-induced CNV model. Bone marrow-derived monocytes (BMDMs) were added to the choroidal sprouting assay and Ccr2-/- mice were subjected to laser-induced CNV. Multi-parameter flow cytometry was performed to characterize the ocular mononuclear phagocyte populations after laser injury and during propranolol treatment. Results Propranolol reduced choroidal angiogenesis by 41% (P < 0.001) in the choroidal sprouting assay. Similarly, propranolol decreased laser-induced CNV by 50% (P < 0.05) in female mice, with no change in males. BMDMs increased choroidal sprouting by 146% (P < 0.0001), and this effect was ablated by propranolol. Beta-AR inhibition had no effect upon laser-induced CNV area in female Ccr2-/- mice. MHCII+ and MHCII- macrophages increased 20-fold following laser treatment in wildtype mice as compared to untreated mice, and this effect was completely attenuated in lasered Ccr2-/- mice. Moreover, propranolol increased the numbers of MHCII+ and MHCII- macrophages by 1.9 (P = 0.07) and 3.1 (P < 0.05) fold in lasered female mice with no change in macrophage numbers in males. Conclusions Our data suggest that propranolol inhibits angiogenesis through recruitment of monocyte-derived macrophages in female mice only. These data show the anti-angiogenic nature of beta-AR blocker-recruited monocyte-derived macrophages in CNV.

Background Neovascular age-related macular degeneration (nAMD) commonly causes vision loss from aberrant angiogenesis, termed choroidal neovascularization (CNV). Macrophages are heterogeneous cells that are necessary for experimental CNV, present in human CNV samples, and can display diverse functions, which are dependent upon both their origin and tissue microenvironment. Despite these associations, choroidal macrophage heterogeneity remains unexplored. Methods We performed multi-parameter flow cytometry on wildtype (WT) and Ccr2−/− mice after laser injury to identify macrophage subtypes, and determine which subsets originate from classical monocytes. To fate map tissue resident macrophages at steady state and after laser injury, we used the Cx3cr1CreER/+ ; Rosa26zsGFP/+ mouse model. We reanalyzed previously published single-cell RNA-seq of human choroid samples from healthy and nAMD patients to investigate human macrophage heterogeneity, disease association, and function. Results We identified 4 macrophage subsets in mice: microglia, MHCII+CD11c−, MHCII+CD11c+, and MHCII−. Microglia are tissue resident macrophages at steady state and unaffected by laser injury. At steady state, MHCII− macrophages are long lived, tissue resident macrophages, while MHCII+CD11c− and MHCII+CD11c+ macrophages are partially replenished from blood monocytes. After laser injury, MHCII+CD11c− macrophages are entirely derived from classical monocytes, MHCII− macrophages originate from classical monocytes (90%) and an expansion of tissue resident macrophages (10%), and MHCII+CD11c+ macrophages are derived from classical monocytes (70%), non-classical monocytes (10%), and an expansion of tissue resident macrophages (20%). Single-cell RNA-seq analysis of human choroid found 5 macrophage subsets: two MHCII+CD11C− and three MHCII+CD11C+ populations. One MHCII+CD11C+ subset was 78% derived from a patient with nAMD. Differential expression analysis identified up-regulation of pro-angiogenic gene expression in one MHCII+CD11C− and two MHCII+CD11C+ subsets, including the disease-associated cluster. The upregulated MHCII+CD11C− pro-angiogenic genes were unique compared to the increased MHCII+CD11C+ angiogenesis genes. Conclusions Macrophage origin impacts heterogeneity at steady state and after laser injury in mice. Both mice and human patients demonstrate similar macrophage subtypes. Two discrete pro-angiogenic macrophage populations exist in the human choroid. Targeting specific, pro-angiogenic macrophage subsets is a potential novel therapeutic for nAMD.

The innate immune system plays important roles in ocular pathophysiology including uveitis, diabetic retinopathy, and age-related macular degeneration. Innate immune cells, specifically mononuclear phagocytes, express overlapping cell surface markers, which makes identifying these populations a challenge. Multi-parameter flow cytometry allows for the simultaneous, quantitative analysis of multiple cell surface markers in order to differentiate monocytes, macrophages, microglia, and dendritic cells in mouse eyes. This protocol describes the enucleation of whole mouse eyes, ocular dissection, digestion into a single cell suspension, and staining of the single cell suspension for myeloid cell markers. Additionally, we explain the proper methods for determining voltages using single color controls and for delineating positive gates using fluorescence minus one controls. The major limitation of multi-parameter flow cytometry is the absence of tissue architecture. This limitation can be overcome by multi-parameter flow cytometry of individual ocular compartments or complimentary immunofluorescence staining. However, immunofluorescence is limited by its lack of quantitative analysis and reduced number of fluorophores on most microscopes. We describe the use of multi-parametric flow cytometry to provide highly quantitative analysis of mononuclear phagocytes in laser-induced choroidal neovascularization. Additionally, multi-parameter flow cytometry can be used for the identification of macrophage subsets, fate mapping, and cell sorting for transcriptomic or proteomic studies.

Purpose To quantitatively characterize macrophage-like cells (MLCs) at the vitreoretinal interface in different severity stages of diabetic retinopathy (DR) using optical coherence tomography angiography (OCTA). Methods The study included 72 eyes of 72 subjects: 18 healthy controls, 22 diabetes mellitus (DM) without DR, 17 nonproliferative DR (NPDR), and 15 proliferative DR (PDR). We obtained repeated (average, 6.5; range, 3–10) macular OCTA scans for each eye. We registered and averaged the 3-µm OCT slab above the vitreoretinal interface to visualize MLCs. Using a semiautomated method, we binarized and quantified MLCs and compared MLC densities among groups. We also evaluated MLC distribution relative to underlying superficial capillary plexus vasculature and quantified MLCs overlying blood vessels within the perivascular 30-µm watershed region and within ischemic zones (defined as >30 µm from the nearest vessel). Results MLC density was 2.8- to 3.8-fold higher in PDR compared with all other groups (P < 0.05 for all). MLC density in PDR was most increased in perivascular areas (3.3- to 4.2-fold; P < 0.05 vs. all) and on blood vessels (3.0- to 4.0-fold; P < 0.05 vs. all), and elevated to a lesser extent in ischemic areas (2.3- to 3.4-fold; P < 0.05 vs. all). MLCs were more likely to localize on blood vessels in DM without DR, NPDR, and PDR (P < 0.05 for all), but not healthy eyes. Conclusions MLC density was significantly increased in PDR. MLCs clustered on blood vessels in diabetic but not in healthy eyes. Further studies are needed to confirm the origin, identity, and function of MLCs during DR.

Purpose The role of β-adrenergic receptor (AR) signaling in neovascular ocular diseases has recently emerged. We have previously reported that intraperitoneal propranolol inhibits choroidal neovascularization (CNV) in vivo and β2-AR blockade reduces vascular endothelial growth factor (VEGF) expression in mouse retinal pigment epithelium and choroidal endothelial cells in culture. Here we tested the hypothesis that the β2-AR regulates CNV through modulation of VEGF and inflammatory cytokine expression. Methods Mice were subjected to laser burns, inducing CNV, and were treated with an intravitreal β2-AR antagonist. After 3 and 5 days, total eye interleukin-6 (IL-6) and VEGF protein levels were measured, respectively. After 14 days, CNV was measured on choroidal-scleral flatmounts. The effects of β-AR signaling on VEGF and IL-6 expression were investigated in various mouse retinal and human RPE cells by using specific β-AR agonists and antagonists. Results β2-Adrenergic receptor signaling increased Vegf mRNA expression by approximately 3- to 4-fold in mouse retinal microglia and pericytes in culture. β2-Adrenergic receptor signaling upregulated IL-6 mRNA expression between 10- and 60-fold in mouse retinal microglia, pericytes, RPE, and choroidal endothelial cells in culture. Intravitreal injection of β2-AR antagonist ICI 118,551 reduced CNV by 35% and decreased IL-6 protein levels by approximately 50%. In primary human RPE cells, β2-AR activation also stimulated VEGF and IL-6 mRNA expression by 2- and 10-fold, respectively. Conclusions Anti-VEGF therapy for CNV is highly effective; however, some patients are resistant to therapy while others undergo repeated, frequent treatments. β2-Adrenergic receptor signaling is a potential therapeutic target because of its angiogenic and inflammatory properties.

Optic pit maculopathy (OPM) is an uncommon cause of vision loss with no standard surgical treatment. Surgical treatment involves pars plana vitrectomy (PPV), often combined with adjunctive procedures. Large studies comparing outcomes of these approaches are lacking because of low disease incidence. Therefore, we conducted a meta-analysis of PPV without or with adjunctive procedures.Meta-analysis and systematic literature review.We conducted a literature search to identify clinical studies and case series of surgically managed OPM. Inclusion criteria were: (1) more than 2 patients, (2) treatment with PPV, and (3) reporting of preoperative and postoperative visual acuity data. We excluded review articles and studies not available in English. Results were analyzed using a 1-way analysis of variance, Pearson's chi-square test, and simple linear regression. Publication bias was modeled using funnel plots.Visual acuity changes, resolution rate, resolution time, and change in OCT thickness.We identified 26 studies, encompassing 27 years and 342 patients. We identified 6 commonly reported techniques: PPV alone (92 patients), PPV plus juxtapapillary laser treatment (JPL; 146 patients), PPV plus internal limiting membrane peeling (ILMP; 50 patients), PPV plus both ILMP and JPL (16 patients), PPV plus inner retinal fenestration (18 patients), and PPV plus autologous platelet concentrate (22 patients). All groups demonstrated improved best-corrected visual acuity (BCVA; average, 0.46 logarithm of the minimum angle of resolution [logMAR]; 95% confidence interval [CI], 0.41-0.51 logMAR) compared with baseline, with no differences between groups (P = 0.11). The average OPM resolution rate was 70% among all groups (range, 56%-100%), and the average time to resolution was 8.4 months for all groups (95% CI, 7.2-9.6 months). Central macular thickness was reduced in all groups with no differences between groups (P = 0.15). Tamponade had no effect on outcomes. Linear regression analysis demonstrated significant correlations between preoperative BCVA and above outcome measures. Funnel plots demonstrated positive publication bias in PPV and PPV plus JPL groups.We did not identify any significant differences in outcomes among 6 different surgical techniques. This study is limited by its inclusion of primarily retrospective studies and positive publication bias.

A patient with bilateral diffuse uveal melanocytic proliferation (BDUMP) associated with endometrial cancer was treated with plasmapheresis, but failed therapy with progressive serous retinal detachment. We collected plasma before and after plasmapheresis therapy. Our goal was to determine if the cultured melanocyte elongation and proliferation (CMEP) factor and hepatocyte growth factor (HGF) was present in the IgG enriched fraction and understand why our patient failed plasmapheresis therapy. Melanocytes were cultured for 3-5 days in the presence of control medium, unfractionated pre-plasmapheresis BDUMP medium, IgG enriched or IgG depleted BDUMP medium, or unfractionated post-plasmapheresis BDUMP medium. Subretinal fluid was collected from patients with BDUMP and control retinal detachments and analyzed by electropheresis with immunoblotting. Medium with unfractionated BDUMP plasma stimulated melanocyte growth 1.4-1.5 fold compared to control medium on days 3-5 (p < 0.001 for all). Both IgG enriched and IgG depleted BDUMP medium mildly increased melanocyte growth 1.3 fold (p < 0.05 for enriched, p < 0.01 for depleted) compared to control. In comparison, unfractionated BDUMP medium caused a 1.7-fold increase in melanocyte growth, which was significantly more than the enriched (p < 0.01) and depleted (p < 0.05) fractions. Pre-plasmapheresis and post-plasmapheresis unfractionated BDUMP medium equally stimulated melanocyte growth 1.7-fold (p < 0.05) compared to control. HGF was present in IgG depleted, pre-plasmapheresis, and post-plasmapheresis samples, but absent in the IgG enriched fraction. There was no enrichment of IgG in the subretinal fluid from eyes with BDUMP. In conclusion, CMEP factor is not concentrated in the IgG enriched plasma fraction in our patient who failed plasmapheresis therapy. HGF levels have no correlation with melanocyte growth. Because plasmapheresis preferentially removes immunoglobulins from the plasma, our patient responded poorly to plasmapheresis treatment with worsening retinal detachment.

To determine the features of primary vitreoretinal lymphoma on multimodal ultra-widefield imaging and correlate these findings to clinical outcomes.We report a retrospective, observational case series of 43 eyes of 23 patients with biopsy-proven B-cell primary vitreoretinal lymphoma. Fundus photography, fluorescein angiography (FA), optical coherence tomography, fundus autofluorescence, and indocyanine green angiography images were reviewed. Medical records were assessed for the central nervous system involvement and visual acuity outcomes at 6 and 12 months after presentation.Common fundus photography findings were sub-retinal pigment epithelium lesions and vitritis alone. Common ultra-widefield FA findings were vascular leakage and scleral staining. Retinal optical coherence tomography features overlying sub-retinal pigment epithelium lesions or within the macula predicted fluorescence patterns. The presence of retinal fluid or disorganization associated with hyperfluorescence and late leakage. Normal retinal structures associated with hypofluorescence of sub-retinal pigment epithelium lesions or macular leopard spotting on FA and fundus autofluorescence. Peripheral abnormalities noted on ultra-widefield fundus photography, FA, and indocyanine green angiography were more frequent than posterior pole abnormalities. No imaging characteristics predicted time to the central nervous system progression.Ultra-widefield imaging was more informative than posterior pole imaging in fundus photography, FA, and indocyanine green angiography. Common findings on multimodal ultra-widefield imaging may lead to early diagnostic vitrectomy and may reduce the delay in primary vitreoretinal lymphoma diagnosis.

BACKGROUND AND OBJECTIVE: To determine the effect of propranolol on retinal neovascularization due to proliferative diabetic retinopathy (PDR). PATIENTS AND METHODS: For this prospective pilot, interventional, case series, patients with diabetes with PDR (n = 10 subjects; 12 eyes) were recruited at the ophthalmology clinic of the University of Wisconsin – Madison. Subjects were administered oral propranolol for 12 weeks and retinopathy and area of retinal neovascularization were monitored with fundus photography and fluorescein angiography (FA). The study's main outcome measures were photographic area of retinal neovascularization and degree of leakage on FA. RESULTS: All eyes demonstrated stable degrees of retinal neovascularization by the end of 12 weeks. CONCLUSION: This dose of oral propranolol during a period of 12 weeks did not demonstrate significant effect on retinal neovascularization due to PDR. [ Ophthalmic Surg Lasers Imaging Retina . 2018;49:35–40.]

An absolute or functional deficit in beta-cell mass is a key factor in the pathogenesis of diabetes. We model obesity-driven beta-cell mass expansion by studying the diabetes-resistant C57BL/6-Leptin(ob/ob) mouse. We previously reported that cholecystokinin (Cck) was the most up-regulated gene in obese pancreatic islets. We now show that islet cholecystokinin (CCK) is up-regulated 500-fold by obesity and expressed in both alpha- and beta-cells. We bred a null Cck allele into the C57BL/6-Leptin(ob/ob) background and investigated beta-cell mass and metabolic parameters of Cck-deficient obese mice. Loss of CCK resulted in decreased islet size and reduced beta-cell mass through increased beta-cell death. CCK deficiency and decreased beta-cell mass exacerbated fasting hyperglycemia and reduced hyperinsulinemia. We further investigated whether CCK can directly affect beta-cell death in cell culture and isolated islets. CCK was able to directly reduce cytokine- and endoplasmic reticulum stress-induced cell death. In summary, CCK is up-regulated by islet cells during obesity and functions as a paracrine or autocrine factor to increase beta-cell survival and expand beta-cell mass to compensate for obesity-induced insulin resistance.

Type 1 and type 2 diabetes result from a deficit in insulin production and β-cell mass. Methods to expand β-cell mass are under intensive investigation for the treatment of type 1 and type 2 diabetes. We tested the hypothesis that cholecystokinin (CCK) can promote β-cell proliferation. We treated isolated mouse and human islets with an adenovirus containing the CCK cDNA (AdCMV-CCK). We measured [3H]thymidine and BrdU incorporation into DNA and additionally, performed flow cytometry analysis to determine whether CCK overexpression stimulates β-cell proliferation. We studied islet function by measuring glucose-stimulated insulin secretion and investigated the cell cycle regulation of proliferating β-cells by quantitative RT-PCR and Western blot analysis. Overexpression of CCK stimulated [3H]thymidine incorporation into DNA 5.0-fold and 15.8-fold in mouse and human islets, respectively. AdCMV-CCK treatment also stimulated BrdU incorporation into DNA 10-fold and 21-fold in mouse and human β-cells, respectively. Glucose-stimulated insulin secretion was unaffected by CCK expression. Analysis of cyclin and cdk mRNA and protein abundance revealed that CCK overexpression increased cyclin A, cyclin B, cyclin E, cdk1, and cdk2 with no change in cyclin D1, cyclin D2, cyclin D3, cdk4, or cdk6 in mouse and human islets. Additionally, AdCMV-CCK treatment of CCK receptor knockout and wild-type mice resulted in equal [3H]thymidine incorporation. CCK is a β-cell proliferative factor that is effective in both mouse and human islets. CCK triggers β-cell proliferation without disrupting islet function, up-regulates a distinct set of cell cycle regulators in islets, and signals independently of the CCK receptors.

Geographic atrophy (GA) of the retinal pigment epithelium (RPE) is a devastating complication of age-related macular degeneration (AMD). GA may be classified as drusen-related (drusen-associated GA) or neovascularization-related (neovascular-associated GA). Drusen-related GA remains a large public health concern due to the burden of blindness it produces, but pathophysiology of the condition is obscure and there are no proven treatment options. Genotyping, cell biology, and clinical imaging point to upregulation of parainflammatory pathways, oxidative stress, and choroidal sclerosis as contributors, among other factors. Onset and monitoring of progression is accomplished through clinical imaging instrumentation such as optical coherence tomography, photography, and autofluorescence, which are the tools most helpful in determining end points for clinical trials at present. A number of treatment approaches with diverse targets are in development at this time, some of which are in human clinical trials. Neovascular-associated GA is a consequence of RPE loss after development of neovascular AMD. The neovascular process leads to a plethora of cellular stresses such as ischemia, inflammation, and dramatic changes in cell environment that further taxes RPE cells already dysfunctional from drusen-associated changes. GA may therefore develop secondary to the neovascular process de novo or preexisting drusen-associated GA may continue to worsen with the development of neovascular AMD. Neovascular-associated GA is a prominent cause of continued vision loss in patients with otherwise successfully treated neovascular AMD. Clearly, treatment with vascular endothelial growth factor (VEGF) inhibitors early in the course of the neovascular disease is of great clinical benefit. However, there is a rationale and some suggestive evidence that anti-VEGF agents themselves could be toxic to RPE and enhance neovascular-associated GA. The increasing prevalence of legal blindness from this condition due to the aging of the general population lends urgency to the search for a therapy to ameliorate GA.

Cholecystokinin (CCK) is a peptide hormone produced in the gut and brain with beneficial effects on digestion, satiety, and insulin secretion. CCK is also expressed in pancreatic β-cells, but only in models of obesity and insulin resistance. Whole body deletion of CCK in obese mice leads to reduced β-cell mass expansion and increased apoptosis. We hypothesized that islet-derived CCK is important in protection from β-cell apoptosis. To determine the specific role of β-cell-derived CCK in β-cell mass dynamics, we generated a transgenic mouse that expresses CCK in the β-cell in the lean state (MIP-CCK). Although this transgene contains the human growth hormone minigene, we saw no expression of human growth hormone protein in transgenic islets. We examined the ability of MIP-CCK mice to maintain β-cell mass when subjected to apoptotic stress, with advanced age, and after streptozotocin treatment. Aged MIP-CCK mice have increased β-cell area. MIP-CCK mice are resistant to streptozotocin-induced diabetes and exhibit reduced β-cell apoptosis. Directed CCK overexpression in cultured β-cells also protects from cytokine-induced apoptosis. We have identified an important new paracrine/autocrine effect of CCK in protection of β-cells from apoptotic stress. Understanding the role of β-cell CCK adds to the emerging knowledge of classic gut peptides in intraislet signaling. CCK receptor agonists are being investigated as therapeutics for obesity and diabetes. While these agonists clearly have beneficial effects on body weight and insulin sensitivity in peripheral tissues, they may also directly protect β-cells from apoptosis.

Background Endogenous fungal endophthalmitis is a serious vision-threatening condition that occurs in immunosuppressed patients with candidemia. Findings We report a complicated case of Candida albicans chorioretinitis that progressed to endophthalmitis. The patient required intravitreal and systemic anti-fungal medications with pars plana vitrectomy for successful treatment. Multimodal imaging using fundus photography, fluorescein angiography, spectral domain optical coherence tomography, and fundus autofluorescence was obtained throughout treatment. These modalities localized the Candida infection in the choroid, penetrating Bruch’s membrane, the retinal pigment epithelium, and the retina to enter the vitreous cavity. This infectious route resulted in loss of the retinal pigment epithelium, photoreceptors, and outer retinal layers, with scar formation that resulted in vision loss and increased future risk of choroidal neovascular membranes. Conclusions Multimodal imaging of C. albicans chorioretinitis allows for accurate diagnosis, assessment of response to therapy, and prognosis for visual recovery and future complications.

Decompensated heart failure with preserved left ventricular (LV) ejection fraction (EF) is often accompanied by hypertensive episodes. We hypothesized that acute increase in arterial pressure results in elevated early and late diastolic LV pressures as a result of further impaired LV relaxation.To test this hypothesis, we used a chronic canine model of LV systolic dysfunction with preserved LV function (LVDPEF) (EF50%) and elevated LV end-diastolic pressure using coronary microsphere embolization. At baseline and with LVDPEF, each dog was paced 10 beats above their baseline heart rate and high-fidelity LV pressures, echocardiographic LV volumes, and transmitral Doppler were obtained before and after methoxamine pressure loading.With normal LV function, LV pressures at peak negative dP/dt (+18 mm Hg, P.05) and at LV pressure minimum (+3.6 mm Hg, P.01) increased. Both tau (P.05) and LV end-diastolic pressure increased (5 +/- 3 vs 13 +/- 4 mm Hg, P.01). EF was unchanged, although LV end-diastolic volume increased (P.01). Pressure loading with LVDPEF resulted in a timing delay (P.05) and a greater increase in LV pressures at peak negative dP/dt (+45 mm Hg) and LV minimal pressure (+7.5 mm Hg) as compared with normal LV function (P.01). LV end-diastolic pressure increased (9 +/- 2-23 +/- 5 mm Hg, P.001), diastolic filling period shortened (288 +/- 51-204 +/- 54 milliseconds, P.01), and tau increased (P.001). EF declined from 54 +/- 9% to 43 +/- 9% (P.05) and LV size increased (P.01).Pressure loading with normal LV function and with LVDPEF results in increased LV diastolic pressures, which are further exaggerated with LVDPEF as a result of prolonged relaxation and shortened diastolic filling.

Type 2 diabetes occurs due to a relative deficit in β-cell mass or function. Glucagon-like peptide 1 (GLP-1), glucose-dependent insulinotropic polypeptide (GIP), cholecystokinin (CCK), and gastrin are gastrointestinal hormones that are secreted in response to nutrient intake, regulating digestion, insulin secretion, satiety, and β-cell mass. In this review, we focus upon β-cell mass regulation. β-cell mass expands through β-cell proliferation and islet neogenesis; β-cell mass is lost via apoptosis. GLP-1 and GIP are well-studied gastrointestinal hormones and influence β-cell proliferation, apoptosis, and islet neogenesis. CCK regulates β-cell apoptosis and mitogenesis, and gastrin stimulates islet neogenesis. GLP-1 and GIP bind to G protein-coupled receptors and regulate β-cell mass via multiple signaling pathways. The protein kinase A pathway is central to this process because it directly regulates proliferative and anti-apoptotic genes and transactivates several signaling cascades, including Akt and mitogen-activated protein kinases. However, the signaling pathways downstream of G protein-coupled CCK receptors that influence β-cell mass remain unidentified. Gastrointestinal hormones integrate nutrient signals from the gut to the β-cell, regulating insulin secretion and β-cell mass adaptation.

Type 1 and type 2 diabetes result from a deficit in insulin production and β-cell mass. Methods to expand β-cell mass are under intensive investigation for the treatment of type 1 and type 2 diabetes. We tested the hypothesis that cholecystokinin (CCK) can promote β-cell proliferation. We treated isolated mouse and human islets with an adenovirus containing the CCK cDNA (AdCMV-CCK). We measured [3H]thymidine and BrdU incorporation into DNA and additionally, performed flow cytometry analysis to determine whether CCK overexpression stimulates β-cell proliferation. We studied islet function by measuring glucose-stimulated insulin secretion and investigated the cell cycle regulation of proliferating β-cells by quantitative RT-PCR and Western blot analysis. Overexpression of CCK stimulated [3H]thymidine incorporation into DNA 5.0-fold and 15.8-fold in mouse and human islets, respectively. AdCMV-CCK treatment also stimulated BrdU incorporation into DNA 10-fold and 21-fold in mouse and human β-cells, respectively. Glucose-stimulated insulin secretion was unaffected by CCK expression. Analysis of cyclin and cdk mRNA and protein abundance revealed that CCK overexpression increased cyclin A, cyclin B, cyclin E, cdk1, and cdk2 with no change in cyclin D1, cyclin D2, cyclin D3, cdk4, or cdk6 in mouse and human islets. Additionally, AdCMV-CCK treatment of CCK receptor knockout and wild-type mice resulted in equal [3H]thymidine incorporation. CCK is a β-cell proliferative factor that is effective in both mouse and human islets. CCK triggers β-cell proliferation without disrupting islet function, up-regulates a distinct set of cell cycle regulators in islets, and signals independently of the CCK receptors.

PURPOSE Determine the safe dose of intravitreal propranolol (IVP), and evaluate its inhibitory effect on laser-induced choroidal neovascularization (CNV). METHODS To determine the IVP safe dose, 32 rabbits were divided into 4 groups. Three of these groups received IVP (15 μL) corresponding to 15 μg (group B), 30 μg (group C), and 60 μg (group D). The control group (A) received 15 μL saline. Safety was assessed by ocular examination, electroretinography (ERG), routine histopathologic evaluation, immunohistochemistry for glial fibrillary acidic protein (GFAP), and real-time qPCR for GFAP, VEGF, thrombospondin 1 (TSP1), and pigment epithelium-derived factor (PEDF). A similar experiment was performed in 24 mice by using a 100-fold lower amount of propranolol (0.15, 0.3, and 0.6 μg in 2 μL) based on vitreous volume. For assessment of the angioinhibitory effects of IVP, CNV was induced in 42 mice via laser burns. Mice were divided into two groups: group 1 received the safe dose of IVP (0.3 μg in 2 μL) and group 2 received saline. Neovascularization area was quantified by intercellular adhesion molecule (ICAM)-2 immunostaining of choroidal-scleral flat mounts by using ImageJ software. RESULTS According to clinical, ERG, and histopathologic findings, 30 μg IVP was chosen as the safe dose in rabbit eyes, comparable to 0.3 μg IVP in mouse eyes. As compared to the control eyes, the development of CNV was attenuated (4.8-fold) in mice receiving 0.3 μg IVP. CONCLUSIONS Intravitreal propranolol injection up to the final dose of 30 μg in rabbits and 0.3 μg in mice was safe, and was effective in attenuation of CNV in mice.

2,3,7,8-Tetrachlorodibenzo-p-dioxin (TCDD) is a potent developmental toxicant in most vertebrates. However, frogs are relatively insensitive to TCDD toxicity, especially during early life stages. Toxicity of TCDD and related halogenated aromatic hydrocarbons is mediated by the aryl hydrocarbon receptor (AhR), and specific differences in properties of the AhR signaling pathway can underlie in TCDD toxicity in different species. This study investigated the role of AhR in frog TCDD insensitivity, using Xenopus laevis as a model system. X. laevis, a pseudotetraploid species, expresses two distinct AhR1 genes, AhR1alpha and AhR1beta. Sharing 86% amino acid identity, these likely represent distinct genes, both orthologous to mammalian AhR and paralogous to the AhR2 gene(s) in most fish. Both AhR1alpha and AhR1beta exhibit TCDD-dependent binding of cognate DNA sequences, but they bind TCDD with at least 20-fold lower affinity than the mouse AhR(b-1) protein, and they are similarly less responsive in TCDD-induced reporter gene induction in conjunction with the mouse CYP1A1 promoter. Furthermore, CYP1A6 and CYP1A7 induction by TCDD in cultured X. laevis A6 cells appears much less responsive than CYP1A induction in cell lines derived from more sensitive animals. Taken together, these data suggest that low affinity binding by X. laevis AhRs plays an important mechanistic role in the insensitivity of frogs to TCDD. An understanding of these molecular mechanisms should aid amphibian ecotoxicology and refine the use of frog embryos as a model [e.g. in FETAX (Frog Embryo Teratogenesis Assay-Xenopus)] for determining developmental toxicity of samples containing dioxin-like compounds.

Objectives To determine whether β-adrenergic blockade inhibits choroidal neovascularization (CNV) in a mouse model of laser-induced CNV and to investigate the mechanism by which β-adrenoreceptor antagonism blunts CNV. Design Mice were subjected to laser burns, inducing CNV, and were treated with daily intraperitoneal injections of propranolol hydrochloride. Neovascularization was measured on choroidal-scleral flat mounts using intercellular adhesion molecule 2 immunofluorescence staining. The effect of β-adrenoreceptor signaling on expression of vascular endothelial growth factor (VEGF) was investigated using primary mouse choroidal endothelial cells (ChECs) and retinal pigment epithelial (RPE) cells. These cells were incubated with β-adrenoreceptor agonists and/or antagonists and assayed for Vegf messenger RNA and protein levels. Setting University of Wisconsin School of Medicine and Public Health. Participants Wild-type 6-week-old female C57BL/6j mice. Main Outcome Measures Inhibition of CNV after propranolol treatment and Vegf messenger RNA and protein expression after treatment with β-adrenoreceptor agonists and antagonists. Results Propranolol-treated mice demonstrated a 50% reduction in laser-induced CNV. Treatment with norepinephrine bitartrate stimulated Vegf messenger RNA expression and protein secretion in ChECs and RPE cells. This effect was blocked by β 2 -adrenoreceptor antagonism and mimicked by β 2 -adrenoreceptor agonists. Conclusions Attenuation of CNV is achieved by β-adrenergic blockade. The β 2 -adrenoreceptors regulate VEGF expression in ChECs and RPE cells. Clinical Relevance Antagonists of β-adrenoreceptors are safe and well tolerated in patients with glaucoma and cardiovascular disease. Thus, blockade of β-adrenoreceptors may provide a new avenue to inhibit VEGF expression in CNV.

beta-Cell mass expansion is one mechanism by which obese animals compensate for insulin resistance and prevent diabetes. FoxM1 is a transcription factor that can regulate the expression of multiple cell cycle genes and is necessary for the maintenance of adult beta-cell mass, beta-cell proliferation, and glucose homeostasis. We hypothesized that FoxM1 is up-regulated by nondiabetic obesity and initiates a transcriptional program leading to beta-cell proliferation. We performed gene expression analysis on islets from the nondiabetic C57BL/6 Leptin(ob/ob) mouse, the diabetic BTBR Leptin(ob/ob) mouse, and an F2 Leptin(ob/ob) population derived from these strains. We identified obesity-driven coordinated up-regulation of islet Foxm1 and its target genes in the nondiabetic strain, correlating with beta-cell mass expansion and proliferation. This up-regulation was absent in the diabetic strain. In the F2 Leptin(ob/ob) population, increased expression of Foxm1 and its target genes segregated with higher insulin and lower glucose levels. We next studied the effects of FOXM1b overexpression on isolated mouse and human islets. We found that FoxM1 stimulated mouse and human beta-cell proliferation by activating many cell cycle phases. We asked whether FOXM1 expression is also responsive to obesity in human islets by collecting RNA from human islet donors (body mass index range: 24-51). We found that the expression of FOXM1 and its target genes is positively correlated with body mass index. Our data suggest that beta-cell proliferation occurs in adult obese humans in an attempt to expand beta-cell mass to compensate for insulin resistance, and that the FoxM1 transcriptional program plays a key role in this process.