Proliferative vitreoretinopathy: pathobiology, surgical management, and adjunctive treatment

Identification of ganglion cell neurites in human subretinal and epiretinal membranes

AIM

To determine whether neural elements are present in subretinal and epiretinal proliferative vitreoretinopathy (PVR) membranes as well as in diabetic, fibrovascular membranes removed from patients during vitrectomy surgery.

METHODS

Human subretinal and epiretinal membranes of varying durations were immunolabelled with different combinations of antibodies to glial fibrillary acidic protein, vimentin, neurofilament protein and laminin.

RESULTS

Anti-neurofilament-labelled neurites from presumptive ganglion cells were frequently found in epiretinal membranes and occasionally found in subretinal membranes. In addition, the neurites were only observed in regions that also contained glial processes.

CONCLUSIONS

These data demonstrate that neuronal processes are commonly found in human peri-retinal cellular membranes similar to that demonstrated in animal models. These data also suggest that glial cells growing out of the neural retina form a permissive substrate for neurite growth and thus may hold clues to factors that support this growth.

Expression of HB-EGF by retinal pigment epithelial cells in vitreoretinal proliferative disease

The heparin-binding epidermal growth factor-like growth factor (HB-EGF) has been implicated in wound-healing processes of various tissues. However, it is not known whether HB-EGF may represent a factor implicated in overstimulated wound-healing processes of the retina during proliferative retinopathies. Therefore, we investigated whether human retinal pigment epithelial (RPE) cells, which are crucially involved in proliferative retinopathies, express and respond to HB-EGF. RPE cells express mRNAs for various members of the EGF-related growth factor family, among them for HB-EGF, as well as for the EGF receptors ErbB1, -2, -3, and -4. The gene expression of HB-EGF is stimulated in the presence of transforming and basic fibroblast growth factors and by oxidative stress and is suppressed during chemical hypoxia. Exogenous HB-EGF stimulates proliferation and migration of RPE cells and the gene and protein expression of the vascular endothelial growth factor (VEGF). HB-EGF activates at least three signal transduction pathways in RPE cells including the extracellular signal-regulated kinases (involved in the proliferation-stimulating action of HB-EGF), p38 (mediates the effects on chemotaxis and secretion of VEGF), and the phosphatidylinositol-3 kinase (necessary for the stimulation of chemotaxis). In epiretinal membranes of patients with proliferative retinopathies, HB-EGF immunoreactivity was partially colocalized with the RPE cell marker, cytokeratins; this observation suggests that RPE cell-derived HB-EGF may represent one factor that drives the uncontrolled wound-healing process of the retina. The stimulating effect on the secretion of VEGF may suggest that HB-EGF is also implicated in the pathological angiogenesis of the retina.

Visual Recovery after Scleral Buckling Procedure for Retinal Detachment

PURPOSE

To evaluate prognostic factors for visual and anatomic outcomes, including complications after scleral buckling procedure (SBP) for primary rhegmatogenous retinal detachments.

DESIGN

Retrospective, consecutive, nonrandomized, comparative interventional case series.

PARTICIPANTS

Patients undergoing SBP for primary rhegmatogenous retinal detachment performed by a single surgeon.

METHODS

The patients' medical records were reviewed. Preoperative and intraoperative factors analyzed for their association with visual acuity and anatomic outcomes included macular detachment, duration of macular detachment, preoperative visual acuity, lens status, refractive error, extent of detachment, number of breaks, internal gas tamponade, and drainage of the subretinal fluid. Secondary outcomes included frequency of further surgery, complications, and fellow eye retinal detachment. The fellow eye of the patients was excluded from consideration of prognostic factors.

MAIN OUTCOME MEASURES

Best-corrected visual acuity at 2 months and at final follow-up examination as well as anatomic factors including retinal reattachment at 1 day, 2 months, and last follow-up examination.

RESULTS

There were 672 patients studied, including 457 (68%) with macular detachment. The use of gas, drainage of subretinal fluid, and lens status did not influence final anatomic or visual results. Macular detachment was the most important prognostic factor for anatomic (P = 0.031) and visual acuity success (P<0.001). Better preoperative visual acuity (P<0.001), fewer quadrants involved by the detachment (P<0.001), and lack of high myopia (P = 0.001) were important positive prognostic factors for visual acuity. The duration of macular detachment was not of prognostic value up to 30 days' duration.

CONCLUSIONS

Visual recovery after retinal reattachment was most dependent on macular involvement. Duration of macular detachment had surprisingly little influence on postoperative visual acuity.

Scleral Buckling Procedures for Longstanding or Chronic Rhegmatogenous Retinal Detachment with Subretinal Proliferation

OBJECTIVE

To investigate longstanding or chronic retinal detachments (RDs) with subretinal strands and their clinical features and therapeutic effects using conventional retinal surgery.

DESIGN

Retrospective, consecutive, noncomparative case series.

PARTICIPANTS

Cases of 36 patients (40 eyes) with longstanding RD and subretinal proliferation who had undergone scleral buckling or encircling procedures between January 1, 1995 and October 31, 2003 at one institution were reviewed.

METHODS

A retrospective analysis of the patient data was conducted from the medical records.

MAIN OUTCOME MEASURES

Visual acuity (VA) and postoperative anatomic retinal reattachment at the final follow-up visit between 3 and 24 months (mean, 6.9).

RESULTS

Forty eyes with an RD (mean duration, 13.8 months) treated with scleral encircling and buckling had a 90% cure rate after one surgery. The VA levels increased in 77.5% of eyes to over 5/100 at the final follow-up visit. Longstanding or chronic RD with subretinal proliferation had subretinal proliferative strands (i.e., a shallow RD) and a smooth atrophic detached retina, not a thickened retina.

CONCLUSIONS

Our results suggest that scleral encircling and buckling can be used in most patients with a longstanding RD. The chronic pathologic course of longstanding rhegmatogenous RD should be considered before treatment.

Intraretinal and periretinal pathology in anterior proliferative vitreoretinopathy

OBJECTIVES

To determine the intraretinal and periretinal pathological changes in early anterior proliferative vitreoretinopathy (APVR).

DESIGN

Observational case series.

PARTICIPANTS

Eighteen patients undergoing retinectomy for APVR.

METHODS

Retinectomy specimens removed at vitrectomy surgery were analysed by (a) semithin light microscopy, (b) immunohistochemistry and (c) electron microscopy.

RESULTS

The specimens showed consistent outer retinal degenerative changes, marked Muller cell hypertrophy and glial continuity to epiretinal membranes. Photoreceptor outer and inner segments were markedly disrupted and occasional photoreceptor nuclear had pyknosis and chromatin clumping consistent with apoptosis. Muller cells expressed upregulated levels of glial fibrillary acid protein (GFAP) and extended through glial bridges to complex epiretinal membranes which in some areas had a bilaminar structure with a glial-negative inner lamina.

CONCLUSION

Retinal degeneration and photoreceptor apoptosis occur in retinal detachment complicated by proliferative vitreoretinopathy (PVR), although during the early stages of the process neural retinal cells remain present, suggesting potential for recovery. The intraretinal glial response appears to be centrally involved in the formation of contractile epiretinal membranes. The retina retains the capacity for a degree of functional recovery following surgery for PVR. Surgical separation of anterior epiretinal membranes in PVR may be difficult and incomplete and alternative surgical strategies may be necessary to prevent recurrence.

Efficient approach to acyloxymethyl esters of nalidixic acid and in vitro evaluation as intra-ocular prodrugs

Various alkylcarbonyloxymethyl esters of nalidixic acid ranging from 3 to 15 carbon units in the pro-moiety have been prepared and assessed as potential prodrugs. Their chromatographic retention factors k', silicone oil solubilities and in vitro conversion to nalidixic acid by a commercial esterase were determined together with their in vitro antimicrobial activity and cytotoxicity. The preliminary results suggest that silicone oil may have potential for the intra-ocular delivery of antibacterial compounds. Moreover, the in vitro release rate can be controlled by the lipophilicity of the prodrug.

Phosphorylation of extracellular signal-regulated kinase and p27(KIP1) after retinal detachment

PURPOSE

The roles of the extracellular signal-regulated kinase (ERK) pathway in the expression of cyclin D1 and p27(KIP1), the phosphorylation of p27(KIP1), and proliferation activity were examined after retinal detachment.

METHODS

Normal eyes and eyes at 15 min, 2 and 4 days after retinal detachment in C57Bl6 mice were examined by immunohistochemistry using anti-phosphorylated (p) ERK1/2, anti-cyclin D1, anti-p27(KIP1), anti-p27(KIP1) phosphorylated at serine 10 (S10-phospho-p27), and anti-proliferating cell nuclear antigen (PCNA) antibodies with or without treatment with a specific ERK inhibitor, PD98059. Mouse Müller cells were isolated and examined for alteration of p27(KIP1) and cyclin D1 after exposure of basic fibroblast growth factor (bFGF) with and without treatment of PD98059 using Western blotting.

RESULTS

In the normal retina, nuclear immunoreactivity for p27(KIP1), but not S10-phospho-p27 or pERK1/2, was observed in the middle sublayer of the inner nuclear layer (INL), where Müller glial cells are situated. At 15 min after the retinal detachment, p27(KIP1), S10-phospho-p27 and pERK1/2-positive nuclei were noted in the INL, whereas immunoreactivity for pERK1/2 or S10-phospho-p27 was not observed after treatment with PD98095. Cyclin D1 was induced in the INL 2 days after the retinal detachment, and the induction was inhibited by PD98059. At 4 days after the detachment, p27(KIP1) immunoreactivity was not observed, and cyclin D1 and PCNA were expressed. The disappearance of p27(KIP1) was suppressed, whereas expression of cyclin D1 and PCNA was not observed in mice treated with PD98059. Exposure of bFGF relatively decreased the expression level of p27(KIP1) and increased the level of cyclin D1 in mouse Müller cells, compared with control level. Induction of cyclin D1 and decrease in p27(KIP1) were inhibited with treatment of PD98059.

CONCLUSION

Phosphorylation of ERK and expression of p27(KIP1) and cyclin D1 are involved in the proliferation of Müller cells after retinal detachment.

A selective cyclic integrin antagonist blocks the integrin receptors alphavbeta3 and alphavbeta5 and inhibits retinal pigment epithelium cell attachment, migration and invasion

Background

Proliferative vitreoretinopathy (PVR) is a leading cause of blindness after failed retinal reattachment surgery. PVR is characterized by the proliferation, migration and contraction of retinal pigmented epithelial cells (RPE), and these cellular responses are influenced by the expression and function of integrin receptors. The effect of a cyclic integrin antagonist containing the amino acid sequence Arg-Gly-Asp-D-Phe-Val (RGDfV), specific for the integrin receptors α_vβ₃ and α_vβ₅, was investigated on basic fibroblast growth factor (bFGF), platelet derived growth factor-BB (PDGF-BB), and serum induced human RPE proliferation, migration, invasion and attachment to the extracellular matrix. Furthermore, the effects of bFGF and PDGF-BB regulated expression of integrins α_vβ₃ and α_vβ₅ on RPE cells was examined.

Methods

The effect of a cyclic integrin antagonist and a control peptide (0.01 μg/ml to 300 μg/ml) was investigated on serum or cytokine (bFGF or PDGF-BB pretreatment) induced human fetal RPE cell proliferation by H³-thymidine uptake. The effect of the cyclic integrin antagonist on RPE cell attachment onto different extracellular matrices (laminin, collagen IV, fibronectin), RPE cell invasion stimulated by PDGF-BB or serum, and migration stimulated by PDGF-BB, vascular endothelial growth factor (VEGF) or serum was explored. PDGF-BB and bFGF modulation of the integrin receptors α_vβ₃ and α_vβ₅ was evaluated by flow cytometry.

Results

The integrin antagonist did not inhibit DNA synthesis stimulated by serum, bFGF, or PDGF-BB treatment. RPE attachment onto fibronectin was inhibited in a concentration range of 1–10 μg/ml (p < 0.05). Attachment of the RPE cells onto collagen IV and laminin was inhibited in a range of 3–10 μg/ml (p < 0.05). Serum and PDGF-BB stimulated migration was inhibited by the cyclic integrin antagonist in a concentration range of 1–10 μg/ml (p < 0.05). Furthermore, the cyclic integrin antagonist inhibited PDGF-BB stimulated RPE cell invasion through fibronectin (3μg/ml: 66% inhibition, p < 0.001). In each of these experiments, the control peptides had no significant effects. PDGF-BB and bFGF pretreatment of RPE cells increased the expression of integrin receptors α_vβ₃ (bFGF: 1.9 fold, PDGF-BB: 2.3 fold) and α_vβ₅ (bFGF: 2.9 fold, PDGF-BB: 1.5 fold).

Conclusion

A selective inhibition of the integrin receptors α_vβ₃ and α_vβ₅ through a cyclic integrin antagonist is able to inhibit RPE cell attachment, migration and invasion. Since these steps are of importance for the progression of PVR, a cyclic integrin antagonist should be further evaluated for the treatment of this disease.

Vascular endothelial growth factor levels in vitreous and serum of patients with either proliferative diabetic retinopathy or proliferative vitreoretinopathy

PURPOSES

To confirm the role of vascular endothelial growth factor (VEGF) in the pathogenesis of proliferative diabetic retinopathy (PDR) and proliferative vitreoretinopathy (PVR) and to investigate the relationship between the level of VEGF in serum and its vitreal level in patients with either disease.

METHODS

Venous blood and vitreous of 18 patients with PDR, 15 patients with PVR and 20 patients forming a control group were collected during vitrectomy. The VEGF level was quantified by using ELISA methods in either serum or vitreous.

RESULTS

The VEGF level in serum and vitreous was similarly high in the case of PDR, but its level was only high in serum in the case of PVR.

DISCUSSION

PDR is closely linked with systemic diabetes mellitus whereas PVR is more localized. More selective systemic anti-VEGF medications with reduced side effects are required to treat PDR successfully.

The activation of IL-8 receptors in cultured guinea pig Müller glial cells is modified by signals from retinal pigment epithelium

Interleukin 8 (IL-8, CXCL8) is a pro-inflammatory chemokine which attracts neutrophils to sites of inflammation via an activation of the G-protein-coupled receptors, CXCR1 and CXCR2. However, both IL-8 and IL-8 receptors are widely expressed in various tissues and cell types, and have been suggested to be involved in other functions such as angiogenesis, tumor growth, or brain pathology. We examined the expression of IL-8 and IL-8 receptors in highly enriched primary cultures of guinea pig Muller glial cells. Immunoreactivity for CXCL8, CXCR1 and CXCR2 was observed in all cultured Muller cells. The expression of CXCL8 was confirmed by PCR, and the secretion of the CXCL8 protein from Muller cells was revealed by ELISA. Western blots showed prominent bands at approximately 40 kDa by using antibodies specific for human CXCR1 and CXCR2, and the expression of a putative CXCR2 receptor in Muller cells was confirmed by PCR. Furthermore, cultured Muller cells responded to application of recombinant human IL-8 with an increase of the cytosolic Ca(2+) concentration. If supernatants of cultured human retinal pigment epithelium (RPE) cells were applied to the Muller cell cultures, no obvious changes were observed in the CXCL8, CXCR1 and CXCR2 expression but (i) Muller cell proliferation was stimulated, and (ii) there was an increased number of CXCL8-responsive Muller cells and the amplitudes of the evoked calcium responses were enhanced. It is concluded that Muller glial cells may participate in the inflammatory response(s) of the retina during ocular diseases, and that this contribution may be modified by interactions with RPE cells.

Effect of alpha2-macroglobulin on retinal glial cell proliferation

BACKGROUND

Activation of the receptor for alpha2-macroglobulin (alpha2 M), the low-density lipoprotein-related protein (LRP1; CD91), has been suggested to represent a possible strategy for the inhibition of uncontrolled retinal cell proliferation via stimulation of the clearance of alpha2 M-bound growth factors and proteinases from the extracellular space. In order to prove this assumption, we investigated the effect of alpha2 M on the proliferation of Müller glial cells in vitro.

METHODS

Proliferation assays using bromodeoxyuridine were carried out on cultured Müller glial cells of the guinea pig in the absence and presence of alpha2 M.

RESULTS

Activated alpha2 M evoked a slight increase of the cell proliferation at control conditions. Addition of alpha2 M to the culture medium inhibited the proliferation evoked by agonists of G-protein-coupled receptors [adenosine 5'-triphosphate (ATP), neuropeptide Y]. However, alpha2 M did not diminish the proliferation evoked by agonists of receptor tyrosine kinases (epidermal and platelet-derived growth factors) and by serum, respectively. Inhibition of LRP1 by a neutralizing antibody did not alter the ATP-evoked proliferation while it increased the proliferation in the presence of alpha2 M.

CONCLUSION

It is concluded that alpha2 M inhibits the proliferation evoked by agonists of G-protein-coupled receptors, possibly via enhanced growth factor clearance by LRP.

Resources involved in managing retinal detachment complicated by proliferative vitreoretinopathy

PURPOSE

To report the differences in cost of treatment and outcome in retinal detachment (RD) cases with and without proliferative vitreoretinopathy (PVR).

METHODS

Analysis of clinical trial databases of RD observed in 190 eyes of 190 patients. Eyes were classified as no PVR, developing PVR, or established PVR. For each eye, total cost of treatment undertaken on Moorfields Eye Hospital vitreoretinal unit, final retinal status, and best-corrected visual acuity were recorded.

RESULTS

Management of patients who developed PVR involved approximately double the resources of RD without PVR. Eyes with pre-exiting PVR had similar resource input to those with RD without PVR. Patients who developed PVR had a mean of 3.7 operations (including subsequent cataract surgery) compared to 1.8 and 2.1 respectively for noncomplicated RD and pre-existing PVR. Anatomic success and visual outcome was significantly worse in eyes with PVR.

CONCLUSIONS

Treatment of eyes that developed PVR after initial surgery cost significantly more than eyes with no PVR or established PVR (P < 0.01). Improvements in the management of RD aimed at preventing PVR and advances in PVR treatment may have significant financial as well as clinical benefits.

A randomized controlled trial of combined 5-fluorouracil and low-molecular-weight heparin in management of established proliferative vitreoretinopathy

OBJECTIVE

To determine the efficacy of a combination of 5-fluorouracil and low-molecular-weight heparin (LMWH) to improve the outcome of surgery for established proliferative vitreoretinopathy (PVR).

DESIGN

Double-masked, prospective, randomized, placebo-controlled clinical trial.

SETTING

Three tertiary-referral teaching hospital vitreoretinal surgical units.

PATIENTS

One hundred fifty-seven patients with established PVR (grade C, anterior or posterior) undergoing vitrectomy surgery.

INTERVENTION

All patients underwent vitreoretinal surgery and silicone oil exchange with or without membrane peeling and/or retinectomy. Patients were randomly allocated to perioperative infusion with or without 5-fluorouracil (200 microg/ml) and LMWH (5 IU/ml) in Hartmann's solution for 1 hour.

OUTCOME MEASURES

The primary outcome measure was defined as posterior retinal reattachment after removal of silicone oil without any reoperations at 6 months. Secondary outcome measures recorded were posterior retinal reattachment, localized/tractional retinal detachment, visual acuity, macular pucker, hypotony, glaucoma, keratopathy, and cataract. Removal of silicone oil and reoperations were also recorded.

RESULTS

Overall, at 6 months 84% of patients had full retinal reattachment and 94% had stable posterior retinal reattachment. There was no significant difference in success in the primary outcome measure (56%, treatment group; 51%, placebo group; P = 0.59) or in secondary outcome measures or rates of complications. Secondary macular pucker occurred less often in the treatment group (6% vs. 17% at 6 months, P = 0.068).

CONCLUSIONS

A perioperative infusion of combined 5-fluorouracil and LMWH does not significantly increase the success rate of vitreoretinal surgery for established PVR.

Neuropeptide Y-evoked proliferation of retinal glial (Muller) cells

BACKGROUND

Glial cells in human retinas and in fibrocellular membranes from patients with proliferative vitreoretinopathy (PVR) have been described to upregulate their expression of Y1 receptors for neuropeptide Y (NPY) (Soler et al.: Glia 39:320, 2002). However, it is unknown whether Y1 receptor activation causes proliferation of retinal glial cells. We investigated whether NPY exerts a proliferation-stimulating effect on retinal glial cells, and compared the NPY-evoked signaling with the signaling of purinergic P2Y receptors.

METHODS

Proliferation assays using bromodeoxyuridine were carried out on primarily cultured Muller glial cells of the guinea pig, in the absence and presence of blockers of Y1 receptors, of receptor tyrosine kinases (RTKs), of mitogen-activated protein kinases (MAPKs) and of phosphatidylinositol-3 kinase (PI3K).

RESULTS

NPY exerted a biphasic effect on Muller cell proliferation. At low concentrations (0.1 ng/ml and 1 ng/ml) it decreased the proliferation rate of the cells, while at higher concentration (100 ng/ml) it increased Muller cell proliferation. The NPY-evoked proliferation was mediated by Y1 receptor stimulation and by activation of the p44/p42 MAPKs and partially of the p38 MAPK. Moreover, Y1 receptor-induced activation of PI3K as well as transactivations of the platelet-derived and the epidermal growth factor RTKs were necessary for full mitogenic effect of NPY. Y1 and P2Y receptors share partially common signal transduction pathways in Muller cells.

CONCLUSION

It is suggested that NPY may be involved in stimulation of retinal glial cell proliferation during PVR when it is released at higher amounts into the injured retina.

Glial cell expression of hepatocyte growth factor in vitreoretinal proliferative disease

The hepatocyte growth factor (HGF) has been crucially implicated in the development of proliferative retinal diseases; however, it is unclear whether retinal glial cells express or respond to HGF. Therefore, we examined the expression of HGF and of the receptor for HGF, c-Met, by immunohistochemical costaining with glial fibrillary acidic protein (GFAP) in epiretinal membranes of patients with proliferative vitreoretinopathy (PVR) and proliferative diabetic retinopathy (PDR), respectively. Furthermore, it was determined whether cells of the human retinal glial cell line, MIO-M1, secrete HGF protein, and whether HGF stimulates proliferation and chemotaxis, and secretion of the vascular endothelial growth factor (VEGF). Neuroretinas of patients with PVR express elevated mRNA level for HGF in comparison to control retinas. In epiretinal membranes of patients with PVR or PDR, immunoreactivity for HGF and for c-Met, respectively, partially colocalized with immunoreactivity for GFAP. Fetal bovine serum and basic fibroblast growth factor, but not heparin-binding epidermal or platelet-derived growth factors, evoked HGF secretion by cultured retinal glial cells. HGF displayed only a marginal effect on cell proliferation while it stimulated chemotaxis. HGF promoted the secretion of VEGF, via activation of the phosphatidylinositol-3 kinase. It is concluded that glial cells in epiretinal membranes express both HGF protein and c-Met receptors. The results suggest an autocrine/paracrine role of HGF in glial cell responses during proliferative vitreoretinal disorders as well as in retinal neovascularization, by stimulating of VEGF release.

Edible mushroom (Agaricus bisporus) lectin inhibits human retinal pigment epithelial cell proliferation in vitro

The retinal pigment epithelium (RPE) plays a major role in the development of the anomalous retinal scarring response termed proliferative vitreoretinopathy. The present study was undertaken to investigate whether agaricus bisporus lectin inhibited human RPE proliferation in vitro. Fluorescein isothiocyanate-labeled agaricus bisporus lectin was used to study binding of lectin to cultured human RPE. The effect of a 24-hour exposure of agaricus bisporus lectin on RPE proliferation was measured using (methyl-3H)-thymidine incorporation into DNA. Toxicity studies were assessed using morphologic evaluation, trypan blue exclusion, and a cell viability assay. Agaricus bisporus lectin bound to RPE cells and was inhibited by preincubation of lectin with asialomucin. Agaricus bisporus lectin caused a dose-dependent inhibition of RPE proliferation (one-way ANOVA, F = 94.470, p < 0.001) that was partially reversible on removal of the lectin. Compared with controls, cells remained viable and no morphological changes or trypan blue staining was noted in RPE exposed to agaricus bisporus lectin. Human RPE binds agaricus bisporus lectin and inhibits proliferation without apparent cytotoxicity. It therefore merits consideration as a potential antiproliferative agent in the prevention and treatment of proliferative vitreoretinopathy and other nonocular anomalous wound healing processes.

CXCR4 expression in vitreoretinal membranes

BACKGROUND/AIM

Proliferative vitreoretinopathy (PVR) and macular pucker (MP) vitreoretinal membranes are caused by abnormal cell migration. By their role in chemotactism, chemokine receptors represent good candidates to sustain this process. The authors thus investigated the expression of one of them, CXCR4, in these pathologies.

METHODS

Three PVR and four MP membranes were surgically removed and processed for immunochemical studies with antibodies for CXCR4, cytokeratins or smooth muscle actin.

RESULTS

CXCR4 expression was found in all membranes. There was no relation between severity of PVR or MP and presence of CXCR4. In addition, there was no difference in CXCR4 expression between MP and PVR.

CONCLUSION

CXCR4 is expressed in PVR and MP. Further experiments are needed to test if CXCR4 and other chemokine receptors are implicated in vitreoretinal membrane formation.

The cell cycle distribution of cultured human retinal pigmented epithelial cells under exposure of anti-proliferative drugs

It has been well documented that RPE cells play an important role in the formation of proliferative vitreoretinopathy (PVR). We studied the effects of four most widely used anti-proliferative drugs, i.e., 5-fluorouracil (5-FU), daunomycin (DM), mitomycin C (MMC) and dexamethasone (DEX) in an in vitro model system (cultured human RPE). The cells treated with indicated concentrations of drugs for 48 h were harvested for DNA content analysis. In addition, a time course study with constant dosage of drugs was performed. The results revealed that, after incubation for 48 h, an increased percentage (31.1%) of S phase cells was noted with exposure to MMC (10 ng/ml). It was confirmed by 5-bromodeoxyuridine (BrdU) incorporation test that this increase does not result from higher transition rate from G1 to S phase. The cells of G2/M phase markedly increased from 13.8% to 29.7% with 10 ng/ml DM. We also demonstrated that 5-FU and MMC treatment led to cell accumulation at S phase and DM treatment resulted in cell accumulation at G2/M phase, These findings were compatible with their pharmacological mechanisms. Development of an in vitro model using cultured human RPE to study the effects of various anti-proliferative drugs on cell cycle can provide a rapid, safe and inexpensive method for selection of drugs used for management of PVR.

Edible mushroom (Agaricus bisporus) lectin modulates human retinal pigment epithelial cell behaviour in vitro

The retinal pigment epithelium (RPE) plays a major role in the development of proliferative vitreoretinopathy (PVR). In particular, RPE cells are implicated in generating the contraction forces seen. The present study was undertaken to investigate whether human RPE binds a lectin from the common edible mushroom, Agaricus bisporus, and to evaluate the effect of any binding on RPE-mediated matrix contraction in an in vitro model of PVR. Fluorescein isothiocyanate (FITC)-labelled Agaricus bisporus lectin (ABL) was used to study binding of lectin to normal retina, PVR scar tissue specimens and cultured human RPE. The effect of a 3-day exposure of ABL on human RPE-mediated contraction was evaluated using 2- and 3D RPE-populated collagen matrices. Effect of ABL on cell adhesion was measured using a collagen type I adhesion assay and determining the relative cellular attachment using absorbance readings. The normal RPE monolayer did not stain with FITC-ABL while PVR scar tissue stained intensely. Staining of in vitro RPE was characteristic but time-dependent. ABL caused a dose-dependent inhibition of RPE-mediated contraction of both 2D (one-way ANOVA, F = 7.94, p < 0.008) and 3D collagen matrices (one-way ANOVA, F = 164.955, p < 0.001). Pre-incubation of ABL with RPE in the 2D model caused a dramatic arrest of contraction (one-way ANOVA, F = 20.1, p < 0.001) that was due to a dose-dependent inhibition of adhesion (one-way ANOVA, F = 15.603, p < 0.001). Recovery of contraction was partially reversible on removal of ABL and was dependent on initial concentration of the lectin. ABL inhibits contraction and adhesion of human RPE cells in vitro without apparent cytotoxicity. It therefore deserves consideration as a potential therapeutic agent in the prevention and treatment of PVR and other non-ocular anomalous wound-healing processes.

A mouse model of proliferative vitreoretinopathy induced by dispase

A proliferative vitreoretinopathy-like condition induced by intravitreal dispase injection in C57BL/6J mice was studied using ophthalmoscopic and histochemical procedures. The frequency of intravitreal hemorrhage, intravitreal spots, retinal folds and epiretinal membranes was scored by ophthalmoscopic examination at 1, 2, 4, 6 and 8 weeks after the injection. Intravitreal spots corresponded to free cells exhibiting F4/80 immunoreactivity, a macrophage/microglial marker. Retinal folds always appeared before an epiretinal membrane could be observed. Dispase-injected eyes always showed a much higher frequency of folds and membranes than saline-injected eyes. Folds and membranes appeared earlier and were more extensive in the presence of intravitreal hemorrhage than in its absence. Müller retinal cells exhibited significant changes in glial fibrillary acidic protein-immunoreactivity. This was absent in normal Müller cells but, in dispase-injected animals, it was expressed in radial processes at the site of retinal folds, later extending to the whole retina. Both epi- and subretinal membranes contained cells probably derived from Müller cells, since they exhibited co-localization of glial fibrillary acidic protein- and glutamine synthase immunoreactivities. F4/80 was also present in numerous cells within the retina, epi- and subretinal membranes. By contrast, the retinal pigment epithelium cell marker RPE65 was restricted to subretinal membranes. It can be concluded that dispase induced a proliferative vitreoretinopathy-like condition in mice, with a strong contribution of macrophage- and glial-derived cells.

Basic fibroblast growth factor, glutamine synthetase, and interleukin-6 in vitreous fluid from eyes with retinal detachment complicated by proliferative vitreoretinopathy

PURPOSE

To investigate the presence of basic fibroblast growth factor (bFGF), glutamine synthetase (GS), and interleukin-6 (IL-6) in vitreous fluid from eyes with retinal detachment complicated by proliferative vitreoretinopathy (PVR).

DESIGN

Comparative case series; experimental study.

METHODS

In a prospective study, we measured bFGF, GS, IL-6, and total protein in vitreous fluid samples from 53 eyes from 53 consecutive patients with PVR operated on in our hospital. As controls, vitreous fluid samples from eyes with a macular hole (n = 9) or pucker (n = 11) were used.

MAIN OUTCOME MEASURES

Laboratory data of the patient group were compared with the control group and correlated with various clinical data, especially with visual recovery and redetachment.

RESULTS

For IL-6, bFGF, and total protein we found significantly higher levels in PVR patients' eyes than in control eyes (P =.03, P =.046, and P <.0001, respectively). Within the PVR group, no significant correlation was found for IL-6, bFGF, GS, or total protein with the various tested clinical variables.

CONCLUSIONS

We found increased levels of IL-6, bFGF, and total protein in vitreous fluid from patients' eyes with PVR. Whether the increased levels of IL-6, bFGF, and total protein are the result of an injury-induced upregulation of these proteins as part of a self-protective mechanism of the retina to minimize photoreceptor damage after the mechanical injury induced by retinal detachment is, at present, not known.

Y1 receptor of neuropeptide Y as a glial marker in proliferative vitreoretinopathy and diseased human retina

The Y1 receptor of neuropeptide Y (NPY) has been demonstrated in glial cells of astrocytic lineage in vitro. We have studied the immunohistochemical expression of Y1 receptors in the glia of the diseased human retina, in tissue samples obtained after surgery for proliferative vitreoretinopathy. In this condition, glia and other cell types migrate and form epi- or subretinal membranes. Both diseased retinas (n = 8) and PVR membranes (n = 43) contained numerous Y1-immunoreactive cells. In the diseased retina, the Y1 antiserum labeled cells with the morphological radial pattern characteristic of Müller cells, whereas in the membranes, label appeared in a large population of elongate cells, measuring up to 250 microm. In both retina and membranes, double labeling demonstrated that the vast majority of Y1-immunoreactive cells were also labeled by a glial fibrillary acidic protein (GFAP) antibody, indicating their glial origin. Retinal regions devoid of GFAP immunoreactivity also lacked the Y1 label. None of these markers was detected in Müller cells of normal retina. Y1 immunoreactivity did not co-localize with smooth muscle actin immunoreactivity, a marker of myofibroblasts. Expression of Y1 receptors would characterize reactive and proliferating glial cells of the diseased retina and could perhaps be involved in the proliferation of injured glial cells causing regrowth of PVR membranes and the consequent secondary retinal detachments.

Proliferative vitreoretinopathy-developments in adjunctive treatment and retinal pathology

Proliferative vitreoretinopathy (PVR) remains a difficult management problem despite advances in vitreoretinal surgery. There is still a significant incidence of PVR in rhegmatogenous retinal detachment and other forms of retinal disease. Surgery for PVR now has a high anatomical success rate although visual results are often disappointing. The use of adjunctive treatments to prevent cellular proliferation holds promise for the prevention of PVR or recurrences after surgery. Control of proliferation and strategies aimed at improving visual outcome are important areas of future research in PVR and other forms of retinal disease. Studies of the intraretinal and peri-retinal pathology of PVR have demonstrated characteristic changes which may have a significant influence on visual outcome and surgical management.

Novel growth factors involved in the pathogenesis of proliferative vitreoretinopathy

AIMS

To determine whether hepatocyte growth factor (HGF) and connective tissue growth factor (CTGF) are expressed in human specimens of proliferative vitreoretinopathy (PVR) and to propose a model of PVR pathogenesis based upon the known activities of these growth factors. Methods Immunohistochemical methods (ABC Elite) were used to demonstrate the presence of HGF and CTGF in cryostat sections of five human PVR membranes.

RESULTS

In each of the five PVR membranes, stromal cells were immunohistochemically positive for both HGF and CTGF. Based upon this information and the known actions of these growth factors, a model of PVR pathogenesis was developed. In this model, injury of the retina induces an inflammatory response that upregulates HGF expression inducing the formation of multilayered groups of migratory retinal pigment epithelial cells (RPE). These RPE, present in a provisional extracellular matrix, come in contact with vitreous containing TGF-beta. The TGF-beta is activated, upregulating expression of CTGF. Under the influence of TGF-beta and CTGF, RPE become myofibroblastic and fibrosis ensues. Retinal traction induces further detachment continuing the cycle of retinal injury.

CONCLUSIONS

HGF and CTGF are expressed in PVR membranes and may play important roles in the pathogenesis of PVR. The expression and function of these growth factors should be critically examined in human PVR specimens, in in vitro cultures of RPE, and in animal models of PVR.

Simple retinal detachments: identifying the at-risk case

The success rate of retinal reattachment surgery has now reached over 90%. The major cause of failure is attributable to the development of proliferative vitreoretinopathy (PVR). It is a complex process comprised of events that are similar to those of the wound healing response with inflammation, migration and proliferation of a variety of cells. These membranes can exert traction and reopen previously closed retinal breaks, create new breaks, and distort or obscure the macula. In the early part of this century the success rate of retinal reattachment surgery was virtually nil and it was not until a better understanding of the pathophysiology of retinal detachment was gained that the success rate improved. It was Gonin who emphasised the relationship between vitreous detachment and traction resulting in retinal tears that led to treatment aimed at closing retinal breaks. To increase even further the final success rate in the treatment of 'simple retinal detachments' a better understanding of the risk factors for PVR is needed in patients presenting with acute retinal detachments. Such risk factors can be broadly divided under the headings of preoperative risk factors, best surgical management and possibly adjuvant therapy.

Induction of proliferative vitreoretinopathy by a unique line of human retinal pigment epithelial cells

BACKGROUND

The most widely used models of proliferative vitreoretinopathy (PVR) rely on injection of cells into the vitreous of animals. Using retinal pigment epithelial (RPE) cells from human PVR membranes may produce a more accurate model of human PVR. We performed a study to determine whether human RPE cells derived from a single epiretinal membrane (ERM) are capable of inducing the same disease in the rabbit eye, and whether the induced ERMs had cellular components similar to those of human PVR membranes.

METHODS

Cells were harvested from a human ERM obtained at surgery for PVR. RPE cells were cultured from the membrane and injected into the right eye of 24 New Zealand albino rabbits. The left eyes served as controls. The eyes were examined by indirect ophthalmoscopy over 4 weeks. The enucleated eyes were then examined by means of microscopy and histochemical analysis.

RESULTS

By day 7, PVR had developed in all but 1 of the 24 experimental eyes, with 8 progressing to localized tractional retinal detachment. By day 21, localized tractional retinal detachment had developed in 17 eyes; 1 eye progressed to extensive tractional retinal detachment by day 28. Immunostaining showed that mostly RPE cells, but also myofibroblasts, glial cells and collagen, were present in the newly formed rabbit PVR membranes.

INTERPRETATION

Human RPE cells cultured from a PVR membrane appear to be capable of inducing PVR in rabbits. The resultant ERMs are similar to those formed in human PVR and consist mainly of RPE cells.

Proliferative vitreoretinopathy: risk factors and pathobiology

Proliferative vitreoretinopathy (PVR) is still a major cause of failure of retinal detachment surgery. Despite a dramatic increase in our pathobiologic knowledge of PVR during the last 10 years, little of this information has been used to modify the surgical management of the disease, and, thus, the anatomic and functional results are still unsatisfactory. Collaborative research involving clinicians and basic researchers must be encouraged. PVR must be considered a multifactorial disease caused by interaction of several cells and intra- and extraocular factors. Therefore, therapeutic options based on the inhibition of one factor or phenomenon may be regarded with scepticism. To prevent PVR, it is necessary to determine the factors involved in its development, and because of its relatively small prevalence, large, prospective, multicenter studies seem necessary. In addition, clinical research must not be underestimated. PVR affects both sides of the retina and the retina itself, a point to which little attention has been paid and that is critical for surgical results. Therefore, a new classification that provides information about clinical relevance, such as the evolutionary stages of the disease (biologic activity) and the degree of surgical difficulty (location of the fibrotic process), seems necessary.

The role of the retinal pigment epithelium: topographical variation and ageing changes

The retinal pigment epithelium (RPE) is a single layer of post-mitotic cells, which functions both as a selective barrier to and a vegetative regulator of the overlying photoreceptor layer, thereby playing a key role in its maintenance. Through the expression and activity of specific proteins, it regulates the transport of nutrients and waste products to and from the retina, it contributes to outer segment renewal by ingesting and degrading the spent tips of photoreceptor outer segments, it protects the outer retina from excessive high-energy light and light-generated oxygen reactive species and maintains retinal homeostasis through the release of diffusible factors. The ageing characteristics of the RPE suggest that in addition to cell loss, pleomorphic changes and loss of intact melanin granules, significant metabolic changes occur resulting, at least in part, from the intracellular accumulation of lipofuscin. This pigment has been shown to be highly phototoxic and has been linked to several oxidative changes, some leading to cell death. While the aetiology of age-related macular degeneration is complex and is as yet unresolved, it is likely that accelerated ageing-like changes in the RPE play a fundamental role in the development of this condition.

Intravitreal invading cells contribute to vitreal cytokine milieu in proliferative vitreoretinopathy

AIM

To examine the contribution of infiltrating cells in the local production of cytokines within the vitreous of patients with proliferative vitreoretinopathy (PVR).

METHODS

The presence of mRNA coding for IL-6, IL-8, IL-1beta, IL-1alpha, TNFalpha, IFNgamma, IL-12, and HPRT was investigated in 25 vitreous samples from patients with PVR, 11 vitreous samples from patients with retinal detachment (RD) not complicated by PVR, and 10 vitreous samples from patients with macular hole (MH). A quantitative reverse transcriptase polymerase chain reaction (RT-PCR) using an internal competitor was used to investigate these samples. From these samples, 15 PVR, 8 RD, and 8 MH were analysed for the protein levels of the same cytokines using enzyme linked immunosorbent assay (ELISA). Spearman correlation was used to test any association between mRNA and cytokine protein levels, as an indicator of the contribution these cells make to the intravitreal cytokine milieu.

RESULTS

A strong correlation was found between mRNA and their respective cytokine levels (protein products) for IL-6, IL-8, IL-1beta, IL-1alpha, TNFalpha, IFNgamma (Spearman r = 0.83, 0.73, 0.67, 0.91, 0.73, and 0.73 respectively), but not for IL-12. The median levels of IL-6, IL-8, IL-1beta, and IFNgamma mRNA and their respective cytokines were significantly higher (p <0.05) in patients with PVR than in those with macular hole. There was no statistically significant difference in the median levels of IL-1alpha mRNA between PVR and MH but the cytokine IL-1alpha was detected at a significantly higher level in PVR compared with MH patients. Between PVR and RD patients, there was no statistically significant difference in mRNA levels for all the investigated cytokines (p >0.05) except for IL-6 where there was a statistical significance (p= 0.038). In contrast, the median levels of IL-6, IL-8, and IL-1beta cytokines were significantly higher (p <0.05) in patients with PVR than in those with RD, whereas for IL-1alpha and IFNgamma no significant statistical difference was detected between PVR and RD patients (p >0.05). When results of RD and MH patients were compared, a statistical difference was only detected in mRNA levels of INFgamma (p = 0.008). However, no difference was detected for INFgamma (protein product) or for any of the other cytokines between RD and MH patients.

CONCLUSION

Levels of both protein and mRNA encoding IL-6, IL-8, IL-1beta, and IFNgamma is significantly increased in vitreous samples from patients with PVR. The strong correlation between ELISA detectable cytokines (protein products) and their respective mRNA levels suggest that intravitreal, invasive cells are the major source of these cytokines, with the exception of IL-12. Cells invading the vitreous do not appear to locally produce IL-12 mRNA. This would appear to implicate cells peripheral to the vitreal mass as the major source of this cytokine.

Challenges in ophthalmic pathology: the vitreoretinal membrane biopsy

The introduction of vitreoretinal microsurgery has produced a new type of biopsy; that of the vitreoretinal membrane. This review investigates methods by which these scar-like tissues are handled in the laboratory and explores the implications of the results of such evaluations. The study of vitreoretinal membrane biopsies has provided much information concerning the pathobiology of the various conditions which may give rise to the tissue as well as insights into how membranes themselves develop. Moreover, the application of new laboratory techniques is expected to enhance our understanding of the formation of vitreoretinal membranes, and lead to further advances in their surgical and medical management.

Survival of the retinal pigment epithelium in vitro: comparison of freshly isolated and subcultured cells

Cells of the retinal pigment epithelium (RPE) are generated prenatally and generally survive the lifetime of the individual without undergoing proliferation or replacement. Therefore, the mechanisms promoting individual RPE cell survival and longevity in vivo may be distinct from, or a limited subset of, the mechanisms known to promote survival in proliferative cells in culture. To identify specific factors that sustain cell viability independent of effects on cell division, we studied RPE cells in low-density suspension culture, in which cell proliferation is inhibited. Single cells from Xenopus laevis eyes were plated onto a non-adhesive surface in protein-free medium, then assayed for survival using the 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyl tetrazolium bromide (MTT) assay. Cell viability in these cultures was essentially undiminished over the initial 2 days. However, by approximately 1 week in culture, only an average of 53% of the cells remained alive. Plating cells on a fibronectin-coated substratum significantly enhanced survival, such that the number of cells alive at 1 week was 80-90% of the initial level. Essentially identical results were obtained with laminin- or collagen IV-coated substrata, or with insulin (5 microg ml(-1)) in the medium. The absence of cell division in these cultures was confirmed by cell counting and BrdU incorporation experiments. Interestingly, in suspension cultures derived from monolayers previously established on microporous membrane filters, cells lost viability much faster (average of 80% dead at 3 days), and showed a relatively greater response to extracellular matrix proteins (five-fold increase in cell survival at 3 days). Enhanced RPE survival in response to fibronectin required spreading of the cell on a substratum, rather than mere adherence, as there was a high correlation between the percentage of spread cells and the percentage that were MTT-positive (r=0.940). Cell spreading apparently enhanced survival by preventing the initiation of programmed cell death: unattached non-viable cells in culture exhibited morphological features expected of apoptosis, as well as positive staining by the TUNEL reaction. These studies demonstrate that, of several factors shown to maintain or increase cell number in proliferating cultures, some have their effect, at least in part, by promoting the survival of individual cells. The increased susceptibility of subcultured RPE to cell death has implications for clinical transplantation applications that may require manipulation of RPE in vitro.

Vitreous levels of intercellular adhesion molecule 1 (ICAM-1) as a risk indicator of proliferative vitreoretinopathy

AIM

To investigate whether high vitreous levels of the soluble intercellular adhesion molecule 1 (sICAM-1) may be related to clinical risk factors of proliferative vitreoretinopathy (PVR) and whether their measurement may serve as an additional risk indicator of this complication in eyes with rhegmatogenous retinal detachment (RRD).

METHODS

Levels of sICAM-1 were measured by enzyme linked immunosorbent assays (ELISA) in vitreous from 36 eyes with RRD clinically considered to be at high risk of developing PVR (large retinal breaks, vitreous haemorrhage, long standing RRD, and previous vitreoretinal surgery). Levels of sICAM-1 in this group were compared with those in vitreous from 31 eyes with RRD without clinical risk factors for PVR, 32 eyes with established PVR and 10 eyes with macular holes.

RESULTS

Vitreous from eyes with RRD at high risk of developing PVR contained significantly higher levels of sICAM-1 (range 6.1-97.7 ng/ml; Mann-Whitney test, p=0.0002) than those from eyes with RRD at low risk of developing this complication (range 4.8-17.7 ng/ml). Vitreous sICAM-1 levels in eyes with RRD at high risk of developing PVR were significantly lower than in eyes with established PVR (p=0.037), but higher than in eyes with macular holes (p <0.0001). Levels of sICAM-1 >/=15 ng/ml (3 x median of the levels present in control eyes) provide a useful cut off point for a highly specific test (96.7%) with high positive (91.6%) and negative (96.7%) predictive values, despite a relatively low sensitivity (30. 5%).

CONCLUSIONS

The present findings suggest that laboratory measurement of sICAM-1 levels in vitreous from eyes with RRD may constitute an additional factor for identifying patients at high risk of PVR. Hence, determination of sICAM-1 levels may aid in the monitoring of patients likely to develop this complication and in the identification of patients who may benefit from adjuvant anti-inflammatory therapy.

Matrix and the retinal pigment epithelium in proliferative retinal disease

In their normal state, RPE cell are strongly adherent to Bruch's membrane. Certain pathological conditions such as retinal detachment cause an injury-type response (probably augmented or induced by the local accumulation of a variety of substances which modulate cell behaviour) in which RPE begin to dissociate from the membrane. This RPE-Bruch's membrane separation may be mediated by proteins with counter-adhesive properties and proteolytic enzymes, partly derived from the RPE themselves. Concomitant with the RPE disassociation, the cells begin to lose tertiary differentiation characteristics and gain macrophage-like features. When the "free" RPE arrive at the surface of the neuroretina, they may attach to or create a provisional matrix. Some of the cells adopt a fibroblast-like phenotype. This phenotype is similar to that of the dermal fibroblast during cutaneous wound repair and the fibroblastic RPE synthesise the types of matrix components found in healing skin wounds. Many of these molecules in turn further modulate the activities of the cells via several families of cell surface receptors, while the RPE continue to remodel the new matrix with a range of proteolytic enzymes. The resulting tissue (or membrane) has many of the features of a contractile scar and is the hallmark of the condition known as proliferative vitreoretinopathy (PVR). Thus the development of PVR, and the resulting tractional distortion of the neuroretina, appears to be dependent on RPE-matrix interactions. The interactions present a number of potential therapeutic targets for the management of the disorder.

Development of a multiple-drug delivery implant for intraocular management of proliferative vitreoretinopathy

A prototype multiple-drug delivery implant has been developed for the intraocular management of proliferative vitreoretinopathy (PVR). Because of the recurrent nature of the disease, PVR causes blindness in approximately 7% of patients who have undergone retinal re-attachment surgery. The poly(dl-lactide-co-glycolide) 50/50 (PLGA) implant consists of three cylindrical segments, each of which contains one of the following drugs: 5-fluorouridine (5FUrd, an antimetabolite), triamcinolone (Triam, a corticosteroid), and human recombinant tissue plasminogen activator (t-PA, a thrombolytic agent). The device can be inserted through a 20-gauge syringe needle into the vitreous body of the eye. The implant also possesses a PLGA coating over the t-PA-containing terminal segment, which creates a lag-time to deliver t-PA when most needed and to decrease the risk of postoperative bleeding. Two methods of cylinder fabrication were investigated: heat and solvent extrusion. The release behavior of several drugs was examined as a function of the processing variables including: extrusion method, drug loading, polymer molecular weight, and drug particle size. The presence of either the organic solvent (acetone) during processing or a highly water-soluble drug (5FUrd) in the formulation increased the polymer porosity, which in turn, increased the drug release-rate. Drug loading effects were consistent with percolation concepts, and a low-molecular-weight PLGA (e.g., Mw=42000 for inherent viscosity=0.58 dl/g) was desirable to produce controlled release close to one month. Based on pharmacological and pharmacokinetic data of these compounds and our clinical experience with this disease, several design criteria for a combined implant were devised. Optimal cylindrical segments from the formulation studies were selected and combined in series to form a contiguous implant. After successful combination and coating procedures were developed, prototype implants were prepared. From the 3-drug prototype, 5FUrd and Triam were released approximately 1 microgram/day for over 4 weeks and 10-190 microgram/day over 2 weeks, respectively. The solvent-extrusion procedure did not significantly alter the stability of the encapsulated t-PA (>94+/-5% serine protease activity after preparation). After a lag-time of approximately 2 days, t-PA was released active at a rate of approximately 0.2-0.5 microgram/day in approximately 2 weeks. The release characteristics from the combined implant largely met our initial design criteria. Hence, controlled-release implants of this kind may have potential use for intraocular treatment of PVR.

The topoisomerase I inhibitors, camptothecin and beta-lapachone, induce apoptosis of human retinal pigment epithelial cells

The aim of the study was to determine whether the topoisomerase I inhibitors, camptothecin and beta-lapachone, are suitable agents for the adjuvant pharmacotherapy of proliferative vitreoretinopathy (PVR). The effects of the drugs on cultured human retinal pigment epithelial (RPE) cells were examined using growth assays, cytotoxicity assays, single cell agarose gel electrophoresis, in situ DNA end labeling and immunoblot analysis for apoptosis-regulatory proteins. Both agents killed RPE cells in a concentration-and time-dependent manner. Cell death was apoptotic as assessed by single cell agarose gel electrophoresis and in situ DNA end labeling. Camptothecin, but not beta-lapachone, induced accumulation of p53 and the major growth arrest-associated p53 response protein, p21. Both drugs enhanced expression of the proapoptotic BAX protein. Camptothecin, but not beta-lapachone, synergistically enhanced RPE cell apoptosis induced by the cytotoxic cytokine, CD95 ligand (CD95L). This effect was linked to camptothecin-induced inhibition of RNA synthesis. Atypical topoisomerase I inhibitors may be promising agents for the adjuvant pharmacotherapy of PVR. Experimental studies to assess possible ocular toxicity upon local administration and to confirm its therapeutic efficacy in an animal model of PVR are required.

Retinal pigment epithelial cells secrete and respond to hepatocyte growth factor

Hepatocyte growth factor (HGF) is normally expressed by mesenchymal cells while its receptor, c-Met, is expressed in epithelial cells. Since HGF is critically involved in epithelial-mesenchyme interactions and the retinal pigment epithelium (RPE) is present at the interface between the retina and choroid, this study was initiated to determine whether the RPE expresses or responds to HGF in vitro. Cultured adult and fetal human RPE expressed mRNA for HGF and c-Met by RT-PCR. ELISA assay demonstrated the secretion of HGF into RPE culture supernatants. Tyrosine phosphorylation of c-Met was constitutively found in 72 hour RPE cultures and could be rapidly induced in serum-starved cells by concentrated RPE supernatants. HGF was mitogenic for cultured RPE (100 ng/ml.) and stimulated their chemotaxis (maximal response at 50 ng/ml). RPE are one of only a very limited number of epithelia that express both HGF and its receptor, suggesting the possibility of an autocrine action for this growth factor.

The mRNA expression of cytokines and their receptors in cultured iris pigment epithelial cells: a comparison with retinal pigment epithelial cells

It has been suggested that human iris pigment epithelial (IPE) cells isolated from iridectomized tissue could be used as autologous cells for transplantation into the subretinal space in diseases with dysfunctional retinal pigment epithelium (RPE). RPE cells synthesize a number of cytokines and their receptors which are important for its proper function. Nearly nothing is known about the capacity of IPE to synthesize cytokines or responding to them. To compare the mRNA expression of 36 cytokines or their receptors in cultured adult IPE cells and RPE cells we used semi-quantitative reverse transcription polymerase chain reactions (RT-PCR). Included in our assay were cytokines with known expression in RPE to get a broad basis for comparing IPE cells: basic fibroblast growth factor (bFGF or FGF-2), and one of its receptor (FGFR-1), epidermal growth factor (EGF), and its receptor EGF-R, transforming growth factor beta(TGFbeta), and its type III receptor TGFbeta-R3, the platelet-derived growth factors and receptors (PDGF A, PDGF B, PDGF-Ralpha, PDGF-Rbeta), tumor necrosis factor alpha(TNFalpha), and two receptors TNF-R1 and TNF-R2, insulin (INS) with receptor INS-R, insulin-like growth factors (IGF1, IGF2), and receptors (IGF1-R, IGF2-R), vascular endothelial growth factor (VEGF), and two receptors (VEGF-R1 or FLT-1 and VEGF-R2 or FLK-1), the receptor for VEGF-C: VEGF-R3 or FLK-4, interleukin 6 (IL6), and its receptor (IL6-R), nerve growth factor (NGF), interleukin 1alpha(IL1alpha), and a receptor (IL1-R). In addition, cytokines or their receptors not known to be expressed in RPE were included to widen our picture of cytokine gene expression in the eye: stem cell factor (SCF), its receptor (SCF-R), low-affinity nerve growth factor receptor p75 (p75(NGF-R), ciliary neutrothropic factor (CNTF), and its receptor (CNTF-R), glycoprotein 130 interleukin 6 transducer (gp130 (IL6-SD), leukemia inhibitory factor (LIF), and its receptor (LIF-R). Semi-quantitative expression data were obtained using series of fivefold dilutions of each cDNA and a fixed number of PCR cycles. The expression of RPE 65, glyceraldehyde-3-phosphate dehydrogenase (GAPDH), and beta2-microglobulin (B2MG) was used as a control for cellular origin, RNA quality and PCR conditions. With the exception of insulin and tumor necrosis factor alphaall other cytokines analysed and their receptors were expressed in both IPE and RPE cells, even though the levels varied. No qualitative or quantitative difference were observed in the mRNA expression level of 34 (94%) of the cytokines or receptors between IPE and RPE. In contrast, the mRNA expression level of vascular endothelial growth factor (VEGF) and vascular endothelial growth factor receptor 2 [VEGF-RS (FLK-1)] was lower in IPE than in RPE cells. As an increased expression of VEGF in the RPE in maculae with age-related macular disease could be involved in its pathogenesis, a decreased expression of angiogenic growth factors in IPE cells could possibly be beneficial for the therapy of age-related maculopathy if indeed other tasks of non-functional RPE cells could be performed by IPE cells. The similarity of the mRNA expression pattern in 94% of the cytokines analyzed supports the assumption that IPE cells potentially can perform functions of RPE cells in the appropriate environment.

Verapamil inhibits proliferation, migration and protein kinase C activity in human retinal pigment epithelial cells

The effects of three calcium channel blockers, verapamil, diltiazem and nifedipine, were examined on in vitro proliferation and migration of human retinal pigment epithelial cells. Human retinal pigment epithelial cells were seeded in Dulbecco's modified essential medium with 10% fetal bovine serum and different concentrations of the three calcium channel blockers. After 3 days of treatment, cell proliferation was determined by cell counting and by [3H]-thymidine uptake. Cell viability was determined with trypan blue exclusion. For determination of cell migration, retinal pigment epithelial cells were grown to confluence and then growth-inhibited with mitomycin C. After a 3 mm zone was denuded, the cells were treated with different concentrations of the calcium channel antagonists. After 24 hr, the cells that had migrated over the wound edge were counted. To determine the involvement of protein kinase C in the verapamil effect, its activity was measured in both verapamil-treated and untreated cells. Verapamil dose dependently inhibited serum-induced proliferation of retinal pigment epithelial cells, when measured by cell number (IC50 14.6 microM) or [3H]-thymidine incorporation (IC50 11.3 microM). At concentrations of 15 microM and below, there was no effect on cell viability, as determined by morphology and trypan blue exclusion. Diltiazem inhibited cell proliferation at a concentration of 100 microM; however, 100 microM nifedipine had no effect. Verapamil showed a significant inhibition of serum-induced migration in the range of 10 microM to 0.1 microM. The IC50 of the inhibition of retinal pigment epithelial cell proliferation and migration by verapamil is significantly higher than that seen for effects on calcium channel blockage. Eight micromolar verapamil reversibly inhibited total protein kinase-C activity in retinal pigment epithelial cells suggesting the possibility that the drug may act by inhibiting the protein kinase-C pathway. These data suggest the potential of the calcium channel blocker verapamil as a pharmacological modulator of disorders such as proliferative vitreoretinopathy in which there is increased retinal pigment epithelial cell proliferation and migration.

Proliferative vitreoretinopathy: an overview

Proliferative vitreoretinopathy (PVR) is still the most common cause of failure of surgery for rhegmatogenous retinal detachment, despite the substantial effort that has been devoted to better understanding and managing this condition during the past 25 years. Basic research has indicated that PVR represents scarring, the end stage of the wound-healing process that occurs after retinal detachment surgery. Medical treatment has been directed toward preventing inflammation, the first phase of the wound healing process, and inhibiting cell proliferation, the second phase. The 1983 Retina Society classification was modified in 1989 by the Silicone Study Group, whose classification differentiates between posterior and anterior forms of PVR and recognizes three patterns of proliferation: diffuse, focal, and subretinal. The anterior form has a worse prognosis than the posterior form, and its treatment requires more complex surgical procedures. In this review, risk factors and pathobiology of PVR are discussed, and management of PVR of various degrees of severity are considered.

Proliferative vitreoretinopathy: a natural history of the fellow eye

OBJECTIVE

To determine how often the fellow eyes of patients with proliferative vitreoretinopathy (PVR) harbor a vision-threatening condition at presentation; to determine how often the fellow eyes of patients with PVR develop vision-threatening conditions; and to determine how often the fellow eyes of patients with PVR lose vision.

DESIGN

A retrospective case review design was used.

PARTICIPANTS

Two hundred and forty-nine patients with PVR were studied.

INTERVENTION

The authors observed the fellow eye of eyes with PVR for vision-threatening pathology.

MAIN OUTCOME MEASURES

The primary anatomic endpoint of this study was the detection of vision-threatening pathology in the fellow eye of patients with PVR. Secondary outcome measures included the development of visual loss in the fellow eye.

RESULTS

A wide variety of vision-threatening conditions were diagnosed in the fellow eyes of patients with PVR. Of patients meeting entry criteria with reliable follow-up data, greater than 50% of fellow eyes demonstrated vision-threatening pathology at some point during follow-up.

CONCLUSIONS

Patients who develop PVR in one eye are at considerable risk for developing vision-threatening pathology or vision-damaging conditions in the fellow eye. This information should be carefully considered when making surgical decisions in patients facing PVR surgery.

Mitogen-activated protein kinase activation mediates PDGF-directed migration of RPE cells

Growth factor-directed migration is a critical component of the wound healing response although little is known about the signaling pathways involved. We examined the effect of inhibiting the mitogen-activated protein kinase (MAPK) pathway on platelet-derived growth factor (PDGF) and fibronectin-induced cell migration of human retinal pigment epithelial (RPE) cells. Using transwell cell-culture chambers, the effect of PDGF-BB (10-50 ng/ml) and fibronectin on components of migration was measured with or without the MAPK pathway inhibitor PD98059 (10-30 microM) MAPK activation of serum-starved cells by PDGF-BB was demonstrated by an immunoprecipitation/kinase assay and by immunohistochemistry using antibody specific for phosphorylated MAPK. PDGF-BB (10 ng/ml) stimulated MAPK activity in RPE (10 min) and its nuclear localization (1 h). PD98059 inhibited the activation of MAPK by PDGF-BB or serum. PDGF-BB stimulated RPE chemokinesis, chemotaxis, and haptotaxis; chemokinesis was additively increased and chemotaxis synergistically increased by the presence of a fibronectin substratum. PD98059 potently inhibited fibronectin-induced haptotaxis and PDGF-BB-induced chemotaxis but inhibited chemokinesis only at higher PDGF-BB (50 ng/ml) concentrations in the presence of fibronectin substratum. These results demonstrate that MAPK is critically involved in multiple components of RPE migration in vitro and suggest the potential of targeting MAPK to inhibit RPE migration in vivo.

Risk factors for proliferative vitreoretinopathy

Proliferative vitreoretinopathy (PVR) is one of the major causes of failure in retinal detachment surgery. To prevent PVR, it is necessary to determine factors predisposing its development. In primary PVR, large retinal tears, long duration of retinal detachment, vitreous hemorrhages, aphakia and choroidal detachment were demonstrated as clinical risk factors for PVR. In postoperative PVR, it was revealed that large breaks, pre- and postoperative choroidal detachment, minor intra- or postoperative hemorrhages, signs of uveitis, extensive retinal detachment, vitrectomy, cryopexy, air injection and preoperative PVR were risk factors for PVR by multivariate analysis. Almost all risk factors for PVR are associated with intravitreal dispersion of retinal pigment epithelial (RPE) cells or breakdown of the blood-ocular barrier which are prerequisite to development of PVR.

13-cis-retinoic acid in silicone-fluorosilicone copolymer oil in a rabbit model of proliferative vitreoretinopathy

The purpose of this study was to evaluate the effect of 13-cis-Retinoic Acid (RA) in Silicone-Fluorosilicone Copolymer Oil (SiFO) in a rabbit model of proliferative vitreoretinopathy (PVR). Rabbits underwent gas-compression vitrectomy. During gas-SiFO exchange, group 1 was injected with 1 ml (10 microg ml-1) 13-cis-RA in SiFO, group 2 with 1.5 ml (9 microg 1.5 ml-1) all-trans-RA in SiFO, group 3 with 1 ml SiFO alone, and group 4 with balanced salt solution (BSS). Groups 1-4 were also injected with 0.1 ml suspension of fibroblasts (75,000 0.1 ml-1) and 0.05 ml platelet rich plasma (70,000 0.1 ml-1), and were observed for 4 weeks. Group 5 was injected with SiFO alone, group 6 with 1 ml (10 microg ml-1) 13-cis-RA in SiFO, group 7 with 1.5 ml (9 microg 1.5 ml-1) all-trans-RA in SiFO, and group 8 with BSS. After 4 weeks, groups 5-7 underwent SiFO-BSS exchange. ERG and histopathology were performed to test for retinal toxicity in groups 5-8. The incidence of traction retinal detachment at 4 weeks was: group 1, 42.9%; group 2, 36.4%; group 3, 87.5%; and group 4, 88.9%. A significant difference in the incidence of PVR was noted between treated eyes (groups 1 and 2) and control eyes (groups 3 and 4) at 2, 3, and 4 weeks (P<0.05). No significant difference in the incidence of PVR was found between groups 1 and 2 during the same observation periods. ERG and histopathological studies showed no differences between the treated and the control fellow eyes (group 5-7) after 4 weeks. 13-cis-RA in SiFO (10 microg ml-1) is as effective as all-trans-RA in SiFO (9 microg 1.5 ml-1) in controlling the incidence of PVR when used for short term retinal tamponade and does not appear to be associated with retinal toxicity.

Antiproliferative effect of retinoic acid in 1% sodium hyaluronate in an animal model of PVR

PURPOSE

To determine the antiproliferative activity in intravitreous retinoic acid (RA) dispersed in 1% sodium hyaluronate (HA).

METHODS

Six groups of pigmented rabbits underwent gas-compression vitrectomy. Four days later, gas/HA or gas/balanced salt solution (BSS) exchange (1.0 m1) was performed in all rabbits. Groups A (n = 10) and B (n = 5) received intravitreous RA dissolved in 0.01 m1 of ethanol and dispersed in 1% HA (10 and 15 micrograms RA/m1, respectively). Group C (n = 10) received intravitreous RA dissolved in ethanol and dispersed in BSS (10 micrograms RA/m1). Groups D (n = 5) and F (n = 4) received 1 m1 of HA with ethanol; group E (n = 5) received 1 m1 of HA without ethanol. All groups except group F also received homologous fibroblasts and autologous, platelet-rich plasma intravitreously. The eyes were examined ophthalmoscopically for 1 month. Proliferative vitreoretinopathy (PVR) findings were graded according to the classification of Fastenberg et al. all group F eyes also were examined by light and electron microscopy.

RESULTS

RA in HA lessened PVR progression within 1 month when compared with HA injection controls and within 2 weeks when compared with the RA in BSS treatment group (both, p < 0.05). NO specific change attributable to ethanol was observed histopathologically.

CONCLUSION

RA dissolved in ethanol and dispersed in HA could be useful to treat PVR when silicone oil is unnecessary.