Increase in endothelin B receptor expression in optic nerve astrocytes in endothelin-1 induced chronic experimental optic neuropathy

Intraocular Adeno-Associated Virus-Mediated Transgene Endothelin-1 Delivery to the Rat Eye Induces Functional Changes Indicative of Retinal Ischemia-A Potential Chronic Glaucoma Model

Endothelin-1 (ET-1) overactivity has been implicated as a factor contributing to glaucomatous neuropathy, and it has been utilized in animal models of retinal ischemia. The functional effects of long-term ET-1 exposure and possible compensatory mechanisms have, however, not been investigated. This was therefore the purpose of our study. ET-1 was delivered into rat eyes via a single intravitreal injection of 500 µM or via transgene delivery using an adeno-associated viral (AAV) vector. Retinal function was assessed using electroretinography (ERG) and the retinal expression of potentially compensatory genes was evaluated by means of qRT-PCR. Acute ET-1 delivery led to vasoconstriction and a significant reduction in the ERG response. AAV-ET-1 resulted in substantial transgene expression and ERG results similar to the acute ET-1 injections and comparable to other models of retinal ischemia. Compensatory changes were observed, including an increase in calcitonin gene-related peptide (CGRP) gene expression, which may both counterbalance the vasoconstrictive effects of ET-1 and provide neuroprotection. This chronic ET-1 ischemia model might be especially relevant to glaucoma research, mimicking the mild and repeated ischemic events in patients with long-term vascular dysfunction. The compensatory mechanisms, and particularly the role of vasodilatory CGRP in mitigating the retinal damage, warrant further investigation with the aim of evaluating new therapeutic strategies.

Long-Term Effects on Retinal Structure and Function in a Mouse Endothelin-1 Model of Retinal Ganglion Cell Degeneration

Purpose

To study the long-term effects of endothelin-1 (ET-1)-induced retinal pathologies in mouse, using clinically relevant tools.

Methods

Adult C57BL/6 mice (7-9 weeks old) were intravitreally injected with PBS (n = 10) or 0.25 (n = 8), 0.5 (n = 8), or 1 nmol ET-1 (n = 9) and examined using electroretinogram, optical coherence tomography (OCT), and Doppler OCT at baseline and postinjection days 10, 28, and 56. Retinal ganglion cell (RGC) survival in retinal whole mount was quantified at days 28 and 56.

Results

ET-1 induced immediate retinal arterial constriction. The significantly reduced total blood flow and positive scotopic threshold response in the 0.5- and 1-nmol ET-1 groups at day 10 were recovered at day 28. A-wave magnitude was also significantly reduced at days 10 and 28. While a comparable and significant reduction in retinal nerve fiber layer thickness was detected in all ET-1 groups at day 56, the 1-nmol group was the earliest to develop such change at day 28. All ET-1 groups showed a transient inner retinal layer thinning at days 10 and 28 and a plateaued outer layer thickness at days 10 to 56. The 1-nmol group showed a significant RGC loss over all retinal locations examined at day 28 as compared with PBS control. As for the lower-dosage groups, significant RGC density loss at central and midperipheral retina was detected at day 56 when compared with day 28.

Conclusions

ET-1 injection in mice resulted in a transient vascular constriction and reduction in retinal functions, as well as a gradual loss of retinal nerve fiber layer and RGC in a dose-dependent manner.

The Association among Blood Pressure, Blood Pressure Medications, and Glaucoma in a Nationwide Electronic Health Records Database

PURPOSE

To measure the association among blood pressure (BP), BP medications, and glaucoma using the All of Us Research Program database.

DESIGN

A retrospective, longitudinal cohort study leveraging a national electronic health record (EHR) database administered by the National Institutes of Health.

PARTICIPANTS

Eye patients in the All of Us Research Program database with at least 15 months of follow-up and 1 BP measurement.

METHODS

Univariable and multivariable Cox regression models predicted the risk of developing incident open-angle glaucoma (OAG). Mean arterial pressure (MAP) and the number of BP medication classes were entered as time-varying predictors to account for changes over time.

MAIN OUTCOME MEASURES

The risk of developing incident OAG, as defined by billing diagnosis codes.

RESULTS

Of 20 815 eligible eye patients who qualified for this study, 462 developed OAG. Low BP (MAP < 83.0 mmHg) was associated with increased risk of developing OAG (hazard ratio [HR], 1.32; 95% confidence interval [CI], 1.04-1.67). High BP (MAP > 101.3 mmHg) and the number of BP medication classes were not associated with OAG after adjustment for covariates. Other risk factors associated with OAG included being Black (HR, 3.31, 95% CI, 2.63-4.17), Hispanic or Latino (HR, 2.53, 95% CI, 1.94-3.28), Asian (HR, 2.22, 95% CI, 1.24-3.97), older in age (80+ years, HR, 20.1, 95% CI, 9.10-44.5), and diabetic (HR, 1.32, 95% CI, 1.04-1.67). Female gender was associated with decreased hazard of developing OAG (HR, 0.66, 95% CI, 0.55-0.80). No significant interaction was observed between MAP and the number of BP medications on the risk of developing OAG.

CONCLUSIONS

We found that low BP is associated with increased risk of developing OAG in a national longitudinal EHR database. We did not find evidence supporting a differential effect of medically treated and untreated low BP. This study adds to the body of literature implicating vascular dysregulation as a potential etiology for the development of OAG, particularly emphasizing the lack of influence of BP medications on this relationship.

Inflammation in Glaucoma: From the back to the front of the eye, and beyond

The pathophysiology of glaucoma is complex, multifactorial and not completely understood. Elevated intraocular pressure (IOP) and/or impaired retinal blood flow may cause initial optic nerve damage. In addition, age-related oxidative stress in the retina concurrently with chronic mechanical and vascular stress is crucial for the initiation of retinal neurodegeneration. Oxidative stress is closely related to cell senescence, mitochondrial dysfunction, excitotoxicity, and neuroinflammation, which are involved in glaucoma progression. Accumulating evidence from animal glaucoma models and from human ocular samples suggests a dysfunction of the para-inflammation in the retinal ganglion cell layer and the optic nerve head. Moreover, quite similar mechanisms in the anterior chamber could explain the trabecular meshwork dysfunction and the elevated IOP in primary open-angle glaucoma. On the other hand, ocular surface disease due to topical interventions is the most prominent and visible consequence of inflammation in glaucoma, with a negative impact on filtering surgery failure, topical treatment efficacy, and possibly on inflammation in the anterior segment. Consequently, glaucoma appears as an outstanding eye disease where inflammatory changes may be present to various extents and consequences along the eye structure, from the ocular surface to the posterior segment, and the visual pathway. Here we reviewed the inflammatory processes in all ocular structures in glaucoma from the back to the front of the eye and beyond. Our approach was to explain how para-inflammation is necessary to maintain homoeostasis, and to describe abnormal inflammatory findings observed in glaucomatous patients or in animal glaucoma models, supporting the hypothesis of a dysregulation of the inflammatory balance toward a pro-inflammatory phenotype. Possible anti-inflammatory therapeutic approaches in glaucoma are also discussed.

A feed-forward regulation of endothelin receptors by c-Jun in human non-pigmented ciliary epithelial cells and retinal ganglion cells

c-Jun, c-Jun N-terminal kinase(JNK) and endothelin B (ET_B) receptor have been shown to contribute to the pathogenesis of glaucoma. Previously, we reported that an increase of c-Jun and CCAAT/enhancer binding protein β (C/EBPβ) immunohistostaining is associated with upregulation of the ET_B receptor within the ganglion cell layer of rats with elevated intraocular pressure (IOP). In addition, both transcription factors regulate the expression of the ET_B receptor in human non-pigmented ciliary epithelial cells (HNPE). The current study addressed the mechanisms by which ET-1 produced upregulation of ET receptors in primary rat retinal ganglion cells (RGCs) and HNPE cells. Treatment of ET-1 and ET-3 increased the immunocytochemical staining of c-Jun and C/EBPβ in primary rat RGCs and co-localization of both transcription factors was observed. A marked increase in DNA binding activity of AP-1 and C/EBPβ as well as elevated protein levels of c-Jun and c-Jun-N-terminal kinase (JNK) were detected following ET-1 treatment in HNPE cells. Overexpression of ET_A or ET_B receptor promoted the upregulation of c-Jun and also elevated its promoter activity. In addition, upregulation of C/EBPβ augmented DNA binding and mRNA expression of c-Jun, and furthermore, the interaction of c-Jun and C/EBPβ was confirmed using co-immunoprecipitation. Apoptosis of HNPE cells was identified following ET-1 treatment, and overexpression of the ET_A or ET_B receptor produced enhanced apoptosis. ET-1 mediated upregulation of c-Jun and C/EBPβ and their interaction may represent a novel mechanism contributing to the regulation of endothelin receptor expression. Reciprocally, c-Jun was also found to regulate the ET receptors and C/EBPβ appeared to play a regulatory role in promoting expression of c-Jun. Taken together, the data suggests that ET-1 triggers the upregulation of c-Jun through both ET_A and ET_B receptors, and conversely c-Jun also upregulates endothelin receptor expression, thereby generating a positive feed-forward loop of endothelin receptor activation and expression. This feed-forward regulation may contribute to RGC death and astrocyte proliferation following ET-1 treatment.

Upregulation of the endothelin A (ETA) receptor and its association with neurodegeneration in a rodent model of glaucoma

Background

Primary open angle glaucoma is a heterogeneous group of optic neuropathies that results in optic nerve degeneration and a loss of retinal ganglion cells (RGCs) ultimately causing blindness if allowed to progress. Elevation of intraocular pressure (IOP) is the most attributable risk factor for developing glaucoma and lowering of IOP is currently the only available therapy. However, despite lowering IOP, neurodegenerative effects persist in some patients. Hence, it would be beneficial to develop approaches to promote neuroprotection of RGCs in addition to IOP lowering therapies. The endothelin system is a key target for intervention against glaucomatous neurodegeneration. The endothelin family of peptides and receptors, particularly endothelin-1 (ET-1) and endothelin B (ET_B) receptor, has been shown to have neurodegenerative roles in glaucoma. The purpose of this study was to examine changes in endothelin A (ET_A) receptor protein expression in the retinas of adult male Brown Norway rats following IOP elevation by the Morrison’s model of ocular hypertension and the impact of ET_A receptor overexpression on RGC viability in vitro.

Results

IOP elevation was carried out in one eye of Brown Norway rats by injection of hypertonic saline through episcleral veins. After 2 weeks of IOP elevation, immunohistochemical analysis of retinal sections from rat eyes showed an increasing trend in immunostaining for ET_A receptors in multiple retinal layers including the inner plexiform layer, ganglion cell layer and outer plexiform layer. Following 4 weeks of IOP elevation, a significant increase in immunostaining for ET_A receptor expression was found in the retina, primarily in the inner plexiform layer and ganglion cells. A modest increase in staining for ET_A receptors was also found in the outer plexiform layer in the retina of rats with IOP elevation. Cell culture studies showed that overexpression of ET_A receptors in 661W cells as well as primary RGCs decreases cell viability, compared to empty vector transfected cells. Adeno-associated virus mediated overexpression of the ET_A receptor produced an increase in the ET_B receptor in primary RGCs.

Conclusions

Elevated IOP results in an appreciable change in ET_A receptor expression in the retina. Overexpression of the ET_A receptor results in an overall decrease in cell viability, accompanied by an increase in ET_B receptor levels, suggesting the involvement of both ET_A and ET_B receptors in mediating cell death. These findings raise possibilities for the development of ET_A/ET_B dual receptor antagonists as neuroprotective treatments for glaucomatous neuropathy.

Electronic supplementary material

The online version of this article (doi:10.1186/s12868-017-0346-3) contains supplementary material, which is available to authorized users.

Retinal Macroglial Responses in Health and Disease

Due to their permanent and close proximity to neurons, glial cells perform essential tasks for the normal physiology of the retina. Astrocytes and Müller cells (retinal macroglia) provide physical support to neurons and supplement them with several metabolites and growth factors. Macroglia are involved in maintaining the homeostasis of extracellular ions and neurotransmitters, are essential for information processing in neural circuits, participate in retinal glucose metabolism and in removing metabolic waste products, regulate local blood flow, induce the blood-retinal barrier (BRB), play fundamental roles in local immune response, and protect neurons from oxidative damage. In response to polyetiological insults, glia cells react with a process called reactive gliosis, seeking to maintain retinal homeostasis. When malfunctioning, macroglial cells can become primary pathogenic elements. A reactive gliosis has been described in different retinal pathologies, including age-related macular degeneration (AMD), diabetes, glaucoma, retinal detachment, or retinitis pigmentosa. A better understanding of the dual, neuroprotective, or cytotoxic effect of macroglial involvement in retinal pathologies would help in treating the physiopathology of these diseases. The extensive participation of the macroglia in retinal diseases points to these cells as innovative targets for new drug therapies.

Influence of Endothelin-1 in Aqueous Humor on Intermediate-Term Trabeculectomy Outcomes

Purpose. To investigate whether increased concentrations of ET-1 in aqueous humor of glaucoma patients influences surgical outcome of standard trabeculectomy with Mitomycin C. Methods. Retrospective chart review of 36 glaucoma patients with known ET-1 concentrations who had undergone trabeculectomy with Mitomycin C. Patients were divided into two groups based on their aqueous ET-1 concentration, a below-median (low ET-1) and an above-median (high ET-1) group. Postoperative IOP development, necessity of glaucoma medication, surgical success and complications, postoperative use of antifibrotics (5-FU), and number of additional glaucoma surgeries were compared between the groups. Results. Overall surgical success of trabeculectomy was comparable to published literature (90%, 81%, 76%, and 68% absolute success at 12, 24, 36, and 48 months after surgery). There was no difference between high and low ET-1 group in the postsurgical development of IOP, surgical success rate, or complication rate. There was no difference in postoperative scarring or indirect indicators thereof (e.g., number of 5-FU injections, needlings, suture lyses, or IOP lowering medications). Conclusion. In this set of patients, ET-1 in aqueous humor does not appear to have influenced surgical outcome of trabeculectomy with Mitomycin C. There is no indication of an increased likelihood of bleb fibrosis in patients with increased ET-1 concentrations.

Endothelin-Mediated Changes in Gene Expression in Isolated Purified Rat Retinal Ganglion Cells

PURPOSE

A growing body of evidence suggests that the vasoactive peptides endothelins (ETs) and their receptors (primarily the ETB receptor) are contributors to neurodegeneration in glaucoma. However, actions of ETs in retinal ganglion cells (RGCs) are not fully understood. The purpose of this study was to determine the effects of ETs on gene expression in primary RGCs.

METHODS

Primary RGCs isolated from rat pups were treated with 100 nM of ET-1, ET-2, or ET-3 for 24 hours. Total RNA was extracted followed by cDNA synthesis. Changes in gene expression in RGCs were detected using Affymetrix Rat Genome 230 2.0 microarray and categorized by DAVID analysis. Real-time PCR was used to validate gene expression, and immunocytochemistry and immunoblotting to confirm the protein expression of regulated genes.

RESULTS

There was more than 2-fold upregulation of 328, 378, or 372 genes, and downregulation of 48, 33, or 28 genes with ET-1, ET-2, or ET-3 treatment, respectively, compared to untreated controls. The Bcl-2 family, S100 family, matrix metalloproteinases, c-Jun, and ET receptors were the major genes or proteins that were regulated by endothelin treatment. Immunocytochemical staining revealed a significant increase in ETA receptor, ETB receptor, growth associated protein 43 (GAP-43), phosphorylated c-Jun, c-Jun, and Bax with ET-1 treatment. Protein levels of GAP-43 and c-Jun were confirmed by immunoblotting.

CONCLUSIONS

Expression of key proteins having regulatory roles in apoptosis, calcium homeostasis, cell signaling, and matrix remodeling were altered by treatment with endothelins. The elucidation of molecular mechanisms underlying endothelins' actions in RGCs will help understand endothelin-mediated neurodegenerative changes during ocular hypertension.

Glial cell interactions and glaucoma

Purpose of review

The present review describes new advances in our understanding of the role of glial cells in the pathogenesis of glaucoma. It is becoming clear that retinal glia should not be studied in isolation in glaucoma because glia have dynamic and diverse interactions with a range of different cell types that could influence the disease process.

Recent findings

Microglial activity is modulated by signals from retinal ganglion cells and macroglia that influence RGC survival in various models of injury. New studies suggest that circulating monocytic populations may play a role in mediating the immune response to glaucoma. Astrocytes have been found to develop discrete localized processes that interact with a specific subset of retinal ganglion cells, possibly responding to the expression of phagocytic signals by stressed retinal ganglion cells.

Summary

Retinal glia constitute a highly versatile population that interacts with various cells to maintain homeostasis and limit disease. Defining the mechanisms that underlie glial communication could enable the development of more selective therapeutic targets, with great potential clinical applications.

Endothelin-2-mediated protection of mutant photoreceptors in inherited photoreceptor degeneration

Expression of the Endothelin-2 (Edn2) mRNA is greatly increased in the photoreceptors (PRs) of mouse models of inherited PR degeneration (IPD). To examine the role of Edn2 in mutant PR survival, we generated Edn2^−/− mice carrying homozygous Pde6b^rd1 alleles or the Tg(RHO P347S) transgene. In the Edn2^−/− background, PR survival increased 110% in Pde6b^rd1/rd1 mice at post-natal (PN) day 15, and 60% in Tg(RHO P347S) mice at PN40. In contrast, PR survival was not increased in retinal explants of Pde6b^rd1/rd1; Edn2^−/− mice. This finding, together with systemic abnormalities in Edn2^−/− mice, suggested that the increased survival of mutant PRs in the Edn2^−/− background resulted at least partly from the systemic EDN2 loss of function. To examine directly the role of EDN2 in mutant PRs, we used a scAAV5-Edn2 cDNA vector to restore Edn2 expression in Pde6b^rd1/rd1; Edn2^−/− PRs and observed an 18% increase in PR survival at PN14. Importantly, PR survival was also increased after injection of scAAV5-Edn2 into Pde6b^rd1/rd1 retinas, by 31% at PN15. Together, these findings suggest that increased Edn2 expression is protective to mutant PRs. To begin to elucidate Edn2-mediated mechanisms that contribute to PR survival, we used microarray analysis and identified a cohort of 20 genes with >4-fold increased expression in Tg(RHO P347S) retinas, including Fgf2. Notably, increased expression of the FGF2 protein in Tg(RHO P347S) PRs was ablated in Tg(RHO P347S); Edn2^−/− retinas. Our findings indicate that the increased expression of PR Edn2 increases PR survival, and suggest that the Edn2-dependent increase in PR expression of FGF2 may contribute to the augmented survival.

Endothelin B receptors contribute to retinal ganglion cell loss in a rat model of glaucoma

Glaucoma is an optic neuropathy, commonly associated with elevated intraocular pressure (IOP) characterized by optic nerve degeneration, cupping of the optic disc, and loss of retinal ganglion cells which could lead to loss of vision. Endothelin-1 (ET-1) is a 21-amino acid vasoactive peptide that plays a key role in the pathogenesis of glaucoma; however, the receptors mediating these effects have not been defined. In the current study, endothelin B (ET_B) receptor expression was assessed in vivo, in the Morrison's ocular hypertension model of glaucoma in rats. Elevation of IOP in Brown Norway rats produced increased expression of ET_B receptors in the retina, mainly in retinal ganglion cells (RGCs), nerve fiber layer (NFL), and also in the inner plexiform layer (IPL) and inner nuclear layer (INL). To determine the role of ET_B receptors in neurodegeneration, Wistar-Kyoto wild type (WT) and ET_B receptor-deficient (KO) rats were subjected to retrograde labeling with Fluoro-Gold (FG), following which IOP was elevated in one eye while the contralateral eye served as control. IOP elevation for 4 weeks in WT rats caused an appreciable loss of RGCs, which was significantly attenuated in KO rats. In addition, degenerative changes in the optic nerve were greatly reduced in KO rats compared to those in WT rats. Taken together, elevated intraocular pressure mediated increase in ET_B receptor expression and its activation may contribute to a decrease in RGC survival as seen in glaucoma. These findings raise the possibility of using endothelin receptor antagonists as neuroprotective agents for the treatment of glaucoma.

Effect of Lycium barbarum Polysaccharides on the expression of endothelin-1 and its receptors in an ocular hypertension model of rat glaucoma

Lycium barbarum, a traditional Chinese anti-aging herb, has been shown to protect retinal ganglion cells (RGCs) in a rat chronic ocular hypertension (COH) model. Here, we investigated the expression of endothelin-1 (ET-1), a strong vasoconstrictor, and its receptors, ETA and ETB, in the COH model and assessed the effects of Lycium barbarum on the ET-1 axis. Elevated intraocular pressure (IOP) was induced in the right eye of SD rats using argon laser photocoagulation. (1) The expression of ET-1, ETA and ETB in normal and COH retinas was studied. (2) Some COH rats were fed daily with Lycium barbarum Polysaccharides (LBP) using 1 mg/kg or phosphate-buffered saline (PBS) for 3 weeks (started 1 week before photocoagulation). The effects of LBP on the expression of ET-1 and its receptors, ETA and ETB, in COH retina were evaluated. A semi-quantitative analysis of staining intensity was used to evaluate the expression levels of ET-1, ETA and ETB in retinal vasculature. We found that (1) Under COH condition, the immunoreactivity of ET-1 was increased in retina associated with an increase of ETB receptor immunoreactivity and a decrease of ETA receptor immunoreactivity. (2) After feeding COH rats with LBP, the expression of ET-1 was decreased with an increase of ETA expression and a decrease of ETB expression in the retina, especially in RGCs. (3) By comparing the staining intensity in the vasculature of COH retina in LBP-fed group with PBS-fed group, there was a decrease in the expression of ET-1 and ETA and an increase in ETB. In summary, ET-1 expression was up-regulated in the retina in COH model. LBP could decrease the expression of ET-1 and modulate the expression of its receptors, ETA and ETB, under the condition of COH. The neuroprotective effect of LBP on RGCs might be related to its ability to regulate the ET-1-mediated biological effects on RGCs and retinal vasculature.

Patient with Chiari malformation Type I presenting with inducible hemifacial weakness

In this report, the authors describe the first known case of inducible hemifacial weakness in a patient with Chiari malformation Type I (CM-I). The patient was a 14-year-old girl with a 1-year history of right facial paresis induced by sustained leftward head rotation. These episodes were characterized by weak activation of her right facial muscles with preserved eye opening and closure. Additionally, she had hypernasal speech, persistent headaches, and intermittent left arm twitching. Magnetic resonance imaging demonstrated a CM-I. A suboccipital craniectomy and C-1 laminectomy were performed for decompression of the CM-I, with duraplasty and coagulation of the pial surface of the cerebellar tonsils. At the 9-month follow-up, the patient's inducible hemifacial weakness had completely resolved. Her symptoms were thought to have resulted from the CM-I, perhaps due to traction on the right facial nerve by the ectopic tonsils with head rotation.

Endothelin, astrocytes and glaucoma

It has become increasingly clear that astrocytes may play an important role in the genesis of glaucoma. Astrogliosis occurs in response to ocular stress or the presence of noxious stimuli. Agents that appear to stimulate reactive gliosis are becoming increasingly clear. One class of agents that is emerging is the endothelins (ETs; specifically, ET-1). In this review we examine the interactions of ET-1 with astrocytes and provide examples where ET-1 appears to contribute to activation of astrocytes and play a role in the neurodegenerative effects that accompany such reactivation resulting in astrogliosis. These actions are presented in the context of glaucoma although information is also presented with respect to ET-1's role in the central nervous system and brain. While much has been learned with respect to ET-1/astrocyte interactions, there are still a number of questions concerning the potential therapeutic implications of these findings. Hopefully this review will stimulate others to examine this potential.

The role of endothelin in the pathophysiology of glaucoma

IMPORTANCE OF THE FIELD

Glaucoma is the second leading cause of blindness worldwide. To date, treatment of glaucoma has focused on lowering intraocular pressure (IOP) though there are other mechanisms that might damage the optic nerve, leading to characteristic visual field loss. Endothelin, a potent vasoconstrictor, is believed to play a role in the pathogenesis of glaucomatous optic neuropathy.

AREAS COVERED IN THIS REVIEW

We review the evidence from the last 20 years exploring the action of endothelin in the eye, its association with the pathophysiology of glaucoma, as well as the potential therapeutic role of targeting the endothelin pathway to affect disease progression in glaucomatous eyes.

WHAT THE READER WILL GAIN

The goal of this paper is to inform readers about endothelin structure, actions, and role in ocular pathology, pharmacology, and potential areas of future research.

TAKE HOME MESSAGE

Overall, we believe that the body of evidence supports the following conclusions; i) endothelin is a potent vasoconstrictor that plays a role in ocular physiology, ii) endothelin may play a role in the pathophysiology of glaucoma and iii) modulation of the endothelin system with newly discovered potent antagonists holds promise in treating glaucoma through both pressure-dependent and pressure-independent pathways.

Blood pressure, perfusion pressure, and glaucoma

PURPOSE

To provide a critical review of the relationships between blood pressure, ocular blood flow, and glaucoma and the potential for glaucoma treatment through modulation of ocular perfusion.

DESIGN

Summaries of the pertinent literature and input from glaucoma researchers and specialists with relevant experience.

METHODS

Review and interpretation of selected literature and the results of a 1-day group discussion involving glaucoma researchers and specialists with expertise in epidemiology, blood flow measurements, and cardiovascular physiology.

RESULTS

Accurate, reproducible, and clinically relevant measurements of blood flow within the optic nerve head and associated capillary beds are not fully achievable with current methodology. Autoregulation of blood flow in the retina and optic nerve head occurs over a large range of intraocular pressures and blood pressures. Regulation of choroidal blood flow is provided by a mix of neurohumoral and local mechanisms. Vascular factors may be important in a subgroup of patients with primary open-angle glaucoma, and particularly in patients with normal-tension glaucoma and evidence of vasospasm. Low ocular perfusion pressure and low blood pressure are associated with an increased risk of glaucoma in population-based studies. The physiologic nocturnal dip in blood pressure is protective against systemic end-organ damage, but its effects on glaucoma are not well elaborated or understood. Large-scale longitudinal studies would be required to evaluate the risk of glaucomatous progression in non-dippers, dippers, and extreme nocturnal blood pressure dippers.

CONCLUSIONS

Decreases in perfusion pressure and blood pressure have been associated with glaucoma. However, there is no evidence to support the value of increasing a patient's blood pressure as therapy for glaucoma. Such recommendations are not currently warranted, since we lack crucial information about the microvascular beds in which perfusion is important in glaucoma, and the appropriate methods to evaluate their blood flow. There are also cardiovascular safety concerns associated with treatments designed to increase ocular perfusion pressure and blood flow by increasing blood pressure, especially in elderly patients. For these reasons and with present evidence it is unlikely that safe and effective glaucoma treatments based on altering optic nerve perfusion will soon be available.