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Warwick AM, Bomze HM, Wang L, Hao Y, Stinnett SS, Gospe SM. Hypoxia-mediated rescue of retinal ganglion cells deficient in mitochondrial complex I is independent of the hypoxia-inducible factor pathway. Sci Rep 2024; 14:24114. [PMID: 39406814 PMCID: PMC11480089 DOI: 10.1038/s41598-024-75916-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2024] [Accepted: 10/09/2024] [Indexed: 10/19/2024] Open
Abstract
Continuous exposure to environmental hypoxia (11% O2) has been shown to markedly slow the progressive degeneration of retinal ganglion cells (RGCs) in a mouse model of mitochondrial optic neuropathy with RGC-specific deletion of the key mitochondrial complex I accessory subunit ndufs4. As a first step toward identifying the therapeutic mechanism of hypoxia in this model, we conducted a series of experiments to investigate the role of the hypoxia-inducible factor (HIF) regulatory pathway in RGC neuroprotection. Vglut2-Cre; ndufs4loxP/loxP mice were crossed with strains bearing floxed alleles of the negative HIF regulatory vhl or of the two major HIF α-subunit isoforms, Hif1α and Hif2α. Deletion of vhl within ndufs4-deficient RGCs failed to prevent RGC degeneration under normoxia, indicating that HIF activation is not sufficient to achieve RGC rescue. Furthermore, the rescue of ndufs4-deficient RGCs by hypoxia remained robust despite genetic inactivation of Hif1α and Hif2α. Our findings demonstrate that the HIF pathway is entirely dispensable to the rescue of RGCs by hypoxia. Future efforts to uncover key HIF-independent molecular pathways induced by hypoxia in this mouse model may be of therapeutic relevance to mitochondrial optic neuropathies such as Leber hereditary optic neuropathy.
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Affiliation(s)
- Alexander M Warwick
- Department of Ophthalmology, Duke University School of Medicine, Durham, NC, 27710, USA
| | - Howard M Bomze
- Department of Ophthalmology, Duke University School of Medicine, Durham, NC, 27710, USA
| | - Luyu Wang
- Department of Ophthalmology, Duke University School of Medicine, Durham, NC, 27710, USA
| | - Ying Hao
- Department of Ophthalmology, Duke University School of Medicine, Durham, NC, 27710, USA
| | - Sandra S Stinnett
- Department of Ophthalmology, Duke University School of Medicine, Durham, NC, 27710, USA
| | - Sidney M Gospe
- Department of Ophthalmology, Duke University School of Medicine, Durham, NC, 27710, USA.
- Department of Ophthalmology, Box 3712 Med Center, Duke University, 2351 Erwin Road, Durham, NC, 27710, USA.
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Muangkram Y, Himeno Y, Amano A. Clarifying the composition of the ATP consumption factors required for maintaining ion homeostasis in mouse rod photoreceptors. Sci Rep 2023; 13:14161. [PMID: 37644037 PMCID: PMC10465610 DOI: 10.1038/s41598-023-40663-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 08/16/2023] [Indexed: 08/31/2023] Open
Abstract
To date, no effective treatment has been established for photoreceptor loss due to energy imbalances, but numerous therapeutic approaches have reported some success in slowing photoreceptor degeneration by downregulating energy demand. However, the detailed mechanisms remain unclear. This study aimed to clarify the composition of ATP consumption factors in photoreceptors in darkness and in light. We introduced mathematical formulas for ionic current activities combined with a phototransduction model to form a new mathematical model for estimating the energy expenditure of each ionic current. The proposed model included various ionic currents identified in mouse rods using a gene expression database incorporating an available electrophysiological recording of each specific gene. ATP was mainly consumed by Na+/K+-ATPase and plasma membrane Ca2+-ATPase pumps to remove excess Na+ and Ca2+. The rod consumed 7 [Formula: see text] 107 molecules of ATP s-1, where 65% was used to remove ions from the cyclic nucleotide-gated channel and 20% from the hyperpolarization-activated current in darkness. Increased light intensity raised the energy requirements of the complex phototransduction cascade mechanisms. Nevertheless, the overall energy consumption was less than that in darkness due to the significant reduction in ATPase activities, where the hyperpolarization-activated current proportion increased to 83%. A better understanding of energy demand/supply may provide an effective tool for investigating retinal pathophysiological changes and analyzing novel therapeutic treatments related to the energy consumption of photoreceptors.
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Affiliation(s)
- Yuttamol Muangkram
- Department of Bioinformatics, College of Life Sciences, Ritsumeikan University, Shiga, Japan.
| | - Yukiko Himeno
- Department of Bioinformatics, College of Life Sciences, Ritsumeikan University, Shiga, Japan
| | - Akira Amano
- Department of Bioinformatics, College of Life Sciences, Ritsumeikan University, Shiga, Japan
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Warwick AM, Bomze HM, Wang L, Klingeborn M, Hao Y, Stinnett SS, Gospe III SM. Continuous Hypoxia Reduces Retinal Ganglion Cell Degeneration in a Mouse Model of Mitochondrial Optic Neuropathy. Invest Ophthalmol Vis Sci 2022; 63:21. [PMID: 36538003 PMCID: PMC9769749 DOI: 10.1167/iovs.63.13.21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Purpose To test whether continuous hypoxia is neuroprotective to retinal ganglion cells (RGCs) in a mouse model of mitochondrial optic neuropathy. Methods RGC degeneration was assessed in genetically modified mice in which the floxed gene for the complex I subunit NDUFS4 is deleted from RGCs using Vlgut2-driven Cre recombinase. Beginning at postnatal day 25 (P25), Vglut2-Cre;ndufs4loxP/loxP mice and control littermates were housed under hypoxia (11% oxygen) or kept under normoxia (21% oxygen). Survival of RGC somas and axons was assessed at P60 and P90 via histological analysis of retinal flatmounts and optic nerve cross-sections, respectively. Retinal tissue was also assessed for gliosis and neuroinflammation using western blot and immunofluorescence. Results Consistent with our previous characterization of this model, at least one-third of RGCs had degenerated by P60 in Vglut2-Cre;ndufs4loxP/loxP mice remaining under normoxia. However, continuous hypoxia resulted in complete rescue of RGC somas and axons at this time point, with normal axonal myelination observed on electron microscopy. Though only partial, hypoxia-mediated rescue of complex I-deficient RGC somas and axons remained significant at P90. Hypoxia prevented reactive gliosis at P60, but the retinal accumulation of Iba1+ mononuclear phagocytic cells was not substantially reduced. Conclusions Continuous hypoxia achieved dramatic rescue of early RGC degeneration in mice with severe mitochondrial dysfunction. Although complete rescue was not durable to P90, our observations suggest that investigating the mechanisms underlying hypoxia-mediated neuroprotection of RGCs may identify useful therapeutic strategies for optic neuropathies resulting from less profound mitochondrial impairment, such as Leber hereditary optic neuropathy.
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Affiliation(s)
- Alexander M. Warwick
- Department of Ophthalmology, Duke University School of Medicine, Durham, North Carolina, United States
| | - Howard M. Bomze
- Department of Ophthalmology, Duke University School of Medicine, Durham, North Carolina, United States,Department of Pharmacology and Cancer Biology, Duke University School of Medicine, Durham, North Carolina, United States
| | - Luyu Wang
- Department of Ophthalmology, Duke University School of Medicine, Durham, North Carolina, United States
| | - Mikael Klingeborn
- Department of Ophthalmology, Duke University School of Medicine, Durham, North Carolina, United States
| | - Ying Hao
- Department of Ophthalmology, Duke University School of Medicine, Durham, North Carolina, United States
| | - Sandra S. Stinnett
- Department of Ophthalmology, Duke University School of Medicine, Durham, North Carolina, United States
| | - Sidney M. Gospe III
- Department of Ophthalmology, Duke University School of Medicine, Durham, North Carolina, United States
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4
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Fu Z, Nilsson AK, Hellstrom A, Smith LEH. Retinopathy of prematurity: Metabolic risk factors. eLife 2022; 11:e80550. [PMID: 36420952 PMCID: PMC9691009 DOI: 10.7554/elife.80550] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 11/16/2022] [Indexed: 11/25/2022] Open
Abstract
At preterm birth, the retina is incompletely vascularized. Retinopathy of prematurity (ROP) is initiated by the postnatal suppression of physiological retinal vascular development that would normally occur in utero. As the neural retina slowly matures, increasing metabolic demand including in the peripheral avascular retina, leads to signals for compensatory but pathological neovascularization. Currently, only late neovascular ROP is treated. ROP could be prevented by promoting normal vascular growth. Early perinatal metabolic dysregulation is a strong but understudied risk factor for ROP and other long-term sequelae of preterm birth. We will discuss the metabolic and oxygen needs of retina, current treatments, and potential interventions to promote normal vessel growth including control of postnatal hyperglycemia, dyslipidemia and hyperoxia-induced retinal metabolic alterations. Early supplementation of missing nutrients and growth factors and control of supplemental oxygen promotes physiological retinal development. We will discuss the current knowledge gap in retinal metabolism after preterm birth.
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Affiliation(s)
- Zhongjie Fu
- Department of Ophthalmology, Boston Children’s Hospital, Harvard Medical SchoolBostonUnited States
| | - Anders K Nilsson
- The Sahlgrenska Centre for Pediatric Ophthalmology Research, Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of GothenburgGothenburgSweden
| | - Ann Hellstrom
- The Sahlgrenska Centre for Pediatric Ophthalmology Research, Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of GothenburgGothenburgSweden
| | - Lois EH Smith
- Department of Ophthalmology, Boston Children’s Hospital, Harvard Medical SchoolBostonUnited States
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Avrutsky MI, Lawson JM, Smart JE, Chen CW, Troy CM. Noninvasive Ophthalmic Imaging Measures Retinal Degeneration and Vision Deficits in Ndufs4-/- Mouse Model of Mitochondrial Complex I Deficiency. Transl Vis Sci Technol 2022; 11:5. [PMID: 35921115 PMCID: PMC9360534 DOI: 10.1167/tvst.11.8.5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Purpose To characterize postnatal ocular pathology in a Ndufs4−/− mouse model of complex I deficiency using noninvasive retinal imaging and visual testing. Methods Ndufs4−/− mice and wild-type (WT) littermates were analyzed at 3, 5, and 7 weeks postnatal. Retinal morphology was visualized by optical coherence tomography (OCT). OCT images were analyzed for changes in retinal thickness and reflectivity profiles. Visual function was assessed by electroretinogram (ERG) and optomotor reflex (OMR). Results Ndufs4−/− animals have normal OCT morphology at weaning and develop inner plexiform layer atrophy over weeks 5 to 7. Outer retinal layers show hyporeflectivity of the external limiting membrane (ELM) and photoreceptor ellipsoid zone (EZ). Retinal function is impaired at 3 weeks, with profound deficits in b-wave, a-wave, and oscillatory potential amplitudes. The b-wave and oscillatory potential implicit times are delayed, but the a-wave implicit time is unaffected. Ndufs4−/− animals have normal OMR at 3 weeks and present with increasing acuity and contrast OMR deficits at 5 and 7 weeks. Physiological thinning of inner retinal layers, attenuation of ELM reflectivity, and attenuation of ERG b- and a-wave amplitudes occur in WT C57BL/6 littermates between weeks 3 and 7. Conclusions Noninvasive ocular imaging captures early-onset retinal degeneration in Ndufs4−/− mice and is a tractable approach for investigating retinal pathology subsequent to complex I deficiency. Translational Relevance Ophthalmic imaging captures clinically relevant measures of retinal disease in a fast-progressing mouse model of complex I deficiency consistent with human Leigh syndrome.
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Affiliation(s)
- Maria I Avrutsky
- Department of Pathology and Cell Biology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Jacqueline M Lawson
- Department of Pathology and Cell Biology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Jade E Smart
- Department of Pathology and Cell Biology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Claire W Chen
- Department of Pathology and Cell Biology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Carol M Troy
- Department of Pathology and Cell Biology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA.,Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA.,The Taub Institute for Research on Alzheimer's Disease and the Aging Brain, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
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6
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Emilsson V, Gudmundsson EF, Jonmundsson T, Jonsson BG, Twarog M, Gudmundsdottir V, Li Z, Finkel N, Poor S, Liu X, Esterberg R, Zhang Y, Jose S, Huang CL, Liao SM, Loureiro J, Zhang Q, Grosskreutz CL, Nguyen AA, Huang Q, Leehy B, Pitts R, Aspelund T, Lamb JR, Jonasson F, Launer LJ, Cotch MF, Jennings LL, Gudnason V, Walshe TE. A proteogenomic signature of age-related macular degeneration in blood. Nat Commun 2022; 13:3401. [PMID: 35697682 PMCID: PMC9192739 DOI: 10.1038/s41467-022-31085-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 06/01/2022] [Indexed: 12/28/2022] Open
Abstract
Age-related macular degeneration (AMD) is one of the most common causes of visual impairment in the elderly, with a complex and still poorly understood etiology. Whole-genome association studies have discovered 34 genomic regions associated with AMD. However, the genes and cognate proteins that mediate the risk, are largely unknown. In the current study, we integrate levels of 4782 human serum proteins with all genetic risk loci for AMD in a large population-based study of the elderly, revealing many proteins and pathways linked to the disease. Serum proteins are also found to reflect AMD severity independent of genetics and predict progression from early to advanced AMD after five years in this population. A two-sample Mendelian randomization study identifies several proteins that are causally related to the disease and are directionally consistent with the observational estimates. In this work, we present a robust and unique framework for elucidating the pathobiology of AMD.
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Affiliation(s)
- Valur Emilsson
- Icelandic Heart Association, Holtasmari 1, IS-201, Kopavogur, Iceland.
- Faculty of Medicine, University of Iceland, 101, Reykjavik, Iceland.
| | | | | | | | - Michael Twarog
- Novartis Institutes for Biomedical Research, 22 Windsor Street, Cambridge, MA, 02139, USA
| | - Valborg Gudmundsdottir
- Icelandic Heart Association, Holtasmari 1, IS-201, Kopavogur, Iceland
- Faculty of Medicine, University of Iceland, 101, Reykjavik, Iceland
| | - Zhiguang Li
- Laboratory of Epidemiology and Population Sciences, National Institute on Aging, Bethesda, MD, USA
| | - Nancy Finkel
- Novartis Institutes for Biomedical Research, 22 Windsor Street, Cambridge, MA, 02139, USA
| | - Stephen Poor
- Novartis Institutes for Biomedical Research, 22 Windsor Street, Cambridge, MA, 02139, USA
| | - Xin Liu
- Novartis Institutes for Biomedical Research, 22 Windsor Street, Cambridge, MA, 02139, USA
| | - Robert Esterberg
- Novartis Institutes for Biomedical Research, 22 Windsor Street, Cambridge, MA, 02139, USA
| | - Yiyun Zhang
- Novartis Institutes for Biomedical Research, 22 Windsor Street, Cambridge, MA, 02139, USA
| | - Sandra Jose
- Novartis Institutes for Biomedical Research, 22 Windsor Street, Cambridge, MA, 02139, USA
| | - Chia-Ling Huang
- Novartis Institutes for Biomedical Research, 22 Windsor Street, Cambridge, MA, 02139, USA
| | - Sha-Mei Liao
- Novartis Institutes for Biomedical Research, 22 Windsor Street, Cambridge, MA, 02139, USA
| | - Joseph Loureiro
- Novartis Institutes for Biomedical Research, 22 Windsor Street, Cambridge, MA, 02139, USA
| | - Qin Zhang
- Novartis Institutes for Biomedical Research, 22 Windsor Street, Cambridge, MA, 02139, USA
| | - Cynthia L Grosskreutz
- Novartis Institutes for Biomedical Research, 22 Windsor Street, Cambridge, MA, 02139, USA
| | - Andrew A Nguyen
- Novartis Institutes for Biomedical Research, 22 Windsor Street, Cambridge, MA, 02139, USA
| | - Qian Huang
- Novartis Institutes for Biomedical Research, 22 Windsor Street, Cambridge, MA, 02139, USA
| | - Barrett Leehy
- Novartis Institutes for Biomedical Research, 22 Windsor Street, Cambridge, MA, 02139, USA
| | - Rebecca Pitts
- Novartis Institutes for Biomedical Research, 22 Windsor Street, Cambridge, MA, 02139, USA
| | - Thor Aspelund
- Icelandic Heart Association, Holtasmari 1, IS-201, Kopavogur, Iceland
| | - John R Lamb
- Novartis Institutes for Biomedical Research, 10675 John Jay Hopkins Drive, San Diego, CA, 92121, USA
| | - Fridbert Jonasson
- Faculty of Medicine, University of Iceland, 101, Reykjavik, Iceland
- Department of Ophthalmology, University Hospital, Reykjavik, Iceland
| | - Lenore J Launer
- Laboratory of Epidemiology and Population Sciences, National Institute on Aging, Bethesda, MD, USA
| | - Mary Frances Cotch
- Division of Epidemiology and Clinical Applications, National Eye Institute, National Institutes of Health, Bethesda, MD, USA
| | - Lori L Jennings
- Novartis Institutes for Biomedical Research, 22 Windsor Street, Cambridge, MA, 02139, USA
| | - Vilmundur Gudnason
- Icelandic Heart Association, Holtasmari 1, IS-201, Kopavogur, Iceland
- Faculty of Medicine, University of Iceland, 101, Reykjavik, Iceland
| | - Tony E Walshe
- Novartis Institutes for Biomedical Research, 22 Windsor Street, Cambridge, MA, 02139, USA.
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7
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Abstract
The outer retina is nourished from the choroid, a capillary bed just inside the sclera. O2, glucose, and other nutrients diffuse out of the choroid and then filter through a monolayer of retinal pigment epithelium (RPE) cells to fuel the retina. Recent studies of energy metabolism have revealed striking differences between retinas and RPE cells in the ways that they extract energy from fuels. The purpose of this review is to suggest and evaluate the hypothesis that the retina and RPE have complementary metabolic roles that make them depend on each other for survival and for their abilities to perform essential and specialized functions. Expected final online publication date for the Annual Review of Vision Science, Volume 7 is September 2021. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.
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Affiliation(s)
- James B Hurley
- Departments of Biochemistry and Ophthalmology, University of Washington, Seattle, Washington 98115, USA;
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Progressive optic atrophy in a retinal ganglion cell-specific mouse model of complex I deficiency. Sci Rep 2020; 10:16326. [PMID: 33004958 PMCID: PMC7529752 DOI: 10.1038/s41598-020-73353-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 09/16/2020] [Indexed: 02/06/2023] Open
Abstract
Optic atrophy resulting from retinal ganglion cell (RGC) degeneration is a prominent ocular manifestation of mitochondrial dysfunction. Although transgenic mice lacking the mitochondrial complex I accessory subunit NDUFS4 develop early-onset optic atrophy, severe systemic mitochondrial dysfunction leads to very early death and makes this mouse line impractical for studying the pathobiology of mitochondrial optic neuropathies. Theoretically, RGC-specific inactivation of ndufs4 would allow characterization of RGC degeneration over a longer time course, provided that RGC death from mitochondrial dysfunction is a cell-autonomous process. We demonstrate that the vesicular glutamate transporter VGLUT2 may be exploited to drive robust Cre recombinase expression in RGCs without any expression observed in directly neighboring retinal cell types. Deletion of ndufs4 in RGCs resulted in reduced expression of NDUFS4 protein within the optic nerves of Vglut2-Cre;ndufs4loxP/loxP mice. RGC degeneration in Vglut2-Cre;ndufs4loxP/loxP retinas commenced around postnatal day 45 (P45) and progressed to loss of two-thirds of RGCs by P90, confirming that intrinsic complex I dysfunction is sufficient to induce RGC death. The rapidly-developing optic atrophy makes the Vglut2-Cre;ndufs4loxP/loxP mouse line a promising preclinical model for testing therapies for currently untreatable mitochondrial optic neuropathies such as Leber Hereditary Optic Neuropathy.
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Dembla E, Dembla M, Maxeiner S, Schmitz F. Synaptic ribbons foster active zone stability and illumination-dependent active zone enrichment of RIM2 and Cav1.4 in photoreceptor synapses. Sci Rep 2020; 10:5957. [PMID: 32249787 PMCID: PMC7136232 DOI: 10.1038/s41598-020-62734-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Accepted: 03/18/2020] [Indexed: 02/08/2023] Open
Abstract
Rod photoreceptor synapses use large, ribbon-type active zones for continuous synaptic transmission during light and dark. Since ribbons are physically connected to the active zones, we asked whether illumination-dependent changes of ribbons influence Cav1.4/RIM2 protein clusters at the active zone and whether these illumination-dependent effects at the active zone require the presence of the synaptic ribbon. We found that synaptic ribbon length and the length of presynaptic Cav1.4/RIM2 clusters are tightly correlated. Dark-adaptation did not change the number of ribbons and active zone puncta. However, mean ribbon length and length of presynaptic Cav1.4/RIM2 clusters increased significantly during dark-adaptation when tonic exocytosis is highest. In the present study, we identified by the analyses of synaptic ribbon-deficient RIBEYE knockout mice that synaptic ribbons are (1) needed to stabilize Cav1.4/RIM2 at rod photoreceptor active zones and (2) are required for the darkness-induced active zone enrichment of Cav1.4/RIM2. These data propose a role of the ribbon in active zone stabilization and suggest a homeostatic function of the ribbon in illumination-dependent active zone remodeling.
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Affiliation(s)
- Ekta Dembla
- Institute of Anatomy and Cell Biology, Department of Neuroanatomy, Saarland University, Medical School, 66421, Homburg, Germany.
| | - Mayur Dembla
- Institute of Anatomy and Cell Biology, Department of Neuroanatomy, Saarland University, Medical School, 66421, Homburg, Germany
| | - Stephan Maxeiner
- Institute of Anatomy and Cell Biology, Department of Neuroanatomy, Saarland University, Medical School, 66421, Homburg, Germany
- Institute of Anatomy and Cell Biology, Saarland University, AG Krasteva-Christ, 66421, Homburg, Germany
| | - Frank Schmitz
- Institute of Anatomy and Cell Biology, Department of Neuroanatomy, Saarland University, Medical School, 66421, Homburg, Germany.
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