Lessons for Glaucoma From Other Neurodegenerative Diseases: Can One Treatment Suit Them All?*

Lycium Barbarum Polysaccharides Rescue Neurodegeneration in an Acute Ocular Hypertension Rat Model Under Pre- and Posttreatment Conditions

Purpose

To investigate the posttreatment neuronal rescue effects of Lycium barbarum polysaccharides (LBP) in an acute ocular hypertensive (AOH) model.

Methods

Intraocular pressure (IOP) was elevated manometrically to 80 mm Hg (AOH) or 15 mm Hg (sham) for 120 minutes in adult Sprague-Dawley rats. Five experimental groups were considered: Three AOH groups were pretreated with PBS (vehicle) (n = 9), LBP 1 mg/kg (n = 8), or 10 mg/kg (n = 13), and one AOH group was posttreated with LBP 10 mg/kg (n = 8), once daily. The sham cannulation group (n = 5) received no treatment. Pretreatments commenced 7 days before and posttreatment 6 hours after AOH, and continued up through postcannulation day 28. All the animals underwent optical coherence tomography and electroretinogram measurements at baseline and postcannulation days 10 and 28. The ganglion cell layer (GCL) densities were quantified at day 28.

Results

Both inner retinal layer thickness (IRLT) and positive scotopic threshold response (pSTR) underwent significant reduction (≥50% of thickness and amplitude) in the vehicle group (P < 0.05). Pretreatment with LBP 1 and 10 mg/kg retained 77 ± 11% and 89 ± 8% of baseline IRLT, respectively, and preserved pSTR functions. The posttreatment group showed a significant reduction in IRLT (-35 ± 8%, P < 0.001) and pSTR (∼48% of baseline, P < 0.001) on day 10. By day 28, there was an improvement in functional pSTR (∼72% of baseline, P > 0.05) with no significant further thinning (-40 ± 8%, P = 0.15) relative to day 10. GCL density was reduced in vehicle control (P = 0.0001), but did not differ between sham and pre- and posttreated AOH groups.

Conclusions

The rescue effect of LBP posttreatment was observed later, which arrested the secondary degeneration and improved the retinal function.

Neuroprotective strategies for retinal disease

Diseases that affect the eye, including photoreceptor degeneration, diabetic retinopathy, and glaucoma, affect 11.8 million people in the US, resulting in vision loss and blindness. Loss of sight affects patient quality of life and puts an economic burden both on individuals and the greater healthcare system. Despite the urgent need for treatments, few effective options currently exist in the clinic. Here, we review research on promising neuroprotective strategies that promote neuronal survival with the potential to protect against vision loss and retinal cell death. Due to the large number of neuroprotective strategies, we restricted our review to approaches that we had direct experience with in the laboratory. We focus on drugs that target survival pathways, including bile acids like UDCA and TUDCA, steroid hormones like progesterone, therapies that target retinal dopamine, and neurotrophic factors. In addition, we review rehabilitative methods that increase endogenous repair mechanisms, including exercise and electrical stimulation therapies. For each approach, we provide background on the neuroprotective strategy, including history of use in other diseases; describe potential mechanisms of action; review the body of research performed in the retina thus far, both in animals and in humans; and discuss considerations when translating each treatment to the clinic and to the retina, including which therapies show the most promise for each retinal disease. Despite the high incidence of retinal diseases and the complexity of mechanisms involved, several promising neuroprotective treatments provide hope to prevent blindness. We discuss attractive candidates here with the goal of furthering retinal research in critical areas to rapidly translate neuroprotective strategies into the clinic.

Autoimmune aspects in glaucoma

The pathogenesis of glaucoma, a common neurodegenerative disease, involves an immunologic component. Studies demonstrate changes of autoantibody concentrations against retinal and optic nerve head antigens in glaucoma patients. Furthermore we found antibody deposits in human glaucomatous retinae in a pro-inflammatory environment. Clinical studies showed up regulated, but also significantly down-regulated autoantibody levels. These antibodies belong to the natural autoimmunity. The upregulation of autoantibodies can be associated with fatal conditions, but several studies demonstrate that natural autoantibodies entail also neuroprotective characteristics and influence the protein expression of neuroretinal cells. A misbalance in the physiological equilibrium may shift from regulatory immunity into a neuroinflammatory degenerative process, what may lead to a predisposition to glaucoma. However, the protective nature of autoantibodies and the molecular mechanisms underlying the very sensitive equilibrium of natural autoimmunity between autoaggression and neuroprotection offer promising target sites for new therapeutic approaches. Finally, the changes in antibody profiles represent a new opportunity as highly sensitive and specific biomarkers for diagnostics purposes.

Citicoline: A Food Beneficial for Patients Suffering from or Threated with Glaucoma

Oral form of citicoline, a nootropic and neuroprotective drug in use for almost five decades, recently was pronounced a food supplement in both USA and EU. The idea of adding citicoline to topical treatment of primary open angle glaucoma (POAG) aimed at decreasing intraocular pressure (IOP) appeared as a logical consequence of accepting neurodegenerative character of this disease. Experimental data, and also few clinical studies indicate that this substance has potential to counteract some important pathological mechanisms which seem to contribute to POAG initiation and progression, such as excitotoxicity and oxidative stress.

The immunological basis of degenerative diseases of the eye

It has become clear that disorders that were once considered "degenerative" have complex mechanisms, with many having been shown to have immune mediation as part of the disease process. These include arteriosclerotic heart disease and Alzheimer's disease. Indeed, several ocular disorders that once fell into the "degenerative" category meet this criterion as well. Immune mediation has been shown to be a part of many of the most common ocular disorders, and not just that of uveitis, or ocular inflammatory disease.

Does autoimmunity play a part in the pathogenesis of glaucoma?

Glaucoma is a chronic neurodegenerative disease and one of the leading causes of blindness. Several risk factors have been described, e.g. an elevated intraocular pressure (IOP), oxidative stress or mitochondrial dysfunction. Additionally, alterations in serum antibody profiles of glaucoma patients, upregulation (e.g. anti-HSP60, anti-MBP) and downregulation (e.g. anti-14-3-3), have been described, but it still remains elusive if the autoantibodies seen in glaucoma are an epiphenomenon or causative. However, it is known that elicited autoimmunity causes retinal ganglion cell loss resulting in glaucomatous-like damage and according to the autoaggressive nature of some autoantibodies we found antibody deposits in human glaucomatous retinae in a pro-inflammatory environment. Furthermore, glaucomatous serum has the potential to influence neuroretinal cell regulatory processes. Importantly, we demonstrate that some autoantibodies hold neuroprotective potential for neuroretinal cells. The protective nature of autoantibodies and the molecular mechanisms underlying the very sensitive equilibrium between autoaggression and protection remain subject of future examinations and offer promising target sites for new therapeutic approaches. Additionally, the changes in antibody profiles could be used as highly sensitive and specific marker for diagnostics purposes. Early diagnosis and intervention in risk patients would offer the chance of early treatment and to slow down the progression of glaucoma and delay the resulting blindness.

Serum levels and H/L gene polymorphism of mannose-binding lectin in primary open angle glaucoma

PURPOSE

To analyze the serum levels and H/L gene polymorphisms of mannose-binding lectin-2 (MBL-2) in primary open angle glaucoma (POAG) cases and control subjects to investigate whether MBL-2 has a possible role in the development and pathogenesis of POAG.

MATERIALS AND METHODS

In 45 POAG cases and age and sex-matched 45 healthy controls, Elisa Kit was used to determine serum levels of MBL-2. The genomic DNA of patient and control groups was extracted from whole blood using High Pure PCR template preparation kit. Genotyping of MBL-2 polymorphisms were detected by using a MBL-2 mutation detection kit in real-time PCR. Chi-square or Fisher's Exact Tests were used to evaluate the distribution of MBL-2 H/L genotypes among patients and control subjects. Associations between the H/L genotype and POAG risk were analyzed by using binary logistic regression. The serum MBL-2 levels of both groups were compared with Independent Sample t-test.

RESULTS

Mean MBL-2 serum levels in the patient group (21.30 ± 4.97 µg/mL) was significantly higher than the control group (17.48 ± 3.66 µg/mL), (p < 0.001). The distribution of alleles in the patient group was 28.9% for LL, 44.4% for HL, 26.7% for HH and in controls was 33.3% for LL, 37.8% for HL, 28.3% for HH. According to genotype ratios, the two groups were not different from each other.

CONCLUSIONS

Our findings may suggest an association between high serum MBL-2 levels and POAG, but H/L gene polymorphism of MBL-2 seems not to be associated with POAG.

Survival effect of PDGF-CC rescues neurons from apoptosis in both brain and retina by regulating GSK3beta phosphorylation

Platelet-derived growth factor CC (PDGF-CC) is the third member of the PDGF family discovered after more than two decades of studies on the original members of the family, PDGF-AA and PDGF-BB. The biological function of PDGF-CC remains largely to be explored. We report a novel finding that PDGF-CC is a potent neuroprotective factor that acts by modulating glycogen synthase kinase 3β (GSK3β) activity. In several different animal models of neuronal injury, such as axotomy-induced neuronal death, neurotoxin-induced neuronal injury, 6-hydroxydopamine–induced Parkinson’s dopaminergic neuronal death, and ischemia-induced stroke, PDGF-CC protein or gene delivery protected different types of neurons from apoptosis in both the retina and brain. On the other hand, loss-of-function assays using PDGF-C null mice, neutralizing antibody, or short hairpin RNA showed that PDGF-CC deficiency/inhibition exacerbated neuronal death in different neuronal tissues in vivo. Mechanistically, we revealed that the neuroprotective effect of PDGF-CC was achieved by regulating GSK3β phosphorylation and expression. Our data demonstrate that PDGF-CC is critically required for neuronal survival and may potentially be used to treat neurodegenerative diseases. Inhibition of the PDGF-CC–PDGF receptor pathway for different clinical purposes should be conducted with caution to preserve normal neuronal functions.

Erratum: Psychoneuroimmunology: application to ocular diseases

Psychoneuroimmunology (PNI) is a relatively new discipline within the field of neuroscience which researches the relationship between emotional states, the central and peripheral nervous systems, and the endocrine and immune systems. Negative psychological states, such as stress, anxiety, and depression, may alter immune system regulation and modulation of peripheral cytokines. A plethora of PNI studies have shown that increased psychological stress and depression are associated with an alteration of immune functioning and worsened health outcomes for many conditions. To date, application of PNI methodology has not been reported for ocular diseases. This article provides an historical perspective on the origins of the rift between the emotional and spiritual from physical aspects of disease. A review of how stress is mediated through sympathetic adrenomedullary and hypothalamic pituitary axis activation with shifts in immunity is provided. The literature which supports spirituality in healing is presented. Finally, ocular diseases which would be most amenable to a PNI approach are discussed.

Erratum to: Immune maintenance in glaucoma: boosting the body's own neuroprotective potential

Glaucoma, a slow progressive neurodegenerative disorder associated with death of retinal ganglion cells and degeneration of their connected optic nerve fibers, has been classically linked to high intraocular pressure. Regardless of the primary risk factor, degeneration may continue, resulting in further loss of neurons and subsequent glaucomatous damage. During the past decade, scientists and clinicians began to accept that, in addition or as an alternative to fighting off the primary risk factor(s), there is a need to protect the tissue from the ongoing spread of damage-an approach collectively termed "neuroprotection." We found that the immune system, the body's own defense mechanism, plays a key role in the ability of the optic nerve and the retina to withstand glaucomatous conditions. This defense involves recruitment of both innate and adaptive immune cells that together create a protective niche and thereby halt disease progression. The spontaneous immune response might not be sufficient, and therefore, we suggest boosting it by immunization (with the appropriate antigen, at specific timing and predetermined optimal dosing) which may be developed into a suitable therapeutic vaccination to treat glaucoma. This view of immune system involvement in glaucoma will raise new challenges in glaucoma research, changing the way in which clinicians perceive the disease and the approach to therapy.[This corrects the article on p. in vol. .].

Psychoneuroimmunology: application to ocular diseases

Psychoneuroimmunology (PNI) is a relatively new discipline within the field of neuroscience which researches the relationship between emotional states, the central and peripheral nervous systems, and the endocrine and immune systems. Negative psychological states, such as stress, anxiety, and depression, may alter immune system regulation and modulation of peripheral cytokines. A plethora of PNI studies have shown that increased psychological stress and depression are associated with an alteration of immune functioning and worsened health outcomes for many conditions. To date, application of PNI methodology has not been reported for ocular diseases. This article provides an historical perspective on the origins of the rift between the emotional and spiritual from physical aspects of disease. A review of how stress is mediated through sympathetic adrenomedullary and hypothalamic pituitary axis activation with shifts in immunity is provided. The literature which supports spirituality in healing is presented. Finally, ocular diseases which would be most amenable to a PNI approach are discussed.

Immune maintenance in glaucoma: boosting the body's own neuroprotective potential

Glaucoma, a slow progressive neurodegenerative disorder associated with death of retinal ganglion cells and degeneration of their connected optic nerve fibers, has been classically linked to high intraocular pressure. Regardless of the primary risk factor, degeneration may continue, resulting in further loss of neurons and subsequent glaucomatous damage. During the past decade, scientists and clinicians began to accept that, in addition or as an alternative to fighting off the primary risk factor(s), there is a need to protect the tissue from the ongoing spread of damage-an approach collectively termed "neuroprotection." We found that the immune system, the body's own defense mechanism, plays a key role in the ability of the optic nerve and the retina to withstand glaucomatous conditions. This defense involves recruitment of both innate and adaptive immune cells that together create a protective niche and thereby halt disease progression. The spontaneous immune response might not be sufficient, and therefore, we suggest boosting it by immunization (with the appropriate antigen, at specific timing and predetermined optimal dosing) which may be developed into a suitable therapeutic vaccination to treat glaucoma. This view of immune system involvement in glaucoma will raise new challenges in glaucoma research, changing the way in which clinicians perceive the disease and the approach to therapy.

Optineurin negatively regulates TNFalpha- induced NF-kappaB activation by competing with NEMO for ubiquitinated RIP

NF-kappaB essential modulator (NEMO), the regulatory subunit of the IkappaB kinase (IKK) that activates NF-kappaB, is essential for NF-kappaB activation. NEMO was recently found to contain a region that preferentially binds Lys (K)63-linked but not K48-linked polyubiquitin (polyUb) chains, and the ability of NEMO to bind to K63-linked polyUb RIP (receptor-interacting protein) is necessary for efficient tumor necrosis factor alpha (TNFalpha)-induced NF-kappaB activation. Optineurin is a homolog of NEMO, and mutations in the optineurin gene are found in a subset of patients with glaucoma, a neurodegenerative disease involving the loss of retinal ganglion cells. Although optineurin shares considerable homology with NEMO, in resting cells, it is not present in the high-molecular-weight complex containing IKKalpha and IKKbeta, and optineurin cannot substitute for NEMO in lipopolysaccharide (LPS)-induced NF-kappaB activation. On the other hand, the overexpression of optineurin blocks the protective effect of E3-14.7K on cell death caused by the overexpression of TNFalpha receptor 1 (TNFR1). Here we show that optineurin has a K63-linked polyUb-binding region similar to that of NEMO, and like NEMO, it bound K63- but not K48-linked polyUb. Optineurin competitively antagonized NEMO's binding to polyUb RIP, and its overexpression inhibited TNFalpha-induced NF-kappaB activation. This competition occurs at physiologic protein levels because microRNA silencing of optineurin resulted in markedly enhanced TNFalpha-induced NF-kappaB activity. These results reveal a physiologic role for optineurin in dampening TNFalpha signaling, and this role might provide an explanation for its association with glaucoma.

Erythropoietin: a candidate neuroprotective agent in the treatment of glaucoma

Glaucoma is a progressive optic neuropathy that is the leading cause of irreversible blindness in the world. Although methods to lower intraocular pressure are the mainstay of glaucoma therapy, there are currently no available treatment modalities targeted at neuroprotection. Erythropoietin is a hematopoietic cytokine that has been shown to possess remarkable tissue-protective properties in preclinical models of neurodegeneration. As a result, there is a growing interest to explore the neuroprotective properties of erythropoietin as a possible therapeutic agent in neuropathic diseases of the eye such as glaucoma. Initial results in animal models have been promising, but further studies are needed to fully evaluate the safety and efficacy of this candidate neuroprotective agent in clinical trials.

Light at the end of the tunnel? Advances in the understanding and treatment of glaucoma and inherited retinal degeneration

Glaucoma and inherited retinal degeneration/dystrophy are leading causes of blindness in veterinary patients. Currently, there is no treatment for the loss of vision that characterizes both groups of diseases. However, this reality may soon change as recent advances in understanding of the disease processes allow researchers to develop new therapies aimed at preventing blindness and restoring vision to blind patients. Elucidating the molecular mechanisms of retinal ganglion cell death in glaucoma patients has led to the development of neuroprotective drugs which protect retinal cells and their function from the disastrous effects of elevated pressure. Identification of the genetic mutation responsible for inherited degenerations and dystrophies of the outer retina has enabled researchers using gene therapy to restore vision to blind dogs. Other patients may benefit from retinal transplantation, stem cell therapy, neuroprotective drugs, nutritional supplementation and even retinal prostheses. It is possible that soon it will be possible to restore sight to some blind patients.

No Increased Risk of Developing Alzheimer Disease in Patients With Glaucoma

PURPOSE

To investigate whether primary open-angle glaucoma (POAG) is associated with increased risk of developing Alzheimer disease (AD).

METHODS

In a nationwide case register linkage study of patients with hospital admission or outpatient contact during the period from 1977 to 2001 in Denmark, the rate of subsequent AD for patients with a diagnosis of POAG was compared with the rate for patients with primary angle-closure glaucoma (PACG), cataract, and osteoarthritis (OA) and with the rate for the general population.

RESULTS

A total of 11,721 patients with a diagnosis of POAG (including normal tension glaucoma), 5975 patients with PACG, 162,640 patients with cataract, and 230,208 patients with OA were identified in the registers. Patients with POAG did not have increased rate of subsequent AD compared to patients with PACG, cataract, or OA or compared with the general population.

CONCLUSIONS

POAG was not associated with increased risk of developing AD. It cannot be excluded that this negative finding is due to diagnostic misclassification as register data were used.