Update on Geographic Atrophy in Age-Related Macular Degeneration

Nano-enhanced Optical Gene Delivery to Retinal Degenerated Mice

BACKGROUND

The efficient and targeted delivery of genes and other impermeable therapeutic molecules into retinal cells is of immense importance for the therapy of various visual disorders. Traditional methods for gene delivery require viral transfection, or chemical methods that suffer from one or many drawbacks, such as low efficiency, lack of spatially targeted delivery, and can generally have deleterious effects, such as unexpected inflammatory responses and immunological reactions.

METHODS

We aim to develop a continuous wave near-infrared laser-based Nano-enhanced Optical Delivery (NOD) method for spatially controlled delivery of ambient-light-activatable Muti-Characteristic opsin-encoding genes into retina in-vivo and ex-vivo. In this method, the optical field enhancement by gold nanorods is utilized to transiently permeabilize cell membrane, enabling delivery of exogenous impermeable molecules to nanorod-binding cells in laser-irradiated regions.

RESULTS AND DISCUSSION

With viral or other non-viral (e.g. electroporation, lipofection) methods, gene is delivered everywhere, causing uncontrolled expression over the whole retina. This will cause complications in the functioning of non-degenerated areas of the retina. In the NOD method, the contrast in temperature rise in laser-irradiated nanorod-attached cells at nano-hotspots is significant enough to allow site-specific delivery of large genes. The in-vitro and in-vivo results using NOD, clearly demonstrate in-vivo gene delivery and functional cellular expression in targeted retinal regions without compromising the structural integrity of the eye or causing immune response.

CONCLUSION

The successful delivery and expression of MCO in the targeted retina after in-vivo NOD in the mice models of retinal degeneration opens a new vista for re-photosensitizing retina with geographic atrophies, such as in dry age-related macular degeneration.

Near-Infrared Laser-Based Spatially Targeted Nano-enhanced Optical Delivery of Therapeutic Genes to Degenerated Retina

Non-viral delivery of therapeutic genes into targeted areas of retina is essential for re-functionalizing the retinal circuitry. While a focused ultrafast laser beam has been recently used for intra-ocular delivery of molecules, it poses the significant technical challenge of overcoming aberrations of the eye and maintaining a tightly focused spot on the retinal cell membrane. Furthermore, to minimize collateral damage and increase the throughput of gene delivery, we introduced a weakly focused near-infrared (NIR) continuous wave (CW) or pulsed laser beam on to the cells wherein the intensity is locally enhanced by gold nanorods bound to the cell membranes to permit gene insertion. Parametric optimization of nano-enhanced optical delivery (NOD) was carried out by varying the exposure time, as well as the power of the CW NIR beam or the energy of the pulsed NIR beam. Using this NOD method, therapeutic genes encoding for multi-characteristic opsins (MCOs) were delivered to spatially targeted regions of degenerated retina ex vivo as well as in vivo. NOD-mediated cell membrane-specific expression of MCOs in targeted retinal regions with photoreceptor degeneration will allow functional recovery in an ambient light environment.

Crocetin Prevents RPE Cells from Oxidative Stress through Protection of Cellular Metabolic Function and Activation of ERK1/2

Age-related macular degeneration (AMD) is a leading cause for visual impairment in aging populations with limited established therapeutic interventions available. Oxidative stress plays an essential role in the pathogenesis of AMD, damaging the retinal pigment epithelium (RPE), which is essential for the function and maintenance of the light-sensing photoreceptors. This study aimed to evaluate the effects of crocetin, one of the main components of Saffron, on an in vitro RPE model of tert-butyl hydroperoxide (TBHP) induced oxidative stress using ARPE19 cells. The effects of crocetin were assessed using lactate de-hydrogenase (LDH) and ATP assays, as well as immunocytochemistry for cell morphology, junctional integrity, and nuclear morphology. The mechanism of crocetin action was determined via assessment of energy production pathways, including mitochondrial respiration and glycolysis in real-time as well as investigation of extracellular signal-regulated kinase 1/2 (ERK1/2) activation and distribution. Our results show that crocetin pre-treatment protects ARPE19 cells from TBHP-induced LDH release, intracellular ATP depletion, nuclear condensation, and disturbance of junctional integrity and cytoskeleton. The protective effect of crocetin is mediated via the preservation of energy production pathways and activation of ERK1/2 in the first minutes of TBHP exposure to potentiate survival pathways. The combined data suggest that a natural antioxidant, such as crocetin, represents a promising candidate to prevent oxidative stress in RPE cells and might halt or delay disease progression in AMD.

Involvement of NYD-SP15 in growth and oxidative-stress responses of ARPE-19

The aim of this study was to investigate the role of NYD-SP15 in the growth and oxidative-stress responses of ARPE-19 cells. ARPE-19 cell lines overexpressing wild type or RNA interference against NYD-SP15 were established via lentivirus transfection. Cell growth and proliferation, migration, apoptosis, and cell cycle progression were monitored using the Cell Counting Kit-8 assay, the wound scratch assay, and flow cytometry, respectively. Caspase-3/8/9 activity was examined using the caspase-3/8/9 assay kit. An hydrogen peroxide (H ₂ O ₂ )-induced oxidative-stress damage model was used to study the effect of NYD-SP15 knockdown by examining the activity of reactive oxygen species (ROS). Expressions of Kelch-like ECH-associated protein 1 (Keap-1)/heme oxygenase-1 (HO-1)/nuclear factor erythroid 2-related factor 2 (Nrf2), mitogen-activated protein kinase (MAPK), and Akt were detected by Western blot analysis. The mRNA chip of NYD-SP15 overexpressed ARPE-19 cells as well as controls were performed by one array plus process. Overexpression (OE) of NYD-SP15 inhibited the proliferation and migration of ARPE-19 cells, and led to apoptosis and caspase-3/9 activation. OE of NYD-SP15 inhibited MAPKs and Akt signaling. Downregulation of NYD-SP15 had no effect on the growth of normally cultured ARP19 cells with 10% fetal bovine serum, but promoted the growth of ARP19 cells in the presence of starvation challenge. Gene chip showed that OE of NYD-SP15 led to downregulation of 254 genes and upregulation of 57 genes. Downregulation of NYD-SP15 also exerted a protective effect on H ₂ O ₂ -induced cell apoptosis and ROS. NYD-SP15 downregulation led to increments in the expression of Nrf2, Keap-1, and HO-1 in response to 200 μM H ₂ O ₂ . NYD-SP15 might inhibit the growth, proliferation, and migration and promote apoptosis of ARPE-19 cells via MAPK and Akt signaling. Downregulation of NYD-SP15 could protect ARPE-19 cells from H ₂ O ₂ -induced oxidative damage by active Keap-1/HO-1/Nrf2, Akt, and MAPK signaling.

Microperimetry for geographic atrophy secondary to age-related macular degeneration

Geographic atrophy (GA) is a progressive, advanced form of age-related macular degeneration leading to visual function impairment and irreversible vision loss. Standard clinical tests to evaluate visual function in patients with GA provide poor anatomic-functional correlation, whereas fundus imaging does not assess the visual function deficit. Microperimetry is a psychophysical visual function test that spatially maps retinal sensitivity and allows for identification of correlation of anatomic features with visual function. In this review, we present an overview of mesopic microperimetry for GA, including commercially available microperimetry devices, strategies to capture a mesopic microperimetry test, and strategies to assess and interpret microperimetry data in patients with GA. We demonstrate the importance of microperimetry data for assessing GA progression and for evaluating visual function loss through anatomic-functional correlations. Although valuable, current microperimetry tests require an extensive time commitment from the patient and examiner, and the development of faster, more reproducible and accessible methods is important to enable broader use of microperimetry in both clinical and research settings.

The inhibition of NOTCH2 reduces UVB-induced damage in retinal pigment epithelium cells

Age-related macular degeneration (AMD) is the leading cause of irreversible blindness in the elderly. The pathogenesis of dry AMD remains indistinct and the mechanism of retinal pigment epithelium (RPE) cells death in dry AMD is controversial. The aim of the present study was to investigate the functions of Notch signaling in ultraviolet B (UVB)-induced damage of RPE cells. It was identified that, in RPE cells, UVB increased intracellular reactive oxygen species (ROS) and induced cell apoptosis. In addition, UVB activated Notch signaling in a dose dependent manner. Surprisingly, NOTCH2, but not NOTCH1, was demonstrated to be the major Notch receptor in RPE cells. Under normal conditions, the inhibition of NOTCH2 reduced cell growth and cell migration, but had no impact on intracellular ROS and cell apoptosis. However, in the presence of UVB, the inhibition of NOTCH2, but not NOTCH1, attenuated intracellular ROS and cell apoptosis. The function of Notch signaling involved in UVB damage of RPE cells may not only be significant to understanding the pathogenesis of AMD (especially dry AMD), but also useful for designing effective therapeutic agents for dry AMD.

VISUALIZING RETINAL PIGMENT EPITHELIUM PHENOTYPES IN THE TRANSITION TO GEOGRAPHIC ATROPHY IN AGE-RELATED MACULAR DEGENERATION

PURPOSE

To inform the interpretation of clinical optical coherence tomography and fundus autofluorescence imaging in geographic atrophy (GA) of age-related macular degeneration by determining the distribution of retinal pigment epithelium (RPE) phenotypes in the transition from health to atrophy in donor eyes.

METHODS

In RPE-Bruch membrane flat mounts of two GA eyes, the terminations of organized RPE cytoskeleton and autofluorescent material were compared. In high-resolution histological sections of 13 GA eyes, RPE phenotypes were assessed at ±500 and ±100 μm from the descent of the external limiting membrane (ELM) toward Bruch membrane. The ELM descent was defined as curved, reflected, or oblique in shape. Thicknesses of RPE, basal laminar deposit (BLamD), and RPE plus BLamD were measured.

RESULTS

A border of atrophy that can be precisely delimited is the ELM descent, as opposed to the termination of the RPE layer itself, because of dissociated RPE in the atrophic area. Approaching the ELM descent, the percentage of abnormal RPE morphologies increases, the percentage of age-normal cells decreases, overall RPE thickens, and BLamD does not thin. The combination of RPE plus BLamD is 19.7% thicker at -100 μm from the ELM descent than that at -500 μm (23.1 ± 10.7 μm vs. 19.3 ± 8.2 μm; P = 0.05).

CONCLUSION

The distribution of RPE phenotypes at the GA transition supports the idea that these morphologies represent defined stages of a degeneration sequence. The idea that RPE dysmorphia including rounding and stacking helps explain variable autofluorescence patterns in GA is supported. The ELM descent and RPE plus BLamD thickness profile may have utility as spectral domain optical coherence tomography metrics in clinical trials.

JAM-C maintains VEGR2 expression to promote retinal pigment epithelium cell survival under oxidative stress

Junctional adhesion molecule-C (JAM-C) has been shown to play critical roles during development and in immune responses. However, its role in adult eyes under oxidative stress remains poorly understood. Here, we report that JAM-C is abundantly expressed in adult mouse retinae and choroids in vivo and in cultured retinal pigment epithelium (RPE) and photoreceptor cells in vitro. Importantly, both JAM-C expression and its membrane localisation are downregulated by H₂O₂-induced oxidative stress. Under H₂O₂-induced oxidative stress, JAM-C is critically required for the survival of human RPE cells. Indeed, loss of JAM-C by siRNA knockdown decreased RPE cell survival. Mechanistically, we show that JAM-C is required to maintain VEGFR2 expression in RPE cells, and VEGFR2 plays an important role in keeping the RPE cells viable since overexpression of VEGFR2 partially restored impaired RPE survival caused by JAM-C knockdown and increased RPE survival. We further show that JAM-C regulates VEGFR2 expression and, in turn, modulates p38 phosphorylation. Together, our data demonstrate that JAM-C plays an important role in maintaining VEGR2 expression to promote RPE cell survival under oxidative stress. Given the vital importance of RPE in the eye, approaches that can modulate JAM-C expression may have therapeutic values in treating diseases with impaired RPE survival.

Retrospective hospital-based analysis of age-related macular degeneration patterns in India: 5-year follow-up

PURPOSE

To provide a detailed analysis of age-related macular degeneration (AMD) with a 5-year follow-up at a Tertiary Eye Care Center in India.

METHODS

In this retrospective institutional study, 408 eyes of 204 subjects (100 males) with a diagnosis of AMD with minimum 5-year follow-up were included. Data collected included demographics, details of the ocular exam, special investigations performed, treatment offered, complications, and systemic diseases, if any.

RESULTS

The median age was 74.24 ± 8.23 years. Median follow-up was 5.77 years. The visual acuity (VA) at baseline and last visit was 0.74 ± 0.12 (Snellen's equivalent 20/100) and 0.54 ± 0.12 logarithm of the minimum angle of resolution (Snellen's equivalent 20/50; P = 0.032) in patients with choroidal neovascular membrane (CNVM). The most common complaint was decreased vision (94.5%). AMD (any stage) was found to be bilateral in 93% of patients at baseline and 197 patients (96.56%) at 5 years. Seventeen eyes had active CNVM (12 of these were occult) at presentation. At baseline, 43 eyes had a disciform scar. Three hundred twenty-one eyes had dry AMD at baseline (geographic atrophy - 12 [3.7%] eyes). Five-year conversion rate into wet AMD and geographic atrophy was 2.87% and 3.12%. Median number of anti-vascular endothelial growth factor injections administered per patient was 2.8 ± 1.2. CNVM bilaterality was low (7.5%).

CONCLUSION

Patients with AMD in India presented later in the course of the disease. Bilateral advanced AMD and geographic atrophy were uncommon. Five-year conversion rate into wet AMD and geographic atrophy was 2.87% and 3.12%.

RPE necroptosis in response to oxidative stress and in AMD

Age-related macular degeneration (AMD) is the leading cause of irreversible blindness in the elderly. The underlying mechanism of non-neovascular AMD (dry AMD), also named geographic atrophy (GA) remains unclear and the mechanism of retinal pigment epithelial (RPE) cell death in AMD is controversial. We review the history and recent progress in understanding the mechanism of RPE cell death induced by oxidative stress, in AMD mouse models, and in AMD patients. Due to the limitation of toolsets to distinguish between apoptosis and necroptosis (or necrosis), most previous research concludes that apoptosis is a major mechanism for RPE cell death in response to oxidative stress and in AMD. Recent studies suggest necroptosis as a major mechanism of RPE cell death in response to oxidative stress. Moreover, ultrastructural and histopathological studies support necrosis as major mechanism of RPE cells death in AMD. In this review, we discuss the mechanism of RPE cell death in response to oxidative stress, in AMD mouse models, and in human AMD patients. Based on the literature, we hypothesize that necroptosis is a major mechanism for RPE cell death in response to oxidative stress and in AMD.

4-Acetoxyphenol Prevents RPE Oxidative Stress-Induced Necrosis by Functioning as an NRF2 Stabilizer

PURPOSE

Oxidative stress has been suggested to be a major risk factor for the pathogenesis of AMD. Retinal pigment epithelial (RPE) cells are essential for maintaining the homeostasis of the retina, and RPE cell death and the resultant photoreceptor apoptosis have been observed in dry AMD, especially in geographic atrophy. The purpose of this article was to identify and repurpose the Food and Drug Administration-approved natural compound 4-Acetoxyphenol (4-AC), and to evaluate its effect and mechanism in protecting against oxidative stress-induced RPE necrosis.

METHODS

We exposed ARPE-19 cells to tert-Butyl hydroperoxide (tBHP) after pretreatment with 4-AC, and measured cell viability by MTT assay. Aggregation of RIPK3 and HMGB1 nuclear release were analyzed by transfected reporter genes. Reactive oxygen species (ROS) were measured using a commercially available ROS detection system. The importance of the NRF2/NQO1/HO-1 pathway in mediating 4-AC function was corroborated by siRNA studies, qRT-PCR, and immunostaining.

RESULTS

We have identified a natural antioxidant, 4-AC, which demonstrates strong abilities to protect RPE cells from oxidative stress-induced necrosis. Mechanistically, 4-AC blocked the increase of cellular ROS induced by oxidative stress, and upregulated NQO1 and HO-1 genes by stabilizing and inducing the nuclear translocation of NRF2 transcription factor. The NQO1, HO-1, and NRF2 were further shown to be required for 4-AC protection of RPE cells from death induced by tBHP. The tBHQ, an NRF2 stabilizer, consistently mimicked the protective effect of 4-AC against tBHP-induced RPE death.

CONCLUSIONS

The compound 4-AC protects ARPE-19 cells from oxidative stress-induced necrosis through upregulation of NQO1 and HO-1 genes by stabilization of NRF2.

Epimacular brachytherapy for wet AMD: current perspectives

Age-related macular degeneration (AMD) is considered the most common cause of blindness in the over-60 age group in developed countries. There are basically two forms of presentation: geographic (dry or atrophic) and wet (neovascular or exudative). Geographic atrophy accounts for approximately 85%–90% of ophthalmic frames and leads to a progressive degeneration of the retinal pigment epithelium and the photoreceptors. Wet AMD causes the highest percentage of central vision loss secondary to disease. This neovascular form involves an angiogenic process in which newly formed choroidal vessels invade the macular area. Today, intravitreal anti-angiogenic drugs attempt to block the angiogenic events and represent a major advance in the treatment of wet AMD. Currently, combination therapy for wet AMD includes different forms of radiation delivery. Epimacular brachytherapy (EMBT) seems to be a useful approach to be associated with current anti-vascular endothelial growth factor agents, presenting an acceptable efficacy and safety profile. However, at the present stage of research, the results of the clinical trials carried out to date are insufficient to justify extending routine use of EMBT for the treatment of wet AMD.

Effect of the Blue Filter Intraocular Lens on the Progression of Geographic Atrophy

Purpose

To clinically evaluate the effect of blue light–filtering intraocular lenses (IOLs) on disease progression in patients with geographic atrophy (GA).

Methods

Clinical data from 66 eyes of 40 patients were investigated, 27 with a blue filter and 39 with a non–blue filter IOL. Spectral-domain optical coherence tomography technology and the advanced retinal pigment epithelium analysis software tool were used to measure lesion size and monitor its progression over 1 year.

Results

The mean and median baseline area of GA for the total sample was 5.55 ± 4.72 mm2 and 4.40 mm2, respectively. There was a statistically significant difference of the mean (p = 0.0002) and median (p<0.0001) GA progression in 1 year between the blue filter and non–blue filter IOL group (0.72 ± 0.39 SD mm2 mean and 0.70 mm2 median compared to 1.48 ± 0.88 SD mm2 and 1.30 mm2, respectively).

Conclusions

The clinical data strongly support a photoprotective role of blue light–filtering IOLs on the progression of the atrophic form of dry age-related macular degeneration after cataract surgery.

Stem cell-based treatment in geographic atrophy: promises and pitfalls

Geographic atrophy is a common and untreatable form of advanced age-related macular degeneration. The degeneration primarily affects the retinal pigment epithelium and photoreceptors of the retina and their restoration by cell transplantation seems attractive. Recently, a patient with geographic atrophy was the first human to receive cells derived from human embryonic stem cells. In this short review, the rationale, potential and obstacles for stem cell-derived therapy in geographic atrophy are discussed.

Diminishing risk for age-related macular degeneration with nutrition: a current view

Age-related macular degeneration (AMD) is the leading cause of blindness in the elderly. Clinical hallmarks of AMD are observed in one third of the elderly in industrialized countries. Preventative interventions through dietary modification are attractive strategies, because they are more affordable than clinical therapies, do not require specialists for administration and many studies suggest a benefit of micro- and macro-nutrients with respect to AMD with few, if any, adverse effects. The goal of this review is to provide information from recent literature on the value of various nutrients, particularly omega-3 fatty acids, lower glycemic index diets and, perhaps, some carotenoids, with regard to diminishing risk for onset or progression of AMD. Results from the upcoming Age-Related Eye Disease Study (AREDS) II intervention trial should be particularly informative.

An update on the pharmacotherapy of neovascular age-related macular degeneration

INTRODUCTION

Neovascular age-related macular degeneration (AMD) is currently the most common cause of legal blindness in industrialized countries. The advent of pharmacotherapy with intravitreal VEGF inhibitors has greatly improved outcomes for the treatment of this disease.

AREAS COVERED

The present review is divided into two major sections: the period prior to the use of anti-VEGF agents (triamcinolone acetonide, verteporfin photodynamic therapy) and the period following their introduction (pegaptanib sodium, bevacizumab, ranibizumab, aflibercept). The main pharmacological and clinical characteristics of each therapy are summarized.

EXPERT OPINION

Monotherapy with anti-VEGF agents is currently the 'gold standard' for treating neovascular AMD, but, with several drug choices and various different dosing regimens available, there is still wide variability in how individual clinicians manage their patients. Despite improved visual outcomes, there remains a significant unmet need for better treatments as the frequent office visits and injections associated with anti-VEGF therapy are costly and place a significant burden on patients, their family members and physicians.

Retinal deimination and PAD2 levels in retinas from donors with age-related macular degeneration (AMD)

Deimination is a form of protein posttranslational modification carried out by the peptidyl arginine deiminases (PADs) enzymes. PAD2 is the principal deiminase expressed in the retina. Elevated levels of PAD2 and protein deimination are present in a number of human neurological diseases, with or without ocular manifestation. To define the association of deimination with the pathogenesis of age-related macular degeneration (AMD), we studied protein deimination and PAD2 levels in retinas of AMD donor eyes compared to age-matched non-AMD retinas. Eyes from non-AMD and AMD donors were fixed in 4% paraformaldehyde and 0.5% glutaraldehyde in phosphate buffer. Retina and retinal pigment epithelium (RPE) from donor eyes were processed for immunohistochemical detection and western blotting using antibodies to PAD2 and citrulline residues. The ganglion cell, inner plexiform, inner nuclear and outer nuclear layers were labeled by both PAD2 and citrulline antibodies. Changes in the localization of deiminated residues and PAD2 were evident as the retinal layers were remodeled coincident with photoreceptor degeneration in AMD retinas. Immunodetection of either PAD2 or citrulline residues could not be evaluated in the RPE layer due to the high autofluorescence levels in this layer. Interestingly, higher deimination immunoreactivity was detected in AMD retinal lysates. However, no significant changes in PAD2 were detected in the AMD and non-AMD retinas and RPE lysates. Our observations show increased levels of protein deimination but not PAD2 in AMD retinas and RPE, suggesting a reduced rate of turnover of deiminated proteins in these AMD retinas.

Nutritional modulation of age-related macular degeneration

Age-related macular degeneration (AMD) is the leading cause of blindness in the elderly worldwide. It affects 30-50 million individuals and clinical hallmarks of AMD are observed in at least one third of persons over the age of 75 in industrialized countries (Gehrs et al., 2006). Costs associated with AMD are in excess of $340 billion US (American-Health-Assistance-Foundation, 2012). The majority of AMD patients in the United States are not eligible for clinical treatments (Biarnes et al., 2011; Klein et al., 2011). Preventive interventions through dietary modulation are attractive strategies because many studies suggest a benefit of micro- and macronutrients with respect to AMD, as well as other age-related debilities, and with few, if any, adverse effects (Chiu, 2011). Preservation of vision would enhance quality of life for millions of elderly people, and alleviate the personal and public health financial burden of AMD (Frick et al., 2007; Wood et al., 2011). Observational studies indicate that maintaining adequate levels of omega-3 fatty acids (i.e. with 2 servings/week of fish) or a low glycemic index diet may be particularly beneficial for early AMD and that higher levels of carotenoids may be protective, most probably, against neovascular AMD. Intervention trials are needed to better understand the full effect of these nutrients and/or combinations of nutrients on retinal health. Analyses that describe effects of a nutrient on onset and/or progress of AMD are valuable because they indicate the value of a nutrient to arrest AMD at the early stages. This comprehensive summary provides essential information about the value of nutrients with regard to diminishing risk for onset or progress of AMD and can serve as a guide until data from ongoing intervention trials are available.

Natural history of age-related retinal lesions that precede AMD in mice fed high or low glycemic index diets

PURPOSE

Epidemiologic data indicate that people who consume low glycemic index (GI) diets are at reduced risk for the onset and progression of age-related macular degeneration (AMD). The authors sought corroboration of this observation in an animal model.

METHODS

Five- and 16-month-old C57BL/6 mice were fed high or low GI diets until they were 17 and 23.5 months of age, respectively. Retinal lesions were evaluated by transmission electron microscopy, and advanced glycation end products (AGEs) were evaluated by immunohistochemistry.

RESULTS

Retinal lesions including basal laminar deposits, loss of basal infoldings, and vacuoles in the retinal pigment epithelium were more prevalent in the 23.5- than in the 17-month-old mice. Within each age group, consumption of a high GI diet increased the risk for lesions and the risk for photoreceptor abnormalities and accumulation of AGEs.

CONCLUSIONS

Consuming high GI diets accelerates the appearance of age-related retinal lesions that precede AMD in mice, perhaps by increasing the deposition of toxic AGEs in the retina. The data support the hypothesis that consuming lower GI diets, or simulation of their effects with nutraceuticals or drugs, may protect against AMD. The high GI-fed C57BL/6 mouse is a new model of age-related retinal lesions that precede AMD and mimic the early stages of disease and may be useful for drug discovery.