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Liao L, Zhu W, Liu H, Wu P, Zhang X, Zhou X, Xu J, Zhao Y, Duan X. Photocrosslinkable Sericin Hydrogel Injected into the Anterior Chamber of Mice with Chronic Ocular Hypertension Efficacy, Medication Sensitivity, and Material Safety. Bioengineering (Basel) 2024; 11:607. [PMID: 38927843 PMCID: PMC11200424 DOI: 10.3390/bioengineering11060607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2024] [Revised: 05/30/2024] [Accepted: 06/05/2024] [Indexed: 06/28/2024] Open
Abstract
(1) Background: A rise in intraocular pressure (IOP) and decreased retinal ganglion cells are frequent indicators of effective modeling of chronic ocular hypertension in mice. In this study, the sensitivity of the mouse model to pharmaceutical therapy to reduce intraocular tension was assessed, the model's safety was confirmed using a cytotoxicity test, and the success rate of the mouse model of ocular hypertension was assessed by assessing alterations in IOP and neurons in the ganglion cell layer. (2) Methods: A mouse model of chronic ocular hypertension was produced in this study by employing photocrosslinkable sericin hydrogel injection and LED lamp irradiation. The eyes of 25 C57BL/6 male mice were subjected to 405 nm UV light from the front for 2 min after being injected with 5 μL of sericin hydrogel in the anterior chamber of the left eye. IOP in the mice was measured daily, and IOP rises greater than 5 mmHg were considered intraocular hypertension. When the IOP was lowered, the intervention was repeated once, but the interval between treatments was at least 2 weeks. The right eyes were not treated with anything as a normal control group. Mice eyeballs were stained with HE, Ni-type, and immunofluorescence to assess the model's efficacy. Two common drugs (tafluprost eye drops and timolol eye drops) were provided for one week after four weeks of stable IOP, and IOP changes were assessed to determine the drug sensitivity of the mouse model of chronic ocular hypertension. Furthermore, CellTiter 96® AQueous One Solution Cell Proliferation Assay (MTS) was utilized to investigate the safety of the ocular hypertension model by evaluating the deleterious effects of photocrosslinkable sericin hydrogel on cells. (3) Results: Before injection, the basal IOP was (9.42 ± 1.28) mmHg (1 kPa = 7.5 mmHg) in the experimental group and (9.08 ± 1.21) in the control group. After injection, cataract occurred in one eye, corneal edema in one eye, endophthalmitis in one eye, iris incarceration in one eye, and eyeball atrophy in one eye. Five mice with complications were excluded from the experiment, and twenty mice were left. Four weeks after injection, the IOP of the experimental group was maintained at (19.7 ± 4.52) mmHg, and that of the control group was maintained at (9.92 ± 1.55) mmHg, and the difference between the two groups was statistically significant (p < 0.05). Before the intervention, the IOP in the experimental group was (21.7 ± 3.31) mmHg in the high IOP control group, (20.33 ± 2.00) mmHg in the tafluprost eye drops group, and (20.67 ± 3.12) mmHg in the timolol maleate eye drops group. The IOP after the intervention was (23.2 ± 1.03) mmHg, (12.7 ± 2.11) mmHg, and (10.4 ± 1.43) mmHg, respectively. Before and after the intervention, there were no significant differences in the high-IOP control group (p > 0.05), there were statistically significant differences in the timolol eye drops group (p < 0.05), and there were statistically significant differences in the tafluprost eye drops group (p < 0.05). One week after drug withdrawal, there was no significant difference in IOP among the three groups (p > 0.05). In the high-IOP group, the protein (sericin hydrogel) showed a short strips or fragmented structure in the anterior chamber, accompanied by a large number of macrophages and a small number of plasma cells. The shape of the chamber angle was normal in the blank control group. The number of retinal ganglion cells decreased significantly 8 weeks after injection of sericin hydrogel into the anterior chamber, and the difference was statistically significant compared with the blank control group (p < 0.05). After the cells were treated with photocrosslinkable sericin hydrogel, there was no significant difference in the data of the CellTiter 96® assay kit of MTS compared with the blank control group (p > 0.05). (4) Conclusions: A mouse model of chronic intraocular hypertension can be established successfully by injecting sericin in the anterior chamber and irradiating with ultraviolet light. The model can simulate the structural and functional changes of glaucoma and can effectively reduce IOP after the action of most antihypertensive drugs, and it is highly sensitive to drugs. Sericin has no obvious toxic effect on cells and has high safety.
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Affiliation(s)
- Li Liao
- Aier Academy of Ophthalmology, Central South University, Changsha 410015, China; (L.L.); (P.W.)
- Aier Glaucoma Institute, Changsha Aier Eye Hospital, Changsha 410015, China; (X.Z.); (X.Z.); (J.X.)
| | - Wenxiang Zhu
- College of Materials Science and Engineering, Hunan University, Changsha 410082, China; (W.Z.); (H.L.)
| | - Hairong Liu
- College of Materials Science and Engineering, Hunan University, Changsha 410082, China; (W.Z.); (H.L.)
| | - Ping Wu
- Aier Academy of Ophthalmology, Central South University, Changsha 410015, China; (L.L.); (P.W.)
- Aier Glaucoma Institute, Changsha Aier Eye Hospital, Changsha 410015, China; (X.Z.); (X.Z.); (J.X.)
| | - Xinyue Zhang
- Aier Glaucoma Institute, Changsha Aier Eye Hospital, Changsha 410015, China; (X.Z.); (X.Z.); (J.X.)
| | - Xiaoyu Zhou
- Aier Glaucoma Institute, Changsha Aier Eye Hospital, Changsha 410015, China; (X.Z.); (X.Z.); (J.X.)
| | - Jiahao Xu
- Aier Glaucoma Institute, Changsha Aier Eye Hospital, Changsha 410015, China; (X.Z.); (X.Z.); (J.X.)
| | - Yang Zhao
- Aier Glaucoma Institute, Changsha Aier Eye Hospital, Changsha 410015, China; (X.Z.); (X.Z.); (J.X.)
| | - Xuanchu Duan
- Aier Academy of Ophthalmology, Central South University, Changsha 410015, China; (L.L.); (P.W.)
- Aier Glaucoma Institute, Changsha Aier Eye Hospital, Changsha 410015, China; (X.Z.); (X.Z.); (J.X.)
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Bou Ghanem GO, Wareham LK, Calkins DJ. Addressing neurodegeneration in glaucoma: Mechanisms, challenges, and treatments. Prog Retin Eye Res 2024; 100:101261. [PMID: 38527623 DOI: 10.1016/j.preteyeres.2024.101261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 03/15/2024] [Accepted: 03/19/2024] [Indexed: 03/27/2024]
Abstract
Glaucoma is the leading cause of irreversible blindness globally. The disease causes vision loss due to neurodegeneration of the retinal ganglion cell (RGC) projection to the brain through the optic nerve. Glaucoma is associated with sensitivity to intraocular pressure (IOP). Thus, mainstay treatments seek to manage IOP, though many patients continue to lose vision. To address neurodegeneration directly, numerous preclinical studies seek to develop protective or reparative therapies that act independently of IOP. These include growth factors, compounds targeting metabolism, anti-inflammatory and antioxidant agents, and neuromodulators. Despite success in experimental models, many of these approaches fail to translate into clinical benefits. Several factors contribute to this challenge. Firstly, the anatomic structure of the optic nerve head differs between rodents, nonhuman primates, and humans. Additionally, animal models do not replicate the complex glaucoma pathophysiology in humans. Therefore, to enhance the success of translating these findings, we propose two approaches. First, thorough evaluation of experimental targets in multiple animal models, including nonhuman primates, should precede clinical trials. Second, we advocate for combination therapy, which involves using multiple agents simultaneously, especially in the early and potentially reversible stages of the disease. These strategies aim to increase the chances of successful neuroprotective treatment for glaucoma.
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Affiliation(s)
- Ghazi O Bou Ghanem
- Vanderbilt Eye Institute, Department of Ophthalmology and Visual Sciences, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Lauren K Wareham
- Vanderbilt Eye Institute, Department of Ophthalmology and Visual Sciences, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - David J Calkins
- Vanderbilt Eye Institute, Department of Ophthalmology and Visual Sciences, Vanderbilt University Medical Center, Nashville, TN, USA.
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Da Silva F, Linhares JMM, Lira M. The influence of the tear film on the intraocular pressure and the corneal biomechanical properties analyzed with the Ocular Response Analyzer. JOURNAL OF OPTOMETRY 2024; 17:100488. [PMID: 37918060 PMCID: PMC10641536 DOI: 10.1016/j.optom.2023.100488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 07/11/2023] [Accepted: 07/25/2023] [Indexed: 11/04/2023]
Abstract
PURPOSE As ocular dryness and glaucoma are more prevalent with increasing age, understanding how the tear film affects tonometry is important. The present study aims to understand the impact that changes in the tear film have on intraocular pressure (IOP), corneal hysteresis, and corneal resistance factor measurements. METHODS Cross-sectional research was conducted and 37 patients were assessed. The tear film lipid layer and the non-invasive break-up time (NIBUT) were evaluated using the Tearscope Plus (Keeler, Windsor, UK). Dry eye symptoms were evaluated using the Ocular Surface Disease Index (OSDI) questionnaire. IOP was measured using rebound tonometry and the Ocular Response Analyzer (ORA, Reichert). Corneal biomechanical properties were measured using ORA. RESULTS It was found that an increase in the IOP measured with the iCare was directly correlated with the subclass that evaluated symptomatology associated with environmental factors (r = 0.414, p<0.05, Spearman). Goldmann-correlated IOP (IOPg) and Corneal-compensated IOP (IOPcc) values were statistically significantly different between the various interferometric patterns (p<0.05). It was also found that an increase in the corneal biomechanical properties measured with ORA was directly correlated with the overall scores obtained when using the OSDI and some of its subclasses. CONCLUSIONS Tear film interferometric patterns were shown to have some impact on the IOP measured using ORA. The IOP measured with iCare seems to be related to the symptomatology obtained from OSDI. Corneal biomechanical properties were related to the OSDI total score and some of its subclasses. An increase in symptomatology was associated with an increase in the measured biomechanical properties of the cornea.
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Affiliation(s)
- Filipe Da Silva
- Physics Center of Minho and Porto Universities (CF-UM-UP), School of Sciences, University of Minho, Braga, Portugal.
| | - João M M Linhares
- Physics Center of Minho and Porto Universities (CF-UM-UP), School of Sciences, University of Minho, Braga, Portugal
| | - Madalena Lira
- Physics Center of Minho and Porto Universities (CF-UM-UP), School of Sciences, University of Minho, Braga, Portugal
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Chaudhary P, Lockwood H, Stowell C, Bushong E, Reynaud J, Yang H, Gardiner SK, Wiliams G, Williams I, Ellisman M, Marsh-Armstrong N, Burgoyne C. Retrolaminar Demyelination of Structurally Intact Axons in Nonhuman Primate Experimental Glaucoma. Invest Ophthalmol Vis Sci 2024; 65:36. [PMID: 38407858 PMCID: PMC10902877 DOI: 10.1167/iovs.65.2.36] [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: 11/02/2023] [Accepted: 01/28/2024] [Indexed: 02/27/2024] Open
Abstract
Purpose To determine if structurally intact, retrolaminar optic nerve (RON) axons are demyelinated in nonhuman primate (NHP) experimental glaucoma (EG). Methods Unilateral EG NHPs (n = 3) were perfusion fixed, EG and control eyes were enucleated, and foveal Bruch's membrane opening (FoBMO) 30° sectoral axon counts were estimated. Optic nerve heads were trephined; serial vibratome sections (VSs) were imaged and colocalized to a fundus photograph establishing their FoBMO location. The peripheral neural canal region within n = 5 EG versus control eye VS comparisons was targeted for scanning block-face electron microscopic reconstruction (SBEMR) using micro-computed tomographic reconstructions (µCTRs) of each VS. Posterior laminar beams within each µCTR were segmented, allowing a best-fit posterior laminar surface (PLS) to be colocalized into its respective SBEMR. Within each SBEMR, up to 300 axons were randomly traced until they ended (nonintact) or left the block (intact). For each intact axon, myelin onset was identified and myelin onset distance (MOD) was measured relative to the PLS. For each EG versus control SBEMR comparison, survival analyses compared EG and control MOD. Results MOD calculations were successful in three EG and five control eye SBEMRs. Within each SBEMR comparison, EG versus control eye axon loss was -32.9%, -8.3%, and -15.2% (respectively), and MOD was increased in the EG versus control SBEMR (P < 0.0001 for each EG versus control SBEMR comparison). When data from all three EG eye SBEMRs were compared to all five control eye SBEMRs, MOD was increased within the EG eyes. Conclusions Structurally intact, RON axons are demyelinated in NHP early to moderate EG. Studies to determine their functional status are indicated.
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Affiliation(s)
- Priya Chaudhary
- Optic Nerve Head Research Laboratory, Legacy Devers Eye Institute, Legacy Research Institute, Portland, Oregon, United States
- Discoveries in Sight, Devers Eye Institute, Legacy Research Institute, Portland, Oregon, United States
| | - Howard Lockwood
- Optic Nerve Head Research Laboratory, Legacy Devers Eye Institute, Legacy Research Institute, Portland, Oregon, United States
- Discoveries in Sight, Devers Eye Institute, Legacy Research Institute, Portland, Oregon, United States
| | - Cheri Stowell
- Optic Nerve Head Research Laboratory, Legacy Devers Eye Institute, Legacy Research Institute, Portland, Oregon, United States
- Discoveries in Sight, Devers Eye Institute, Legacy Research Institute, Portland, Oregon, United States
| | - Eric Bushong
- National Center for Microscopy & Imaging Research, UCSD, La Jolla, California, United States
| | - Juan Reynaud
- Optic Nerve Head Research Laboratory, Legacy Devers Eye Institute, Legacy Research Institute, Portland, Oregon, United States
- Discoveries in Sight, Devers Eye Institute, Legacy Research Institute, Portland, Oregon, United States
| | - Hongli Yang
- Optic Nerve Head Research Laboratory, Legacy Devers Eye Institute, Legacy Research Institute, Portland, Oregon, United States
- Discoveries in Sight, Devers Eye Institute, Legacy Research Institute, Portland, Oregon, United States
| | - Stuart K Gardiner
- Discoveries in Sight, Devers Eye Institute, Legacy Research Institute, Portland, Oregon, United States
| | - Galen Wiliams
- Optic Nerve Head Research Laboratory, Legacy Devers Eye Institute, Legacy Research Institute, Portland, Oregon, United States
- Discoveries in Sight, Devers Eye Institute, Legacy Research Institute, Portland, Oregon, United States
| | - Imee Williams
- Optic Nerve Head Research Laboratory, Legacy Devers Eye Institute, Legacy Research Institute, Portland, Oregon, United States
- Discoveries in Sight, Devers Eye Institute, Legacy Research Institute, Portland, Oregon, United States
| | - Mark Ellisman
- National Center for Microscopy & Imaging Research, UCSD, La Jolla, California, United States
| | - Nick Marsh-Armstrong
- Department of Ophthalmology, University of California, Davis, California, United States
| | - Claude Burgoyne
- Optic Nerve Head Research Laboratory, Legacy Devers Eye Institute, Legacy Research Institute, Portland, Oregon, United States
- Discoveries in Sight, Devers Eye Institute, Legacy Research Institute, Portland, Oregon, United States
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Gustavsson ST, Enz TJ, Tribble JR, Nilsson M, Lindqvist A, Lindén C, Hagström A, Rutigliani C, Lardner E, Stålhammar G, Williams PA, Jóhannesson G. Nicotinamide Prevents Retinal Vascular Dropout in a Rat Model of Ocular Hypertension and Supports Ocular Blood Supply in Glaucoma Patients. Invest Ophthalmol Vis Sci 2023; 64:34. [PMID: 38010699 PMCID: PMC10683769 DOI: 10.1167/iovs.64.14.34] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 10/30/2023] [Indexed: 11/29/2023] Open
Abstract
Purpose To investigate whether nicotinamide (NAM) modulates retinal vasculature in glaucoma. Methods This was a prospective controlled clinical trial investigating animal and human histopathology. Participants included normotensive and ocular hypertensive rats, postmortem human ocular tissue, glaucoma patients (n = 90), and healthy controls (n = 30). The study utilized histopathology, computer-assisted retinal vasculature analysis, optical coherence tomography angiography (OCTA), and NAM treatment. The main outcome measures included retinal vascular parameters in rats as assessed by AngioTool; retinal vasculature integrity in rats and humans as assessed by histopathology, antibody-staining, and ImageJ-based measurements; and retinal perfusion density (PD) and flux index in humans as assessed by OCTA. Results A number of vessel parameters were altered in ocular hypertension/glaucoma compared to healthy controls. NAM treatment improved the retinal vasculature in ocular hypertensive rats, with an increase in mean vessel area, percentage area covered by vessels, total vessel length, total junctions, and junction density as assessed by AngioTool (all P < 0.05); vessel wall integrity as assessed by VE-cadherin antibody staining was also improved (P < 0.01). In humans, as assessed by OCTA, increases in PD in the optic nerve head and macula complete image (0.7%, P = 0.04 and 1.0%, P = 0.002, respectively) in healthy controls, and an increase in the temporal quadrant of the macula (0.7%, P = 0.02) in glaucoma patients was seen after NAM treatment. Conclusions NAM can prevent retinal vascular damage in an animal model of glaucoma. After NAM treatment, glaucoma patients and healthy controls demonstrated a small increase in retinal vessel parameters as assessed by OCTA.
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Affiliation(s)
- Simon T. Gustavsson
- Department of Clinical Sciences, Ophthalmology, Umeå University, Umeå, Sweden
| | - Tim J. Enz
- Department of Clinical Neuroscience, Division of Eye and Vision, St. Erik Eye Hospital, Karolinska Institutet, Stockholm, Sweden
- Department of Ophthalmology, University of Basel, Basel, Switzerland
| | - James R. Tribble
- Department of Clinical Neuroscience, Division of Eye and Vision, St. Erik Eye Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Mattias Nilsson
- Department of Clinical Neuroscience, Division of Eye and Vision, St. Erik Eye Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Anna Lindqvist
- Department of Clinical Sciences, Ophthalmology, Umeå University, Umeå, Sweden
| | - Christina Lindén
- Department of Clinical Sciences, Ophthalmology, Umeå University, Umeå, Sweden
| | - Anna Hagström
- Department of Clinical Neuroscience, Division of Eye and Vision, St. Erik Eye Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Carola Rutigliani
- Department of Clinical Neuroscience, Division of Eye and Vision, St. Erik Eye Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Emma Lardner
- Department of Clinical Neuroscience, Division of Eye and Vision, St. Erik Eye Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Gustav Stålhammar
- Department of Clinical Neuroscience, Division of Eye and Vision, St. Erik Eye Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Pete A. Williams
- Department of Clinical Neuroscience, Division of Eye and Vision, St. Erik Eye Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Gauti Jóhannesson
- Department of Clinical Sciences, Ophthalmology, Umeå University, Umeå, Sweden
- Wallenberg Centre for Molecular Medicine, Umeå University, Umeå, Sweden
- Department of Ophthalmology, University of Iceland, Iceland
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Patko E, Szabo E, Vaczy A, Molitor D, Tari E, Li L, Csutak A, Toth G, Reglodi D, Atlasz T. Protective Effects of Pituitary Adenylate-Cyclase-Activating Polypeptide on Retinal Vasculature and Molecular Responses in a Rat Model of Moderate Glaucoma. Int J Mol Sci 2023; 24:13256. [PMID: 37686074 PMCID: PMC10487862 DOI: 10.3390/ijms241713256] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Revised: 08/14/2023] [Accepted: 08/21/2023] [Indexed: 09/10/2023] Open
Abstract
Despite the high probability of glaucoma-related blindness, its cause is not fully understood and there is no efficient therapeutic strategy for neuroprotection. Vascular factors have been suggested to play an important role in glaucoma development and progression. Previously, we have proven the neuroprotective effects of pituitary adenylate-cyclase-activating polypeptide (PACAP) eye drops in an inducible, microbeads model in rats that is able to reproduce many clinically relevant features of human glaucoma. In the present study, we examined the potential protective effects of PACAP1-38 on the retinal vasculature and the molecular changes in hypoxia. Ocular hypertension was induced by injection of microbeads into the anterior chamber, while control rats received PBS. PACAP dissolved in vehicle (1 µg/drop) or vehicle treatment was started one day after the injections for four weeks three times a day. Retinal degeneration was assessed with optical coherence tomography (OCT), and vascular and molecular changes were assessed by immunofluorescence labeling. HIF1-α and VEGF-A protein levels were measured by Western blot. OCT images proved severe retinal degeneration in the glaucomatous group, while PACAP1-38 eye drops had a retinoprotective effect. Vascular parameters were deteriorated and molecular analysis suggested hypoxic conditions in glaucoma. PACAP treatment exerted a positive effect against these alterations. In summary, PACAP could prevent the severe damage to the retina and its vasculature induced by ocular hypertension in a microbeads model.
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Affiliation(s)
- Evelin Patko
- Department of Anatomy, ELKH-PTE PACAP Research Team, Medical School, University of Pecs, 7624 Pecs, Hungary
| | - Edina Szabo
- Department of Anatomy, ELKH-PTE PACAP Research Team, Medical School, University of Pecs, 7624 Pecs, Hungary
| | - Alexandra Vaczy
- Department of Anatomy, ELKH-PTE PACAP Research Team, Medical School, University of Pecs, 7624 Pecs, Hungary
| | - Dorottya Molitor
- Department of Anatomy, ELKH-PTE PACAP Research Team, Medical School, University of Pecs, 7624 Pecs, Hungary
| | - Eniko Tari
- Department of Anatomy, ELKH-PTE PACAP Research Team, Medical School, University of Pecs, 7624 Pecs, Hungary
| | - Lina Li
- Department of Anatomy, ELKH-PTE PACAP Research Team, Medical School, University of Pecs, 7624 Pecs, Hungary
| | - Adrienne Csutak
- Department of Ophthalmology, Clinical Centre, Medical School, University of Pecs, 7632 Pecs, Hungary
| | - Gabor Toth
- Department of Medical Chemistry, Albert Szent-Györgyi Medical School, University of Szeged, 6720 Szeged, Hungary
- MTA-SZTE Biomimetic Systems Research Group, Albert Szent-Györgyi Medical School, University of Szeged, 6720 Szeged, Hungary
| | - Dora Reglodi
- Department of Anatomy, ELKH-PTE PACAP Research Team, Medical School, University of Pecs, 7624 Pecs, Hungary
| | - Tamas Atlasz
- Department of Anatomy, ELKH-PTE PACAP Research Team, Medical School, University of Pecs, 7624 Pecs, Hungary
- Department of Sportbiology, Faculty of Sciences, University of Pecs, 7624 Pecs, Hungary
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Tribble JR, Hui F, Quintero H, El Hajji S, Bell K, Di Polo A, Williams PA. Neuroprotection in glaucoma: Mechanisms beyond intraocular pressure lowering. Mol Aspects Med 2023; 92:101193. [PMID: 37331129 DOI: 10.1016/j.mam.2023.101193] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 05/25/2023] [Accepted: 06/04/2023] [Indexed: 06/20/2023]
Abstract
Glaucoma is a common, complex, multifactorial neurodegenerative disease characterized by progressive dysfunction and then loss of retinal ganglion cells, the output neurons of the retina. Glaucoma is the most common cause of irreversible blindness and affects ∼80 million people worldwide with many more undiagnosed. The major risk factors for glaucoma are genetics, age, and elevated intraocular pressure. Current strategies only target intraocular pressure management and do not directly target the neurodegenerative processes occurring at the level of the retinal ganglion cell. Despite strategies to manage intraocular pressure, as many as 40% of glaucoma patients progress to blindness in at least one eye during their lifetime. As such, neuroprotective strategies that target the retinal ganglion cell and these neurodegenerative processes directly are of great therapeutic need. This review will cover the recent advances from basic biology to on-going clinical trials for neuroprotection in glaucoma covering degenerative mechanisms, metabolism, insulin signaling, mTOR, axon transport, apoptosis, autophagy, and neuroinflammation. With an increased understanding of both the basic and clinical mechanisms of the disease, we are closer than ever to a neuroprotective strategy for glaucoma.
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Affiliation(s)
- James R Tribble
- Department of Clinical Neuroscience, Division of Eye and Vision, St. Erik Eye Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Flora Hui
- Centre for Eye Research Australia, Royal Victorian Eye and Ear Hospital, Melbourne, Australia; Department of Optometry & Vision Sciences, The University of Melbourne, Melbourne, Australia
| | - Heberto Quintero
- Department of Neuroscience, University of Montreal, Montreal, Canada; Neuroscience Division, Centre de recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), Montreal, Canada
| | - Sana El Hajji
- Department of Neuroscience, University of Montreal, Montreal, Canada; Neuroscience Division, Centre de recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), Montreal, Canada
| | - Katharina Bell
- NHMRC Clinical Trials Centre, University of Sydney, Australia; Eye ACP Duke-NUS, Singapore
| | - Adriana Di Polo
- Department of Neuroscience, University of Montreal, Montreal, Canada; Neuroscience Division, Centre de recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), Montreal, Canada
| | - Pete A Williams
- Department of Clinical Neuroscience, Division of Eye and Vision, St. Erik Eye Hospital, Karolinska Institutet, Stockholm, Sweden.
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Washington J, Ritch R, Liu Y. Homocysteine and Glaucoma. Int J Mol Sci 2023; 24:10790. [PMID: 37445966 DOI: 10.3390/ijms241310790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Revised: 06/10/2023] [Accepted: 06/11/2023] [Indexed: 07/15/2023] Open
Abstract
Elevated levels of homocysteine (Hcy), a non-proteinogenic amino acid, may lead to a host of manifestations across the biological systems, particularly the nervous system. Defects in Hcy metabolism have been associated with many neurodegenerative diseases including glaucoma, i.e., the leading cause of blindness. However, the pathophysiology of elevated Hcy and its eligibility as a risk factor for glaucoma remain unclear. We aimed to provide a comprehensive review of the relationship between elevated Hcy levels and glaucoma. Through a systemic search of the PubMed and Google Scholar databases, we found that elevated Hcy might play an important role in the pathogenesis of glaucoma. Further research will be necessary to help clarify the specific contribution of elevated Hcy in the pathogenesis of glaucoma. A discovery and conceptual understanding of Hcy-associated glaucoma could be the keys to providing better therapeutic treatment, if not prophylactic treatment, for this disease.
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Affiliation(s)
- Joshua Washington
- Department of Cellular Biology and Anatomy, Medical College of Georgia, Augusta University, Augusta, GA 30912, USA
| | - Robert Ritch
- New York Eye & Ear Infirmary, New York, NY 10003, USA
| | - Yutao Liu
- Department of Cellular Biology and Anatomy, Medical College of Georgia, Augusta University, Augusta, GA 30912, USA
- James & Jean Culver Vision Discovery Institute, 4 Center for Biotechnology and Genomic Medicine, Medical College of Georgia, Augusta University, Augusta, GA 30912, USA
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Amato R, Cammalleri M, Melecchi A, Bagnoli P, Porciatti V. Natural History of Glaucoma Progression in the DBA/2J Model: Early Contribution of Müller Cell Gliosis. Cells 2023; 12:cells12091272. [PMID: 37174673 PMCID: PMC10177096 DOI: 10.3390/cells12091272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 04/21/2023] [Accepted: 04/24/2023] [Indexed: 05/15/2023] Open
Abstract
Glaucoma is a chronic optic neuropathy characterized by progressive degeneration of retinal ganglion cells (RGCs). Elevated intraocular pressure (IOP) and the resulting mechanical stress are classically considered the main causes of RGC death. However, RGC degeneration and ensuing vision loss often occur independent of IOP, indicating a multifactorial nature of glaucoma, with the likely contribution of glial and vascular function. The aim of the present study was to provide a comprehensive evaluation of the time course of neuro-glial-vascular changes associated with glaucoma progression. We used DBA/2J mice in the age range of 2-15 months as a spontaneous model of glaucoma with progressive IOP elevation and RGC loss typical of human open-angle glaucoma. We found that the onset of RGC degeneration at 10 months of age coincided with that of IOP elevation and vascular changes such as decreased density, increased lacunarity and decreased tight-junction protein zonula occludens (ZO)-1, while hypoxia-inducible factor (HIF)-1α and vascular endothelial growth factor (VEGF) were already significantly upregulated at 6 months of age together with the onset of Müller cell gliosis. Astrocytes, however, underwent significant gliosis at 10 months. These results indicate that Müller cell activation occurs well before IOP elevation, with probable inflammatory consequences, and represents an early event in the glaucomatous process. Early upregulation of HIF-1α and VEGF is likely to contribute to blood retinal barrier failure, facilitating RGC loss. The different time courses of neuro-glial-vascular changes during glaucoma progression provide further insight into the nature of the disease and suggest potential targets for the development of efficient therapeutic intervention aside from IOP lowering.
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Affiliation(s)
- Rosario Amato
- Department of Biology, University of Pisa, 56127 Pisa, Italy
| | | | | | - Paola Bagnoli
- Department of Biology, University of Pisa, 56127 Pisa, Italy
| | - Vittorio Porciatti
- Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, FL 33136, USA
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10
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Lee KM, Song DY, Kim SH. Effect of Strain on Rodent Glaucoma Models: Magnetic Bead Injection Versus Hydrogel Injection Versus Circumlimbal Suture. Transl Vis Sci Technol 2022; 11:31. [PMID: 36173647 PMCID: PMC9527335 DOI: 10.1167/tvst.11.9.31] [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 compare the inter-strain differences of three rodent glaucoma models as induced by magnetic bead injection, hydrogel injection, and circumlimbal suture. Methods In Brown Norway (BN) and Sprague Dawley (SD) rat strains, intraocular pressure (IOP) was elevated by injection of magnetic beads or hydrogel to obstruct the aqueous humor outflow or by external compression of circumlimbal suture. Maximum and average IOP values were compared according to both procedure and rat strain over 1 month postoperatively. Retinal ganglion cell (RGC) density loss was evaluated using confocal microscopic images of the flat-mounted retina obtained at postoperative days 14 and 30. Results The maximum IOPs were higher in the hydrogel injection or circumlimbal injection models than in the magnetic bead injection model (P < 0.001), whereas average IOP showed no difference between the two strains (both P ≥ 0.05). A generalized estimating equation regression model showed that the IOP increase was maintained better in the BN rats than in the SD rats (P < 0.001). Such inter-strain difference was smaller in the circumlimbal suture model. A significant decrease in RGC density was observed in all of the models for the BN rats and in the circumlimbal suture model for the SD rats at postoperative day 30. Conclusions BN rats were advantageous for the magnetic bead or hydrogel injection model, but either rat strain could be used for the circumlimbal suture model. Strains should be considered cautiously when establishing rodent glaucoma models with different IOP profiles. Translational Relevance This comparison offers the best strain for each rodent glaucoma model for assessment of glaucoma-relevant therapeutics.
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Affiliation(s)
- Kyoung Min Lee
- Department of Ophthalmology, Seoul National University College of Medicine, Seoul, Korea.,Department of Ophthalmology, Seoul National University Boramae Medical Center, Seoul, Korea
| | - Da Young Song
- Department of Ophthalmology, Seoul National University Boramae Medical Center, Seoul, Korea
| | - Seok Hwan Kim
- Department of Ophthalmology, Seoul National University College of Medicine, Seoul, Korea.,Department of Ophthalmology, Seoul National University Boramae Medical Center, Seoul, Korea
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11
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Tribble JR, Kastanaki E, Uslular AB, Rutigliani C, Enz TJ, Williams PA. Valproic Acid Reduces Neuroinflammation to Provide Retinal Ganglion Cell Neuroprotection in the Retina Axotomy Model. Front Cell Dev Biol 2022; 10:903436. [PMID: 35646919 PMCID: PMC9135180 DOI: 10.3389/fcell.2022.903436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 04/18/2022] [Indexed: 11/13/2022] Open
Abstract
Neuroinflammation is a critical and targetable pathogenic component of neurodegenerative diseases, including glaucoma, the leading cause of irreversible blindness. Valproic acid has previously been demonstrated to reduce neuroinflammation and is neuroprotective in a number of experimental settings. To determine whether valproic acid can limit retinal neuroinflammation and protect retinal neurons we used an ex vivo retina explant (axotomy) model to isolate resident glial responses from blood-derived monocytes. Neuroinflammatory status was defined using high resolution confocal imaging with 3D morphological reconstruction and cytokine protein arrays. Valproic acid significantly reduced microglia and astrocyte morphological changes, consistent with a reduction in pro-inflammatory phenotypes. Cytokine profiling demonstrated that valproic acid significantly attenuated or prevented expression of pro-inflammatory cytokines in injured retina. This identifies that the retinal explant model as a useful tool to explore resident neuroinflammation in a rapid timescale whilst maintaining a complex system of cell interactions and valproic acid as a useful drug to further explore anti-neuroinflammatory strategies in retinal disease.
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12
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Intraocular pressure measurement: A Review. Surv Ophthalmol 2022; 67:1319-1331. [DOI: 10.1016/j.survophthal.2022.03.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 02/16/2022] [Accepted: 03/01/2022] [Indexed: 11/21/2022]
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13
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Enz TJ, Tribble JR, Williams PA. Comparison of Glaucoma-Relevant Transcriptomic Datasets Identifies Novel Drug Targets for Retinal Ganglion Cell Neuroprotection. J Clin Med 2021; 10:3938. [PMID: 34501387 PMCID: PMC8432026 DOI: 10.3390/jcm10173938] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 08/10/2021] [Accepted: 08/27/2021] [Indexed: 12/20/2022] Open
Abstract
Glaucoma is a leading cause of blindness and is characterized by the progressive dysfunction and irreversible death of retinal ganglion cells. We aimed to identify shared differentially expressed genes (DE genes) between different glaucoma relevant models of retinal ganglion cell injury using existing RNA-sequencing data, thereby discovering targets for neuroprotective therapies. A comparison of DE genes from publicly available transcriptomic datasets identified 12 shared DE genes. The Comparative Toxicogenomics Database (CTD) was screened for compounds targeting a significant proportion of the identified DE genes. Forty compounds were identified in the CTD that interact with >50% of these shared DE genes. We next validated this approach by testing select compounds for an effect on retinal ganglion cell survival using a mouse retinal explant model. Folic acid, genistein, SB-431542, valproic acid, and WY-14643 (pirinixic acid) were tested. Folic acid, valproic acid, and WY-14643 demonstrated significant protection against retinal ganglion cell death in this model. The increasing prevalence of open access-omics data presents a resource to discover targets for future therapeutic investigation.
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Affiliation(s)
| | | | - Pete A. Williams
- Department of Clinical Neuroscience, Division of Eye and Vision, St. Erik Eye Hospital, Karolinska Institutet, 171 64 Stockholm, Sweden; (T.J.E.); (J.R.T.)
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14
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Tribble JR, Otmani A, Sun S, Ellis SA, Cimaglia G, Vohra R, Jöe M, Lardner E, Venkataraman AP, Domínguez-Vicent A, Kokkali E, Rho S, Jóhannesson G, Burgess RW, Fuerst PG, Brautaset R, Kolko M, Morgan JE, Crowston JG, Votruba M, Williams PA. Nicotinamide provides neuroprotection in glaucoma by protecting against mitochondrial and metabolic dysfunction. Redox Biol 2021; 43:101988. [PMID: 33932867 PMCID: PMC8103000 DOI: 10.1016/j.redox.2021.101988] [Citation(s) in RCA: 89] [Impact Index Per Article: 29.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 04/06/2021] [Accepted: 04/20/2021] [Indexed: 12/16/2022] Open
Abstract
Nicotinamide adenine dinucleotide (NAD) is a REDOX cofactor and metabolite essential for neuronal survival. Glaucoma is a common neurodegenerative disease in which neuronal levels of NAD decline. We assess the effects of nicotinamide (a precursor to NAD) on retinal ganglion cells (the affected neuron in glaucoma) in normal physiological conditions and across a range of glaucoma relevant insults including mitochondrial stress and axon degenerative insults. We demonstrate retinal ganglion cell somal, axonal, and dendritic neuroprotection by nicotinamide in rodent models which represent isolated ocular hypertensive, axon degenerative, and mitochondrial degenerative insults. We performed metabolomics enriched for small molecular weight metabolites for the retina, optic nerve, and superior colliculus which demonstrates that ocular hypertension induces widespread metabolic disruption, including consistent changes to α-ketoglutaric acid, creatine/creatinine, homocysteine, and glycerophosphocholine. This metabolic disruption is prevented by nicotinamide. Nicotinamide provides further neuroprotective effects by increasing oxidative phosphorylation, buffering and preventing metabolic stress, and increasing mitochondrial size and motility whilst simultaneously dampening action potential firing frequency. These data support continued determination of the utility of long-term nicotinamide treatment as a neuroprotective therapy for human glaucoma. Nicotinamide is neuroprotective in cell and animal models that recapitulate isolated features of glaucoma. Systemic nicotinamide administration has limited molecular side-effects on visual system tissue under basal conditions. Nicotinamide provides a robust reversal in the disease metabolic profile of glaucomatous animals. Nicotinamide increases oxidative phosphorylation, buffers and prevents metabolic stress, and increases mitochondrial size.
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Affiliation(s)
- James R Tribble
- Department of Clinical Neuroscience, Division of Eye and Vision, St. Erik Eye Hospital, Karolinska Institutet, Stockholm, Sweden.
| | - Amin Otmani
- Department of Clinical Neuroscience, Division of Eye and Vision, St. Erik Eye Hospital, Karolinska Institutet, Stockholm, Sweden.
| | - Shanshan Sun
- School of Optometry and Vision Sciences, Cardiff University, Cardiff, UK.
| | - Sevannah A Ellis
- The Florey Institute of Neuroscience and Mental Health, The University of Melbourne, Melbourne, Australia.
| | - Gloria Cimaglia
- Department of Clinical Neuroscience, Division of Eye and Vision, St. Erik Eye Hospital, Karolinska Institutet, Stockholm, Sweden; School of Optometry and Vision Sciences, Cardiff University, Cardiff, UK.
| | - Rupali Vohra
- Department of Veterinary and Animal Sciences, Pathobiological Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark; Department of Drug Design and Pharmacology, Eye Translational Research Unit, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark.
| | - Melissa Jöe
- Department of Clinical Neuroscience, Division of Eye and Vision, St. Erik Eye Hospital, Karolinska Institutet, Stockholm, Sweden.
| | - Emma Lardner
- Department of Clinical Neuroscience, Division of Eye and Vision, St. Erik Eye Hospital, Karolinska Institutet, Stockholm, Sweden.
| | - Abinaya P Venkataraman
- Department of Clinical Neuroscience, Division of Eye and Vision, St. Erik Eye Hospital, Karolinska Institutet, Stockholm, Sweden.
| | - Alberto Domínguez-Vicent
- Department of Clinical Neuroscience, Division of Eye and Vision, St. Erik Eye Hospital, Karolinska Institutet, Stockholm, Sweden.
| | - Eirini Kokkali
- School of Optometry and Vision Sciences, Cardiff University, Cardiff, UK.
| | - Seungsoo Rho
- School of Optometry and Vision Sciences, Cardiff University, Cardiff, UK; Department of Ophthalmology, CHA Bundang Medical Center, CHA University, Seongnam, Republic of Korea.
| | - Gauti Jóhannesson
- Department of Clinical Sciences, Ophthalmology, Umeå University, Umeå, Sweden; Wallenberg Centre of Molecular Medicine, Umeå University, Umeå, Sweden.
| | | | - Peter G Fuerst
- WWAMI Medical Education Program, University of Idaho, Moscow, ID, USA.
| | - Rune Brautaset
- Department of Clinical Neuroscience, Division of Eye and Vision, St. Erik Eye Hospital, Karolinska Institutet, Stockholm, Sweden.
| | - Miriam Kolko
- Department of Drug Design and Pharmacology, Eye Translational Research Unit, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark; Department of Ophthalmology, Copenhagen University Hospital, Rigshospitalet-Glostrup, Glostrup, Denmark.
| | - James E Morgan
- School of Optometry and Vision Sciences, Cardiff University, Cardiff, UK; Cardiff Eye Unit, University Hospital Wales, Cardiff, UK; School of Medicine, Cardiff University, Cardiff, UK.
| | - Jonathan G Crowston
- Centre for Eye Research Australia, Royal Victorian Eye and Ear Hospital, Melbourne, Australia; Singapore Eye Research Institute, Singapore National Eye Centre, Singapore, Singapore; Centre for Vision Research, Neuroscience and Behavioural Disorders, Duke-NUS, Singapore, Singapore.
| | - Marcela Votruba
- School of Optometry and Vision Sciences, Cardiff University, Cardiff, UK; Cardiff Eye Unit, University Hospital Wales, Cardiff, UK.
| | - Pete A Williams
- Department of Clinical Neuroscience, Division of Eye and Vision, St. Erik Eye Hospital, Karolinska Institutet, Stockholm, Sweden.
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15
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Tribble JR, Kokkali E, Otmani A, Plastino F, Lardner E, Vohra R, Kolko M, André H, Morgan JE, Williams PA. When Is a Control Not a Control? Reactive Microglia Occur Throughout the Control Contralateral Pathway of Retinal Ganglion Cell Projections in Experimental Glaucoma. Transl Vis Sci Technol 2021; 10:22. [PMID: 33510961 PMCID: PMC7804521 DOI: 10.1167/tvst.10.1.22] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 12/02/2020] [Indexed: 12/19/2022] Open
Abstract
Purpose Animal models show retinal ganglion cell (RGC) injuries that replicate features of glaucoma and the contralateral eye is commonly used as an internal control. There is significant crossover of RGC axons from the ipsilateral to the contralateral side at the level of the optic chiasm, which may confound findings when damage is restricted to one eye. The effect of unilateral glaucoma on neuroinflammatory damage to the contralateral pathway of RGC projections has largely been unexplored. Methods Ocular hypertensive glaucoma was induced unilaterally or bilaterally in the rat and RGC neurodegenerative events were assessed. Neuroinflammation was quantified in the retina, optic nerve head, optic nerve, lateral geniculate nucleus, and superior colliculus by high-resolution imaging, and in the retina by flow cytometry and protein arrays. Results After ocular hypertensive stress, peripheral monocytes enter the retina and microglia become reactive. This effect is more marked in animals with bilateral ocular hypertensive glaucoma. In rats where glaucoma was induced unilaterally, there was significant microglia activation in the contralateral (control) eye. Microglial activation extended into the optic nerve and terminal visual thalami, where it was similar across hemispheres in unilateral ocular hypertension. Conclusions These data suggest that caution is warranted when using the contralateral eye as a control and in comparing visual thalami in unilateral models of glaucoma. Translational Relevance The use of a contralateral eye as a control may confound the discovery of human-relevant mechanism and treatments in animal models. We also identify neuroinflammatory protein responses that warrant further investigation as potential disease-modifiable targets.
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Affiliation(s)
- James R. Tribble
- Department of Clinical Neuroscience, Division of Eye and Vision, St. Erik Eye Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Eirini Kokkali
- School of Optometry and Vision Sciences, Cardiff University, Cardiff, Wales, UK
| | - Amin Otmani
- Department of Clinical Neuroscience, Division of Eye and Vision, St. Erik Eye Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Flavia Plastino
- Department of Clinical Neuroscience, Division of Eye and Vision, St. Erik Eye Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Emma Lardner
- Department of Clinical Neuroscience, Division of Eye and Vision, St. Erik Eye Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Rupali Vohra
- Department of Veterinary and Animal Sciences, Pathobiological Sciences, University of Copenhagen, Denmark
- Department of Drug Design and Pharmacology, University of Copenhagen, Copenhagen, Denmark
| | - Miriam Kolko
- Department of Drug Design and Pharmacology, University of Copenhagen, Copenhagen, Denmark
- Department of Ophthalmology, Rigshospitalet-Glostrup, Copenhagen, Denmark
| | - Helder André
- Department of Clinical Neuroscience, Division of Eye and Vision, St. Erik Eye Hospital, Karolinska Institutet, Stockholm, Sweden
| | - James E. Morgan
- School of Optometry and Vision Sciences, Cardiff University, Cardiff, Wales, UK
- School of Medicine, Cardiff University, Cardiff, Wales, UK
| | - Pete A. Williams
- Department of Clinical Neuroscience, Division of Eye and Vision, St. Erik Eye Hospital, Karolinska Institutet, Stockholm, Sweden
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