Sex-dependent parameters related to electrolyte, water and glycoprotein secretion in rabbit lacrimal glands

TFOS DEWS II Sex, Gender, and Hormones Report

One of the most compelling features of dry eye disease (DED) is that it occurs more frequently in women than men. In fact, the female sex is a significant risk factor for the development of DED. This sex-related difference in DED prevalence is attributed in large part to the effects of sex steroids (e.g. androgens, estrogens), hypothalamic-pituitary hormones, glucocorticoids, insulin, insulin-like growth factor 1 and thyroid hormones, as well as to the sex chromosome complement, sex-specific autosomal factors and epigenetics (e.g. microRNAs). In addition to sex, gender also appears to be a risk factor for DED. "Gender" and "sex" are words that are often used interchangeably, but they have distinct meanings. "Gender" refers to a person's self-representation as a man or woman, whereas "sex" distinguishes males and females based on their biological characteristics. Both gender and sex affect DED risk, presentation of the disease, immune responses, pain, care-seeking behaviors, service utilization, and myriad other facets of eye health. Overall, sex, gender and hormones play a major role in the regulation of ocular surface and adnexal tissues, and in the difference in DED prevalence between women and men. The purpose of this Subcommittee report is to review and critique the nature of this role, as well as to recommend areas for future research to advance our understanding of the interrelationships between sex, gender, hormones and DED.

The aging lacrimal gland: changes in structure and function

The afferent nerves of the cornea and conjunctiva, efferent nerves of the lacrimal gland, and the lacrimal gland are a functional unit that works cooperatively to produce the aqueous component of tears. A decrease in the lacrimal gland secretory function can lead to dry eye disease. Because aging is a risk factor for dry eye disease, study of the changes in the function of the lacrimal gland functional unit with age is important for developing treatments to prevent dry eye disease. No one mechanism is known to induce the changes that occur with aging, although multiple different mechanisms have been associated with aging. These fall into two theoretical categories: programmed theories of aging (immunological, genetic, apoptotic, and neuroendocrine) and error theories of aging (protein alteration, somatic mutation, etc). Lacrimal glands undergo structural and functional alteration with increasing age. In mouse models of aging, it has been shown that neural stimulation of protein secretion is an early target of aging, accompanied by an increase in mast cells and lipofuscin accumulation. Hyperglycemia and increased lymphocytic infiltration can contribute to this loss of function at older ages. These findings suggest that an increase in oxidative stress may play a role in the loss of lacrimal gland function with age. For the afferent and efferent neural components of the lacrimal gland functional unit, immune or inflammatory mediated decrease in nerve function could contribute to loss of lacrimal gland secretion with age. More research in this area is critically needed.

Ocular Mucosal Immunity

Mucosal immunity defends the ocular surface against antigenic challenge and microbial invasion. The principal effector site is the lacrimal gland, where immunoglobulin A (IgA) antibodies are produced. Nasal-associated lymphoid tissue and posterior cervical lymph nodes function as major inductive sites for tear IgA responses. Neural connections and systemic hormones maintain the integrity and function of the ocular surface. Neuroenzyme activities in the lacrimal gland are influenced by ocular infections, leading to reduced expression of acetylcholine and modulation of receptors on acinar cells and on plasma cells, thereby decreasing fluid and immunoglobulin secretion. T lymphocyte-dependent responses result in production of interleukin-4 in lacrimal glands, thereby influencing cholinergic enzyme activity affecting immune processes and lacrimal physiology. Furthermore, neuropeptides released into lymphoid structures or inflamed tissues are chemotactic for antigen-presenting cells and affect their interactions with T cells. Thus, in developing therapeutic approaches for treating dry-eye conditions and vaccination strategies to elicit protective ocular mucosal immune responses, the entire lacrimal functional unit should be considered.

Sex hormones and the dry eye

The greater prevalence of dry eye in women compared to men suggests that sex hormones may have a role in this condition. This review aims to present evidence for how sex hormones may affect the ocular structures involved in the production, regulation and maintenance of the normal tear film. It is hypothesised that hormone changes alter the homeostasis of the ocular surface and contribute to dry eye. Androgens impact on the structure and function of the meibomian and lacrimal glands and therefore androgen deficiency is, at least in part, associated with the aetiology of dry eye. In contrast, reports of the effects of oestrogen and progesterone on these ocular structures and on the conjunctiva are contradictory and the mechanisms of action of these female-specific sex hormones in the eye are not well understood. The uncertainty of the effects of oestrogen and progesterone on dry eye symptoms is reflected in the controversial relationship between hormone replacement therapy and the signs and symptoms of dry eye. Current understanding of sex hormone influences on the immune system suggests that oestrogen may modulate a cascade of inflammatory events, which underlie dry eye.

Sex differences in expression and differential regulation by androgen and estrogen of two odorant-binding tear lipocalins in lacrimal glands of immature hamsters

In adults of several mammalian species, lacrimal glands (LG) have sex differences but there is no report of any sexual dimorphism in LG of immatures. In LG and tears of adult hamsters, we found female-specific expression of two closely related odorant-/pheromone-binding lipocalins, FLP (female lacrimal protein) and MSP (male-specific protein; initially identified in salivary glands of males). Although, both androgens and estrogens markedly repress FLP and MSP in LG of adults, the expression of these lipocalins in females is due to their incomplete repression by endogenous estrogens. Here we report a marked sexual dimorphism in the expression of FLP and MSP in LG and tears of 20-day-old immature hamsters. The age-dependant expression of these lipocalins and effect of neonatal-gonadectomy and sex hormone treatments on their expression in immatures was investigated. FLP and MSP are detectable in LG at 10-day age in both sexes of hamster but by 20-day age levels of both lipocalins show sex differences wherein FLP is several fold higher in males and MSP is obliterated in males. Thereafter, FLP declines in male LG and is obliterated by 36-day age, resulting in female-specific expression of both LG lipocalins as seen in adults. In LG of 20-day-old immatures, FLP and MSP are insensitive to repression by androgen and estrogen, respectively, which was unlike the androgen/estrogen-repressed regulation of both lipocalins in adult LG. The estrogenic repression of FLP and androgenic repression of MSP in LG of immature hamsters could be prevented by treatment with tamoxifen and flutamide, respectively. Our studies indicate that (i) presence of gonads in immatures can have significant effects on LG lipocalins resulting in their sexually dimorphic expression, (ii) in immatures, unlike adults, the repressive effects of estrogen and androgen on LG lipocalins are selective for FLP and MSP, respectively, and (iii) these repressions are likely to be mediated by sex hormone receptors.

Sex hormone regulation of tear lipocalin in the rabbit lacrimal gland

Tear lipocalin (TL) (approximately 18 kDa), a member of the lipocalin superfamily, has been identified as one of the major proteins present in rabbit lacrimal fluid. The concentration of TL has been found to be decreased in the tears of patients with dry eye disease. Lacrimal gland insufficiency, one of the major causes of dry eye disease, is known to affect mainly postmenopausal women, where there is a significant decrease in the production of androgen and estrogen. These observations suggest that sex hormones might influence dry eye indirectly by regulating the expression of TL. The purpose of this study was to determine: (1) the effect of sexual maturation on the expression of TL; and (2) if the expression of TL is regulated by the estrogen, 17beta-estradiol, and/or the androgen, dihydrotestosterone, in sexually mature female rabbits. Lacrimal fluid (LF) and lacrimal gland soluble fraction (Si) was collected from juvenile (2 kg) and sexually mature (4 kg) male and female New Zealand white (NZW) rabbits. In addition, LF and Si were collected from 4 kg rabbits, 7 days after being either sham operated (control), ovariectomized (OVX), ovariectomized treated with estrogen (OVX+E) or ovariectomized treated with dihydrotestosterone (OVX+DHT). Samples were analyzed for protein levels of TL by SDS-PAGE and Western blotting using a polyclonal rat anti-rabbit TL antibody. Densitometry analysis showed that TL protein levels in both LF and Si increased with age in male and female rabbits. In addition, TL protein levels were significantly higher in the sexually mature 4 kg male compared with the 4 kg female, while no significant difference in TL protein levels were seen among the juvenile male and female rabbits. Furthermore, ovariectomy decreased the protein levels of TL in LF and Si fraction by 50% and 20% respectively, compared with control values. Estrogen treatment increased TL protein levels by 30% and 50% in the LF and Si fraction respectively, compared with the sham operated group. DHT treatment also increased TL protein levels by approximately 150% in both LF and Si fraction compared with control values. These results support the hypothesis that sex hormones influence TL protein levels in rabbit lacrimal glands. The possibility of a role of TL in dry eye needs to be further investigated.

Tearful relationships? Sex, hormones, the lacrimal gland, and aqueous-deficient dry eye

Sex and the endocrine system exert a significant influence on the physiology and pathophysiology of the lacrimal gland. The purpose of this article is to briefly review the nature and magnitude of these interactions between sex, hormones and lacrimal tissue, and to address how they may relate to the pathogenesis of aqueous-deficient dry eye. Towards this end, this article has a 3-fold approach: first, to summarize the influence of androgens, estrogens, glucocorticoids, mineralocorticoids, retinoic acid, prolactin, alpha-melanocyte stimulating hormone, adrenocorticotropic hormone, luteinizing hormone, follicle-stimulating hormone, growth hormone, thyroid-stimulating hormone, arginine vasopressin, oxytocin, thyroxine, parathyroid hormone, insulin, glucagon, melatonin, human chorionic gonadotropin and cholecystokinin on the structure and function of the lacrimal gland; second, to discuss the mechanism of action of each hormone on lacrimal tissue; and third, to discuss the clinical relevance of the endocrine-lacrimal gland interrelationship, with a particular focus on each hormone's role (i.e. if relevant) in the development of aqueous-tear deficiency.

Traffic of endogenous, transduced, and endocytosed prolactin in rabbit lacrimal acinar cells

The rabbit lacrimal gland undergoes an immunophysiological transformation during pregnancy, reminiscent of that of the mammary gland as it prepares to deliver secretory IgA into the nascent fluid product. The contents of TGF-beta and prolactin (PRL) within ductal epithelial cells increase, and their primary localizations shift from the apical to the basal cytoplasm, suggesting a transformation from exocrine to paracrine secretion. Studies with ex vivo acinar cell models demonstrated that elevated PRL suppresses traffic of secretory proteins into the regulated exocrine apparatus and directs them into a novel, induced, regulated paracrine apparatus [Wang, Y., Chiu, C.T., Nakamura, T., Walker, A.M., Petridou, B., Trousdale M.D., Hamm-Alvarez S.F., Schechter J.E., Mircheff A.K., 2007. Elevated prolactin redirects secretory vesicle traffic in rabbit lacrimal acinar cells. Am. J. Physiol. Endocrinol. Metab. 292, E1122-E1134]. However, it was not clear whether PRL itself entered the induced paracrine apparatus. In the present study, confocal immunofluorescence microscopy revealed that natively expressed PRL and over-expressed PRL co-localized with PRL receptors (PRLR); rab11, a marker for the recycling endosome; gamma-adaptin, a marker for the Golgi complex and trans-Golgi network; and rab7, a marker for the autophagic lysosomal apparatus. Natively expressed, over-expressed, and endocytosed PRL also co-localized with rab4 and rab5A, markers for the early endosome, and with rab3D, a marker for regulated exocrine secretory vesicles. Endocytosed PRL was stored in intact form and released in response to stimulation with carbachol. Subcellular fractionation analysis detected relative excesses of PRL over PRLR in fractions that contained fragments of the recycling endosome and fractions that contained both secretory vesicle fragments and prelysosomal and autolysosomal fragments. EM-gold microscopy demonstrated PRL within small vesicles, consistent with endosomes or secondary lysosomes, and in large vesicles, consistent with regulated secretory vesicles. The secretory vesicles were preponderantly localized in the apical cytoplasm of control cells, and in the basal cytoplasm of PRL over-expressing cells. These results indicate that when lacrimal epithelial cells synthesize PRL, and when they endocytose it from their ambient medium, they traffic it both into the endosomes that constitute the constitutive transcytotic paracrine apparatus and also into regulated secretory vesicles, which are associated with the exocrine apparatus at low PRL levels and with the induced paracrine apparatus at high PRL levels.

Estrogen up-regulation of metalloproteinase-2 and -9 expression in rabbit lacrimal glands

Increased levels of the matrix metalloproteinases (MMPs)-2 and -9 have been found in tear fluids of patients with dry eye disease, suggesting that these MMPs may be implicated in the pathogenesis of this disease. One of the main causes of dry eye disease is lacrimal gland insufficiency. However, the contribution of the lacrimal gland (LG) to the expression and production of MMP-2 and MMP-9 in tears is not known. Since dry eye disease occurs more frequently in women, sex hormones, especially estrogens, have also been implicated in the pathogenesis of this disease. Estrogens have been shown to regulate the synthesis levels of MMP-2 and MMP-9 in several tissues, Thus, the purpose of these studies was to determine if: (1) rabbit lacrimal glands secrete MMP-2 and MMP-9; (2) MMP-2 and MMP-9 are produced by lacrimal epithelial cells and/or lacrimal lymphocytes; and (3) the expression, activity and level of these enzymes are regulated by sex hormones. Lacrimal epithelial cells (LEC) and lacrimal lymphocytes (LL) from sexually mature New Zealand White female rabbits were isolated, purified and cultured with and without 10(-6)M dihydrotestosterone (DHT) or 10(-6), 10(-8), 10(-9) and 10(-10)M 17beta-estradiol (E2). The culture supernatants were analyzed by zymography and western blotting (WB) using polyclonal anti-human MMP-2 and MMP-9 antibodies. LGs were also collected from rabbits 7 days after being sham-operated, ovariectomized (OVX), OVX treated with 4 mg/kg DHT, and OVX treated with 0.5 mg/kg of E2. LGs were collected and processed for RNA extraction as well as protein determination using WB and immunocytochemistry. The pro-forms of MMP-2 and MMP-9 were detected in primary LEC and LL culture medium by zymography and WB. Pro-MMP-2 and pro-MMP-9 were also detected at the gene and protein levels in the lacrimal glands of all four treatment groups, with the highest levels and gene expression found in the estrogen-treated group. These results suggest that both pro-MMP-2 and pro-MMP-9 are secreted by the lacrimal gland and appear to be up-regulated by estrogen. The role of the lacrimal MMPs in the pathogenesis of dry eye disease needs to be further investigated.

Influence des hormones sur le film lacrymal

Tear film quality depends on fine regulatory mechanisms affected by neuronal and hormonal influences. Indeed, receptors for androgens, estrogens, progesterone and prolactin have been identified in several ocular tissues in the rat, rabbit and in humans. The eye is thus a target organ for sex hormones, particularly the androgens. These hormones regulate the immune system, the morphology and secretory functions of lacrimal glands and the functioning of Meibomian glands. The influence of hormone replacement therapy in menopausal women remains unclear, as some authors support the idea that they improve the quality and the volume of tear film, whereas others have shown that they increase the risk of dry eye. Finally, knowledge of the interactions between the hormones that influence the lacrimal glands is essential for the understanding of the regulation of lacrimal gland function. However, the data presently available strongly suggest that optimal bioavailable androgen levels are essential for normal lacrimal gland function and that prolactin and estrogens also play important roles in providing a hormonal milieu that contributes to normal lacrimal gland function.

[Dry eye disease as a complex dysregulation of the functional anatomy of the ocular surface. New concepts for understanding dry eye disease]

INTRODUCTION

Dry eye disease is a disorder of the tear film that results in epithelial damage and in a disruption of the normal homeostasis at the ocular surface. It is widespread and causes symptoms ranging from discomfort to blindness.

METHODS

A review of the existing literature was used to compare different past and recent concepts for the understanding of dry eye disease with a focus on aspects of the integrating functional anatomy of the ocular surface.

RESULTS

The understanding of the pathogenesis of dry eye disease has proceeded from the mere recognition of a lack of tears to a consideration of their quality and to the concept of wetting of the ocular surface. However, several other aspects as epithelial differentiation, innervation, hormonal status or immune protection contribute to the intact functional anatomy of the ocular surface. Recently it has been recognized that immunologically regulated mechanisms of inflammation represent a primary or secondary pathogenetic factor for dry eye disease. This is conceivably regulated by the cells of the physiological mucosal immune defence system, the eye-associated lymphoid tissue (EALT). Androgens represent an important trophic factor for the ocular surface and their deficiency predisposes to inflammation.

CONCLUSION

Dry eye disease represents a complex dysregulation of the functional anatomy of the ocular surface that can start from different alterations (e.g. insufficient secretion, defects in wetting or innervation). Immune-based inflammation is able to interconnect and negatively reinforce these different pathomechanisms, resulting in a vicious circle.

Role of gap junctions in fluid secretion of lacrimal glands

In glands such as the liver and pancreas, gap junctions containing connexin 26 and 32 (Cx26 and Cx32, respectively) couple the secretory cells. Uncoupling these junctions compromises the secretory function of these glands. Lacrimal glands also contain extensive arrays of gap junctions consisting of Cx26 and Cx32. We wanted to determine the role of these junctions in fluid secretion. In Cx32-deficient mice, immunocytochemistry showed that, in the male lacrimal gland, the remaining Cx26 was found evenly distributed in the membrane whereas there was little in the membranes of female glands. Western blot analysis of Cx26 showed that female Cx32-deficient mice expressed Cx26. Patch-clamp analyses of acinar cell coupling showed that the cell pairs from male glands were coupled whereas those from female glands were not. Stimulated fluid production by the glands from Cx32-deficient mice was abnormally low in female glands compared with controls at low topical doses of carbachol. The protein secretory response to different doses of carbachol was the same in all animals. These data suggest that gap junctions are essential for optimal fluid secretion in lacrimal glands.

Androgen support of lacrimal gland function

The effects of dihydrotestosterone (DHT) (1 mg/kg) on biochemical parameters related to lacrimal secretion, basal tear flow rate, and pilocarpine-stimulated lacrimal gland fluid secretion, in mature ovariectomized rabbits were studied. The effects of the synthetic estrogen diethylstilbestrol (DES) (100 micrograms/kg), on lacrimal gland biochemical parameters in normal mature female rabbits was also studied. Ovariectomy decreased the total serum levels of testosterone (T) by 88.5% and androstenedione by 35.9%, without changing the levels of dehydroepiandrosterone (DHEA) of its sulfate. Ovariectomy caused a significant regression of the lacrimal glands, decreasing total DNA by 35%, and total protein by 22%. DHT treatment of ovariectomized animals prevented lacrimal gland regression, increasing total gland DNA (31%) and total protein (18%). DHT treatment also increases Na+, K(+)-ATPase activity (29%) and beta-adrenergic receptor binding sites (23%) compared to the ovariectomized group. DHT increased pilocarpine stimulated lacrimal gland fluid secretion (13.26 +/- 1.47 microL/min) compared to the ovariectomized group (7.72 +/- 0.41 microL/min), but DHT treatment paradoxically decreased basal tear flow rate (1.02 +/- 0.04 microL/min) as compared to the ovariectomized rabbits (1.96 +/- 0.12 microL/min). DES decreased the total serum T from 59.33 +/- 10.54 pg/mL to 21.5 +/- 6.06 pg/mL. DES decreased total Na+,K(+)-ATPase by 12% and increased beta-adrenergic receptor binding sites by 83.3%. These results suggest that androgens play a major role in supporting lacrimal gland secretory function. Additionally, they suggest that estrogens may influence certain aspects of lacrimal functions, although it is not clear to what extent those actions are elicited directly or indirectly.

MR imaging of the lacrimal gland. Age-related and gender-dependent changes in size and structure

PURPOSE

The subject of this study was to define age-related and gender-dependent changes in MR features of the lacrimal gland.

MATERIAL AND METHODS

MR images were retrospectively analyzed in 104 normal subjects aged 2-79 years to measure thickness and area of the lacrimal gland, its MR signal intensity ratio, and SD of the MR signal intensity profile.

RESULTS

Thickness and area of the lacrimal gland decreased with age in women (p < 0.001), but not in men. Furthermore, MR signal intensity ratio of the lacrimal gland showed an age-related increase in women (p < 0.001), but not in men. On the other hand, SD of the MR signal intensity increased with age in both women and men (p < 0.001).

CONCLUSION

These findings demonstrate that gender has a significant influence on lacrimal gland structure during development and aging.