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Buffault J, Reboussin É, Blond F, Guillonneau X, Bastelica P, Kessal K, Akkurt Arslan M, Melik-Parsadaniantz S, Réaux-le Goazigo A, Labbé A, Brignole-Baudouin F, Baudouin C. RNA-seq transcriptomic profiling of TGF-β2-exposed human trabecular meshwork explants: Advancing insights beyond conventional cell culture models. Exp Cell Res 2024; 442:114220. [PMID: 39214330 DOI: 10.1016/j.yexcr.2024.114220] [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: 05/25/2024] [Revised: 07/26/2024] [Accepted: 08/20/2024] [Indexed: 09/04/2024]
Abstract
Primary open-angle glaucoma (POAG), a leading cause of irreversible vision loss, is closely linked to increased intraocular pressure (IOP), with the trabecular meshwork (TM) playing a critical role in its regulation. The TM, located at the iridocorneal angle, acts as a sieve, filtering the aqueous humor from the eye into the collecting ducts, thus maintaining proper IOP levels. The transforming growth factor-beta 2 (TGF-β2) signaling pathway has been implicated in the pathophysiology of primary open-angle glaucoma POAG particularly, in the dysfunction of the TM. This study utilizes human TM explants to closely mimic in vivo conditions, thereby minimizing transcriptional changes that could arise from cell culture enabling an exploration of the transcriptomic impacts of TGF-β2. Through bulk RNA sequencing and immunohistological analysis, we identified distinct gene expression patterns and morphological changes induced by TGF-β2 exposure (5 ng/ml for 48 h). Bulk RNA sequencing identified significant upregulation in genes linked to extracellular matrix (ECM) regulation and fibrotic signaling. Immunohistological analysis further elucidated the morphological alterations, including cytoskeletal rearrangements and ECM deposition, providing a visual confirmation of the transcriptomic data. Notably, the enrichment analysis unveils TGF-β2's influence on both bone morphogenic protein (BMP) and Wnt signaling pathways, suggesting a complex interplay of molecular mechanisms contributing to TM dysfunction in glaucoma. This characterization of the transcriptomic modifications on an explant model of TM obtained under the effect of this profibrotic cytokine involved in glaucoma is crucial in order to develop and test new molecules that can block their signaling pathways.
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Affiliation(s)
- J Buffault
- Department of Ophthalmology III, Quinze-Vingts National Ophthalmology Hospital, IHU Foresight, Paris, France; Sorbonne Université, INSERM, CNRS, IHU Foresight, Institut de La Vision, Paris, France; Department of Ophthalmology, Ambroise Paré Hospital, APHP, Université de Paris Saclay, Boulogne-Billancourt, France.
| | - É Reboussin
- Sorbonne Université, INSERM, CNRS, IHU Foresight, Institut de La Vision, Paris, France
| | - F Blond
- Sorbonne Université, INSERM, CNRS, IHU Foresight, Institut de La Vision, Paris, France
| | - X Guillonneau
- Sorbonne Université, INSERM, CNRS, IHU Foresight, Institut de La Vision, Paris, France
| | - P Bastelica
- Department of Ophthalmology III, Quinze-Vingts National Ophthalmology Hospital, IHU Foresight, Paris, France; Sorbonne Université, INSERM, CNRS, IHU Foresight, Institut de La Vision, Paris, France
| | - K Kessal
- Sorbonne Université, INSERM, CNRS, IHU Foresight, Institut de La Vision, Paris, France
| | - M Akkurt Arslan
- Sorbonne Université, INSERM, CNRS, IHU Foresight, Institut de La Vision, Paris, France
| | - S Melik-Parsadaniantz
- Sorbonne Université, INSERM, CNRS, IHU Foresight, Institut de La Vision, Paris, France
| | - A Réaux-le Goazigo
- Sorbonne Université, INSERM, CNRS, IHU Foresight, Institut de La Vision, Paris, France
| | - A Labbé
- Department of Ophthalmology III, Quinze-Vingts National Ophthalmology Hospital, IHU Foresight, Paris, France; Department of Ophthalmology, Ambroise Paré Hospital, APHP, Université de Paris Saclay, Boulogne-Billancourt, France
| | - F Brignole-Baudouin
- Sorbonne Université, INSERM, CNRS, IHU Foresight, Institut de La Vision, Paris, France; Department of Biology, CHNO des Quinze-Vingts, IHU Foresight, Paris, France
| | - C Baudouin
- Department of Ophthalmology III, Quinze-Vingts National Ophthalmology Hospital, IHU Foresight, Paris, France; Sorbonne Université, INSERM, CNRS, IHU Foresight, Institut de La Vision, Paris, France.
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2
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Zheng YJ, Dilbeck MD, Economides JR, Horton JC. Permanent transduction of retinal ganglion cells by rAAV2-retro. Exp Eye Res 2024; 240:109793. [PMID: 38246331 DOI: 10.1016/j.exer.2024.109793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 12/28/2023] [Accepted: 01/15/2024] [Indexed: 01/23/2024]
Abstract
Adeno-associated virus (AAV) is widely used as a vector for delivery of gene therapy. Long term therapeutic benefit depends on perpetual expression of the wild-type gene after transduction of host cells by AAV. To address this issue in a mass population of identified single cells, 4 rats received an injection of a 1:1 mixture of rAAV2-retro-hSyn-EGFP and rAAV2-retro-hSyn-mCherry into each superior colliculus. After the virus was transported retrogradely to both retinas, serial fundus imaging was performed at days 14, 45, 211, and 375 to visualize individual fluorescent ganglion cells. The location of each cell was plotted to compare labeling at each time point. In 12/16 comparisons, 97% or more of the cells identified in the initial baseline fundus image were still labeled at day 375. In 4 cases the percentage was lower, but in these cases the apparent reduction in the number of labeled cells at day 375 was attributable to the lower quality of follow-up fundus images, rather than true loss of transgene expression. These data indicate that retinal ganglion cells transduced by rAAV2-retro are transduced permanently.
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Affiliation(s)
- Yicen J Zheng
- Program in Neuroscience, Department of Ophthalmology University of California, San Francisco, San Francisco, CA, 94143, USA
| | - Mikayla D Dilbeck
- Program in Neuroscience, Department of Ophthalmology University of California, San Francisco, San Francisco, CA, 94143, USA
| | - John R Economides
- Program in Neuroscience, Department of Ophthalmology University of California, San Francisco, San Francisco, CA, 94143, USA
| | - Jonathan C Horton
- Program in Neuroscience, Department of Ophthalmology University of California, San Francisco, San Francisco, CA, 94143, USA.
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Vallabh NA, Armstrong J, Czanner G, McDonagh B, Choudhary A, Criddle DN, Willoughby CE. Evidence of impaired mitochondrial cellular bioenergetics in ocular fibroblasts derived from glaucoma patients. Free Radic Biol Med 2022; 189:102-110. [PMID: 35872337 DOI: 10.1016/j.freeradbiomed.2022.07.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Revised: 06/29/2022] [Accepted: 07/12/2022] [Indexed: 11/20/2022]
Abstract
Glaucoma is a progressive optic neuropathy characterized by the neurodegeneration of the retinal ganglion cells (RGCs) resulting in irreversible visual impairment and eventual blindness. RGCs are extremely susceptible to mitochondrial compromise due to their marked bioenergetic requirements and morphology. There is increasing interest in therapies targeting mitochondrial health as a method of preventing visual loss in managing glaucoma. The bioenergetic profile of Tenon's ocular fibroblasts from glaucoma patients and controls was investigated using the Seahorse XF24 analyser. Impaired mitochondrial cellular bioenergetics was detected in glaucomatous ocular fibroblasts including basal respiration, maximal respiration and spare capacity. Spare respiratory capacity levels reflect mitochondrial bio-energetic adaptability in response to pathophysiological stress. Basal oxidative stress was elevated in glaucomatous Tenon's ocular fibroblasts and hydrogen peroxide (H2O2) induced reactive oxygen species (ROS) simulated the glaucomatous condition in normal Tenon's ocular fibroblasts. This work supports the role of therapeutic interventions to target oxidative stress or provide mitochondrial energetic support in glaucoma.
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Affiliation(s)
- Neeru A Vallabh
- Department of Eye and Vision Science, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, L69 3BX, United Kingdom; St. Paul's Eye Unit, Royal Liverpool University Hospital, Liverpool, L7 8XP, United Kingdom
| | - Jane Armstrong
- Institute of Systems, Molecular and Integrative Biology, Biosciences Building, University of Liverpool, Liverpool, L69 7BE, United Kingdom
| | - Gabriela Czanner
- School of Computer Science and Mathematics, Liverpool John Moores University, Byrom Street, Liverpool, L3 3AF, United Kingdom; Faculty of Informatics and Information Technology, Slovak University of Technology, 842 16, Bratislava, Slovakia
| | - Brian McDonagh
- Discipline of Physiology, School of Medicine, National University of Ireland, Galway, Ireland
| | - Anshoo Choudhary
- St. Paul's Eye Unit, Royal Liverpool University Hospital, Liverpool, L7 8XP, United Kingdom
| | - David N Criddle
- Institute of Systems, Molecular and Integrative Biology, Biosciences Building, University of Liverpool, Liverpool, L69 7BE, United Kingdom
| | - Colin E Willoughby
- Department of Eye and Vision Science, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, L69 3BX, United Kingdom; Genomic Medicine, Biomedical Sciences Research Institute, Ulster University, Coleraine, BT52 1SA, United Kingdom.
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Lindner M, Gilhooley MJ, Hughes S, Hankins MW. Optogenetics for visual restoration: From proof of principle to translational challenges. Prog Retin Eye Res 2022; 91:101089. [PMID: 35691861 DOI: 10.1016/j.preteyeres.2022.101089] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 05/17/2022] [Accepted: 05/19/2022] [Indexed: 01/04/2023]
Abstract
Degenerative retinal disorders are a diverse family of diseases commonly leading to irreversible photoreceptor death, while leaving the inner retina relatively intact. Over recent years, innovative gene replacement therapies aiming to halt the progression of certain inherited retinal disorders have made their way into clinics. By rendering surviving retinal neurons light sensitive optogenetic gene therapy now offers a feasible treatment option that can restore lost vision, even in late disease stages and widely independent of the underlying cause of degeneration. Since proof-of-concept almost fifteen years ago, this field has rapidly evolved and a detailed first report on a treated patient has recently been published. In this article, we provide a review of optogenetic approaches for vision restoration. We discuss the currently available optogenetic tools and their relative advantages and disadvantages. Possible cellular targets will be discussed and we will address the question how retinal remodelling may affect the choice of the target and to what extent it may limit the outcomes of optogenetic vision restoration. Finally, we will analyse the evidence for and against optogenetic tool mediated toxicity and will discuss the challenges associated with clinical translation of this promising therapeutic concept.
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Affiliation(s)
- Moritz Lindner
- The Nuffield Laboratory of Ophthalmology, Jules Thorn SCNi, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, OX1 3QU, United Kingdom; Institute of Physiology and Pathophysiology, Department of Neurophysiology, Philipps University, 35037, Marburg, Germany
| | - Michael J Gilhooley
- The Nuffield Laboratory of Ophthalmology, Jules Thorn SCNi, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, OX1 3QU, United Kingdom; The Institute of Ophthalmology, University College London, EC1V 9EL, United Kingdom; Moorfields Eye Hospital, London, EC1V 2PD, United Kingdom
| | - Steven Hughes
- The Nuffield Laboratory of Ophthalmology, Jules Thorn SCNi, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, OX1 3QU, United Kingdom
| | - Mark W Hankins
- The Nuffield Laboratory of Ophthalmology, Jules Thorn SCNi, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, OX1 3QU, United Kingdom.
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Zehden JA, Raviskanthan S, Mortensen PW, Ferré M, Reynier P, Milea D, Lee AG. Dominant Optic Atrophy: How to Determine the Pathogenicity of Novel Variants? J Neuroophthalmol 2022; 42:149-153. [PMID: 34629404 DOI: 10.1097/wno.0000000000001352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Jason A Zehden
- Baylor College of Medicine (JZ), Houston, Texas, US; Department of Ophthalmology (SR, PWM, AGL), Blanton Eye Institute, Houston Methodist Hospital, Houston, Texas; MITOVASC Institute (MF, PR, DM), CNRS 6015, INSERM U1083, University of Angers, France ; Singapore National Eye Center (DM), Singapore, Singapore ; Singapore Eye Research Institute (DM), Singapore, Singapore ; Duke-NUS Medical School (DM), Singapore, Singapore ; Copenhagen University Hospital Denmark (DM), Copenhagen, Denmark; Departments of Ophthalmology (AGL), Neurology, and Neurosurgery, Weill Cornell Medicine, New York, New York; Department of Ophthalmology (AGL), University of Texas Medical Branch, Galveston, Texas; University of Texas MD Anderson Cancer Center (AGL), Houston, Texas; Texas A and M College of Medicine (AGL), Bryan, Texas; and Department of Ophthalmology (AGL), The University of Iowa Hospitals and Clinics, Iowa City, Iowa
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Nanjappa R, Dilbeck MD, Economides JR, Horton JC. Fundus imaging of retinal ganglion cells transduced by retrograde transport of rAAV2-retro. Exp Eye Res 2022; 219:109084. [PMID: 35460667 DOI: 10.1016/j.exer.2022.109084] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 03/07/2022] [Accepted: 04/13/2022] [Indexed: 11/18/2022]
Abstract
Access of adeno-associated virus (AAV) to ganglion cells following intravitreal injection for gene therapy is impeded by the internal limiting membrane of the retina. As an alternative, one could transduce ganglion cells via retrograde transport after virus injection into a retinal target nucleus. It is unknown if recombinant AAV2-retro (rAAV2-retro), a variant of AAV2 developed specifically for retrograde transport, is capable of transducing retinal ganglion cells. To address this issue, equal volumes of rAAV2-retro-hSyn-EGFP and rAAV2-retro-hSyn-mCherry were mixed in a micropipette and injected into the rat superior colliculus. The time-course of viral transduction was tracked by performing serial in vivo fundus imaging. Cells that were labeled by the fluorophores within the first week remained consistent in distribution and relative signal strength on follow-up imaging. Most transduced cells were double-labeled, but some were labeled by only EGFP or mCherry. Fundus images were later aligned with retinal wholemounts. Ganglion cells in the wholemounts matched precisely the cells imaged by fundus photography. As seen in the fundus images, ganglion cells in wholemounts were sometimes labeled by only EGFP or mCherry. Overall, there was detectable label in 32-41% of ganglion cells. Analysis of the number of cells labeled by 0, 1, or 2 fluorophores, based on Poisson statistics, yielded an average of 0.66 virions transducing each ganglion cell. Although this represents a low number relative to the quantity of virus injected into the superior colliculus, the ganglion cells showed sustained and robust fluorescent labeling. In the primate, injection of rAAV2-retro into the lateral geniculate nucleus might provide a viable approach for the transduction of ganglion cells, bypassing the obstacles that have prevented effective gene delivery via intravitreal injection.
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Affiliation(s)
- Rakesh Nanjappa
- Program in Neuroscience, Department of Ophthalmology, University of California, San Francisco, San Francisco, CA, 94143, USA
| | - Mikayla D Dilbeck
- Program in Neuroscience, Department of Ophthalmology, University of California, San Francisco, San Francisco, CA, 94143, USA
| | - John R Economides
- Program in Neuroscience, Department of Ophthalmology, University of California, San Francisco, San Francisco, CA, 94143, USA
| | - Jonathan C Horton
- Program in Neuroscience, Department of Ophthalmology, University of California, San Francisco, San Francisco, CA, 94143, USA.
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Gueguen N, Piarroux J, Sarzi E, Benkirane M, Manes G, Delettre C, Amedro P, Leboucq N, Koenig M, Meyer P, Meunier I, Reynier P, Lenaers G, Roubertie A. Optic neuropathy linked to ACAD9 pathogenic variants: A potentially riboflavin-responsive disorder? Mitochondrion 2021; 59:169-174. [PMID: 34023438 DOI: 10.1016/j.mito.2021.05.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 05/19/2021] [Accepted: 05/19/2021] [Indexed: 12/14/2022]
Abstract
Mitochondrial complex I (CI) deficiencies (OMIM 252010) are the commonest inherited mitochondrial disorders in children. Acyl-CoA dehydrogenase 9 (ACAD9) is a flavoenzyme involved chiefly in CI assembly and possibly in fatty acid oxidation. Biallelic pathogenic variants result in CI dysfunction, with a phenotype ranging from early onset and sometimes fatal mitochondrial encephalopathy with lactic acidosis to late-onset exercise intolerance. Cardiomyopathy is often associated. We report a patient with childhood-onset optic and peripheral neuropathy without cardiac involvement, related to CI deficiency. Genetic analysis revealed compound heterozygous pathogenic variants in ACAD9, expanding the clinical spectrum associated to ACAD9 mutations. Importantly, riboflavin treatment (15 mg/kg/day) improved long-distance visual acuity and demonstrated significant rescue of CI activity in vitro.
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Affiliation(s)
- Naig Gueguen
- Department of Biochemistry and Molecular Biology, CHU Angers, 49933 Angers, France; University of Angers, Unité Mixte de Recherche (UMR) MITOVASC, Centre National de la Recherche Scientifique (CNRS) 6015, Institut National de la Santé et de la Recherche Médicale (INSERM) U1083, 49933 Angers, France
| | - Julie Piarroux
- CHU Montpellier, Département de Neuropédiatrie, Montpellier, France
| | - Emmanuelle Sarzi
- NeuroMyoGene Institute-UCBL/CNRS UMR5310/INSERM U1217-Lyon, France
| | - Mehdi Benkirane
- PhyMedExp, CNRS, INSERM, University of Montpellier, Montpellier, France; Laboratoire de Génétique Moléculaire, Institut Universitaire de Recherche Clinique, CHU de Montpellier, France
| | - Gael Manes
- INM, University Montpellier, INSERM, Montpellier, France
| | | | - Pascal Amedro
- PhyMedExp, CNRS, INSERM, University of Montpellier, Montpellier, France; Pediatric and Adult Congenital Cardiology Department, M3C Rare Cardiac Disease Reference Center, CHU Montpellier, France
| | - Nicolas Leboucq
- Département de Neuroradiologie, CHU Montpellier, Montpellier, France
| | - Michel Koenig
- PhyMedExp, CNRS, INSERM, University of Montpellier, Montpellier, France; Laboratoire de Génétique Moléculaire, Institut Universitaire de Recherche Clinique, CHU de Montpellier, France
| | - Pierre Meyer
- CHU Montpellier, Département de Neuropédiatrie, Montpellier, France; PhyMedExp, CNRS, INSERM, University of Montpellier, Montpellier, France
| | - Isabelle Meunier
- National Center in Rare Diseases, Genetics of Sensory Diseases, University Hospital, Montpellier, France
| | - Pascal Reynier
- Department of Biochemistry and Molecular Biology, CHU Angers, 49933 Angers, France; University of Angers, Unité Mixte de Recherche (UMR) MITOVASC, Centre National de la Recherche Scientifique (CNRS) 6015, Institut National de la Santé et de la Recherche Médicale (INSERM) U1083, 49933 Angers, France
| | - Guy Lenaers
- University of Angers, Unité Mixte de Recherche (UMR) MITOVASC, Centre National de la Recherche Scientifique (CNRS) 6015, Institut National de la Santé et de la Recherche Médicale (INSERM) U1083, 49933 Angers, France
| | - Agathe Roubertie
- CHU Montpellier, Département de Neuropédiatrie, Montpellier, France; INM, University Montpellier, INSERM, Montpellier, France; National Center in Rare Diseases, Genetics of Sensory Diseases, University Hospital, Montpellier, France.
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Kim US, Mahroo OA, Mollon JD, Yu-Wai-Man P. Retinal Ganglion Cells-Diversity of Cell Types and Clinical Relevance. Front Neurol 2021; 12:661938. [PMID: 34093409 PMCID: PMC8175861 DOI: 10.3389/fneur.2021.661938] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 04/06/2021] [Indexed: 11/24/2022] Open
Abstract
Retinal ganglion cells (RGCs) are the bridging neurons that connect the retinal input to the visual processing centres within the central nervous system. There is a remarkable diversity of RGCs and the various subtypes have unique morphological features, distinct functions, and characteristic pathways linking the inner retina to the relevant brain areas. A number of psychophysical and electrophysiological tests have been refined to investigate this large and varied population of RGCs. Technological advances, such as high-resolution optical coherence tomography imaging, have provided additional tools to define the pattern of RGC involvement and the chronological sequence of events in both inherited and acquired optic neuropathies. The mechanistic insights gained from these studies, in particular the selective vulnerability and relative resilience of particular RGC subtypes, are of fundamental importance as they are directly relevant to the development of targeted therapies for these invariably progressive blinding diseases. This review provides a comprehensive description of the various types of RGCs, the developments in proposed methods of classification, and the current gaps in our knowledge of how these RGCs are differentially affected depending on the underlying aetiology. The synthesis of the current body of knowledge on the diversity of RGCs and the pathways that are potentially amenable to therapeutic modulation will hopefully lead to much needed effective treatments for patients with optic neuropathies.
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Affiliation(s)
- Ungsoo Samuel Kim
- Kim's Eye Hospital, Seoul, South Korea
- John van Geest Centre for Brain Repair and MRC Mitochondrial Biology Unit, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
- Cambridge Eye Unit, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, United Kingdom
- Moorfields Eye Hospital NHS Foundation Trust, London, United Kingdom
- *Correspondence: Ungsoo Samuel Kim
| | - Omar A. Mahroo
- Moorfields Eye Hospital NHS Foundation Trust, London, United Kingdom
- Institute of Ophthalmology, University College London, London, United Kingdom
- Section of Ophthalmology, King's College London, St. Thomas' Hospital Campus, London, United Kingdom
| | - John D. Mollon
- Department of Psychology, University of Cambridge, Cambridge, United Kingdom
| | - Patrick Yu-Wai-Man
- John van Geest Centre for Brain Repair and MRC Mitochondrial Biology Unit, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
- Cambridge Eye Unit, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, United Kingdom
- Moorfields Eye Hospital NHS Foundation Trust, London, United Kingdom
- Institute of Ophthalmology, University College London, London, United Kingdom
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