Visual Dysfunction in Diabetes PDF

Visual Dysfunction in Diabetes
Ophthalmology Research
Joyce Tombran-Tink, PhD, and Colin J. Barnstable, DPhil
SERIES EDITORS
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Visual Dysfunction
in Diabetes
The Science of
Patient Impairment
and Health Care
Edited by
Joyce Tombran-Tink, PhD

Department of Ophthalmology
Department of Neural and Behavioral Sciences
Milton S. Hershey Medical Center
Penn State University College of Medicine, Hershey, PA, USA
Colin J. Barnstable, DPhil

Milton S. Hershey Medical Center
Penn State University College of Medicine, Hershey, PA, USA
Thomas W. Gardner
Department of Ophthalmology and Visual Sciences, Kellogg Eye Center
University of Michigan Medical School, Ann Arbor, MI, USA
Editors
Joyce Tombran-Tink, PhD Colin J. Barnstable, DPhil
Department of Ophthalmology Department of Neural
and Behavioral Sciences Milton S. Hershey Medical Center
Milton S. Hershey Medical Center Penn State University College of Medicine
Penn State University College of Medicine Hershey, PA, USA
Hershey, PA, USA [email protected]
[email protected]
Thomas W. Gardner
Department of Ophthalmology
and Visual Sciences
Kellogg Eye Center
University of Michigan Medical School
Ann Arbor, MI, USA
[email protected]
http://extras.springer.com
ISBN 978-1-60761-149-3 e-ISBN 978-1-60761-150-9

DOI 10.1007/978-1-60761-150-9
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Preface
INTRODUCTION
This monograph is intended to serve two functions: first, to help readers understand
the impact of vision impairment in people living daily with diabetes rather than consid-
ering diabetic retinopathy solely as a medical problem; second, to explore what we know
and what we do not know about the ways diabetes affect the eye. Even with the plethora
of new information being generated, there are still a series of fundamental questions that
must be addressed if we are to develop effective treatments for diabetic retinopathy.
In the first chapter of this volume, Stuckey relates her experiences with proliferative
diabetic retinopathy (PDR) and associated laser treatment. She provides a perspective
on the visual and emotional component of vision loss that can be explained only by
someone who has experienced it firsthand. She describes not only the loss of vision
from the vitreous hemorrhage, the pain of the laser treatments, but also the permanent
consequence of reduced peripheral vision and ability to adapt to dark conditions and
from dark to light. Thus, it is clear that ophthalmologists do not “cure” diabetic retin-
opathy with retinal photocoagulation, but merely keep people from really becoming
blind. Stuckey provides powerful incentives for us to do a better job to understand the
nature of the problems she and other people with diabetes face, or at least dread. She
also provokes us to prevent diabetic retinopathy or at least maintain vision without the
need for destructive treatment.
HOW IS DIABETIC RETINOPATHY DETECTED?

For the detection and diagnosis of diabetic retinopathy in standard clinical practice,
each patient is assessed individually with standard clinical tools including indirect oph-
thalmoscopy and slit lamp biomicroscopy following pupillary dilation. These methods
of physical examination not only provide structural information about the ocular media
and the status of the retinal blood vessels and optic nerve, but also provide little informa-
tion regarding the structure or function of the neural retina, the part that is key to vision.
So, the evaluation of large populations for the presence of retinopathy is usually done
by photographic methods; the analysis of the resulting images has dramatically reduced
vision impairment in communities of countries such as Iceland and Norway. However,
the protocols for capturing and assessing the images continue to evolve because they
require manual interpretation and are not quantitative.
Scanlon summarizes the progress in screening for diabetic retinopathy based on his
extensive experience in the United Kingdom. Clearly, screening in European countries is
much more widely implemented and successful than in the United States or elsewhere,
revealing the distinct cultural and economic differences in response to a common prob-
lem across the oceans. Thus, there is no single solution to population screenings for
diabetic retinopathy and multiple approaches may be needed to achieve optimal specificity
and sensitivity.
v
vi Preface
Adams and Bearse detail their extensive cross-sectional and longitudinal studies
of patients with diabetes and no or mild nonproliferative retinopathy using multifocal
ERGs and visual field tests. They find that prolonged implicit time on the mfERG, an
indicator of bipolar cell and outer plexiform layer integrity, predicts the development of
vascular lesions, with topographical correspondence. This technique has the advantage
of being independent of patient responses and can assess nearly the entire retina. Their
data clearly show the early impact of diabetes on the neurosensory retina prior to the loss
of visual acuity, and illustrate the potential to diagnose retinal impairment early so that
it can be slowed if treatments can be developed.
HOW DOES DIABETES AFFECT THE EYE?

The clinical impact of diabetes on the eye is generally discussed in terms of diabetic
retinopathy, but Midena reinforces the importance of corneal neuropathy which pre-
disposes patients to epithelium breakdown, and is reflected by changes in the corneal
structure as seen with confocal microscopy and by reduced corneal sensation. Diabetic
corneal neuropathy has little direct impact on visual function but is further evidence of
the widespread impact of diabetes in the eye. Furthermore, diabetes often frequently
causes dysfunction of the autonomic nerves that regulate pupil size. Taken together with
the impact of diabetes on sensory neurons in the retina, it is now evident that diabetes
causes widespread neuropathic changes in the eye.
Cunha-Vaz and colleagues point out that there may be variable phenotypes of diabetic
retinopathy based on clinical findings of microaneurysm turnover, vascular leakage, and
macular thickening. In several longitudinal studies, they have quantified microaneurysm
turnover on fundus photographs as well as vascular leakage and macular thickening to
form a composite multimodal retinal analysis system that provides a more comprehen-
sive assessment of retinopathy grade than any measure alone.
The clinical phenotype of diabetic retinopathy has generally been descriptive with
little effort to provide quantitative parameters that predict the progress of diabetic retin-
opathy. The composite scoring system developed by Cunha-Vaz et al. is one of the first
endeavors to account for consequences of increased vascular leakage and capillary clo-
sure. They found a greater rate of microaneurysm formation turnover in patients with
more severe diabetes and worse visual acuity. This careful analysis of various patterns
of vascular damage is an important step toward an improved understanding of diabetic
retinopathy.
Medina and Vujosevic address the fundamental issue of the impact of diabetes on
various aspects of vision. They trace a series of investigation into this question over the
past 3 decades in which increasingly sensitive tests have been used to quantify defects
in the inner vs. outer retina, and macular vs. mid-peripheral retinal in patients with vari-
ous stages of diabetes. Most studies have evaluated a limited number of parameters in
small cohorts of patients, so it remains difficult to have a comprehensive assessment of
the impact of the range of diabetic retinopathy on vision over time. However, the net
knowledge at this point that there is evidence of ganglion cell and inner retinal defects,
as well as defects in the photoreceptor/pigmented epithelium with increased retinopa-
thy grade, macular edema, and proliferative retinopathy. However, it remains uncertain
Preface vii
which cellular defects primarily give rise to loss of visual acuity or the relationship of
functional defects to alterations in retinal structure.
Two chapters examine various aspects of blood–retinal barrier break down in diabetic
retinopathy. First, Hafezi-Moghadam discusses the normal role of the blood–retinal bar-
rier to protect the neural retina and the role of inflammation and BRB permeability in
diabetic retinopathy. In particular, he summarizes the role of inflammatory leukocyte
recruitment to capillary endothelium by adhesion molecules such as ICAM-1, integrins,
and other molecules that allow leukocytes to migrate through extracellular matrix. One
of the mechanisms by which leukocytes increase permeability is through the release
of azurocidin, a protease that attracts other inflammatory cells and increases vascular
permeability. The actions of azurocidin can be blocked by a protease inhibitor such as
aprotinin in experimental models of diabetic retinopathy, and he points out that aprotinin
is used clinically in patients undergoing cardiothoracic and orthopedic surgery to reduce
vascular leakage. In sum, this model suggests that leukocyte recruitment and activation
may play a critical role in retinal vascular leakage particularly media through azurocidin
release and this strategy may provide a therapeutic target.
Runkle, Titchenell, and Antonetti detail the known cellular and molecular regula-
tion of the blood–retinal barrier and its compromise by diabetes, notably VEGF. VEGF
induces phosphorylation and ubiquitination of occludin, leading to its internalization
and movement away from the plasma membrane, and increased endothelial cell perme-
ability, as mediated by activation of protein kinase C (PKC) isoforms. Several of these
steps may be targets for therapeutic regulation.
In addition to a change in the barrier function of the retinal vasculature, the vessels
themselves undergo pathological changes. Kern describes the capillary nonperfusion
and degeneration that are early hallmarks of diabetic retinopathy. These changes can
lead to preretinal neovascularization, and many of the current therapeutic approaches
are based on the premise that blocking the early vascular pathology will prevent this
subsequent pathology.
Extracellular serine proteinases include urokinase plasminogen activator (uPA) and
members of the family of zinc-dependent endopeptidases called matrix metalloprotei-
nases (MMPs). These proteinases participate in the degradation of interstitial extracel-
lular matrices and basement membranes, and help in the recruitment of progenitor cells
into the extracellular matrix during tissue remodeling. Proteinases are expressed by nor-
mal cells in tissue remodeling events and also during pathological events such as tumor
angiogenesis and metastasis. The roles of these proteinases in diabetic retinopathy are
summarized in the chapter by Rangasamy, McGuire, and Das.
Urokinase activates its cognitive receptor, a member of the lymphocyte antigen recep-
tor superfamily, and leads to MAPK activation. MMPs release extracellular matrix from
angiogenic growth factors such as VEGF and bFGF. They are expressed in multiple
retinal cell types and are potential targets for therapeutic manipulation, either directly
or via tissue inhibitors of matrix proteinases (TIMPs). To date most of the work in the
eye relates to the control of abnormal vascular leakage and macular edema or neovas-
cularization.
One of the ways of gaining insight into the biochemical changes occurring in diabetic
retinopathy is to examine the proteins in the vitreous. Feener describes the identification
viii Preface
of several hundred proteins in the human vitreous and the changes that occur in diabetes.
Though many of the changes seen can be attributed a breakdown in the blood–retinal
barrier, other may represent proteins secreted from the retina or attempts by the retina
to counteract the deleterious effects of diabetes. As well as providing insights into the
pathogenesis of the disease, these proteomic studies may give us sensitive biomarkers to
indicate the stage and prognosis for patients.
Diabetic retinopathy is much more than a vascular disease and Barber, Robinson, and
Jackson summarize the current knowledge of neurodegeneration in diabetic retinopathy.
There are close similarities in structure in alterations and structure and function of the
retina in animal models of diabetic retinopathy and humans. That is, there is delayed
oscillatory potentials and reduction of the b-wave amplitude that corresponds with, but
is not necessarily the direct result of increased death of retinal ganglion cells, ama-
crine neurons, bipolar neurons, and photoreceptors and/or reduced neurotransmission.
Together, this extensive evidence clearly shows that there is neurodegeneration in early
stages of diabetic retinopathy concomitant with the early detection of vascular changes.
These findings are fundamental to our understanding of the nature of diabetic retinopa-
thy and have a great impact on future efforts in diagnosis, prevention, and treatment.
Khan and Chakrabarti summarize the mechanisms by which hyperglycemia depresses
the viability and function of retinal endothelial cells such that they have an increased rate
of apoptosis, alters their participation in autoregulation, damages basement membranes
matrix constituents, and contributes to neovascularization. Multiple biochemical changes
have been described in animal models of diabetes and endothelial cells and cultural but
the understanding of their roles in human diabetic retinopathy remains limited.
Stahl and coworkers discuss regarding insulin-like growth factor binding protein-3
(IGFBP-3) as a regulator of the growth hormone/insulin-like growth factor pathway in
proliferative retinopathies. They summarize the relationship between VEGF-induced
angiogenesis in retinopathy of prematurity (ROP) and PDR. Both conditions are char-
acterized by peripheral retinal capillary closure, followed by peripheral retinal neovas-
cularization, and treatments for both conditions are currently limited to growth factor
inhibition and/or laser photocoagulation after the development of neovascularization.
Their previous work in experimental models of ROP suggests that there are reduced insu-
lin-like growth factor-1 (IGF-1) levels in the serum of premature infants associated with
a loss of peripheral retinal vessels, and that systemic IGF-1 administration increases the
risk of neovascularization. Likewise, patients with type 1 diabetes have reduced serum
IGF-1 levels in the preproliferative stage, and systemic IGF treatment can accelerate the
development of ocular neovascularization. Elevated serum IGF-1 levels are associated
with accelerated proliferative retinopathy in pregnant diabetic women.
The authors describe the role of (IGFBP-3) which forms a molecular complex with
insulin-like growth factors in the serum and retards their degradation. They propose that
IGFBP-3 could be used as an adjunct to IGF-1 supplementation during the nonprolifera-
tive phase of retinopathy. In the proliferative phase IGF-1 may accelerate the involve-
ment of neovascularization. Thus, titration of the levels of IGF and binding proteins may
allow for improved regulation of proliferative retinopathies.
Murray and Ma summarize the panoply of proteins that exert prosurvival and
differentiation features in retinal vascular and neuronal cells. They emphasize that despite
Preface ix
laboratory-based studies of the biological roles of these factors, most of them have not
been studied sufficiently to enable clinical trials. Moreover, most of them are studied as
single factors whereas they function in combination with others in vivo. Nevertheless,
these naturally derived biological products have potential for clinical application.
The most severe forms of diabetic retinopathy occur due to vitroretinal traction lead-
ing to epiretinal membranes with tingental or anterior traction, frequently resulting in
retinal detachment and blindness.
For the past 15 years, the major emphasis in diabetic retinopathy research has been
VEGF-induced neovascularization but the cause of fibrosis following treatment of neovas-
cularization has remained unclear. van Geest et al. have pioneered the concept that connect
tissue growth factor (CTGF) is increased during the fibrotic stage of diabetic retinopathy,
or at least is expressed without the opposition of VEGF. In fact, they also show in strong
evidence that CTGF expression increases in the blood vessels of diabetic rats shortly after
diabetes induction suggesting that the fibrotic process actually starts in the preclinical
stage of diabetic retinopathy, concomitant with basement lamina thickening, gloss of peri-
cytes, and capitulary occlusion. Further studies will help to determine if CTGF inhibition
can prevent fibrosis within the retina and the risk of tractional retinal detachment.
HOW CAN VISION LOSS BE LIMITED: EXPERIMENTAL THERAPIES

The ultimate test of a proposed disease mechanism lies in its relevance as a therapeutic
target. Since the initial discovery of increased VEGF levels in human diabetic retinopa-
thy in 1994, numerous studies have demonstrated a relationship with DME and increas-
ing severity of retinopathy. Kim, Do, and Nguyen review the literature on the effects of
intravitreally administered VEGF antagonists on DME. The positive effects of repeated
treatments have now been shown in several clinical trials, but the authors remind us that
the mechanisms by which vision improves after VEGF inhibition remain uncertain. As
they also point out, it is unknown precisely why and how vision is impaired by DME
in the first place. The growing evidence of a key role of VEGF and its inhibition will
stimulate further investigations into these important questions.
Simo and colleagues point out that the metabolic pathways leading to retinal neuro-
degeneration are poorly understood, but there is likely an imbalance of neuroprotective
factors vs. neurotoxic metabolites such as glutamate. The authors also emphasize the
use of the db/db mouse with a leptin receptor mutation as a model to study retinal neu-
rodegeneration in diabetes because it eliminates any potential for confounding effects of
streptozotocin on the findings.
The range of neuropeptides in the retina is extensive and includes pigment epithelial-
derived factor (PEDF), somatostatin (SST), erythropoietin (Epo), neuroprotectin D1
(NPD1), brain-derived neurotrophic factor (BDNF), glial cell line-derived neurotrophic
factor (GDNF), ciliary neurotrophic factor (CNTF), and adrenomedullin (AM). SST is
potentially interesting in diabetes since its general function in the peripheral tissues is
to mediate the effects of growth hormone and IGF-1. In the retina, SST is expressed by
amacrine cells and pigmented epithelium, and is reduced in diabetic rats and in diabetic
human vitreous. Retinal lipids are also important because docosahexaenoic acid is a
precursor to NPD1.
x Preface
One group of cells that serve as an important source of active peptides in the retina are
the glial cells. Sawada and colleagues document the effects that cytokines released from
glial cells can have on the blood–retinal barrier and discuss treatments that may show
some benefit by altering the pattern of expression of these cytokines.
Begg and colleagues thoroughly reviewed the effects of improved diabetes control
on the development and progression of diabetic retinopathy, detailing the results of the
DCCT and EDIC studies. They also cite less known findings, such as the improved out-
come in patients undergoing panretinal photocoagulation who have HBA1c < 8% at the
time of treatment than those whose control is worse.
In addition, they summarize the studies that confirm strong beneficial effects of pan-
creas transplantation and islet cell transplantation, although the ocular benefits arise at
the cost of more hypoglycemia and side effects of immunosuppression. In short, the
prognosis for vision is markedly better with better metabolic control, irrespective of the
means by which it is achieved.
From the chapters in this volume, it will be apparent that we have an overview of
the timing and pathology of vascular lesions in the retinas of patients with diabetes. We
also know that macular edema is a major factor in the loss of visual acuity and that laser
photocoagulation and anti-VEGF therapies convey substantial benefit to many patients.
The list of what we do not know is much longer. We need to know whether metabolic
factors beyond glucose contribute to vision-threatening diabetic retinopathy and how
these lead to vision impairment. Is diabetic retinopathy a response to systemic metabolic
abnormalities or are there unique ocular problems related to insulin resistance? Perhaps,
the most fundamental gap in our knowledge is the relationship between the neural,
vascular, and inflammatory abnormalities in diabetic retinopathy. Do they represent a
pathological cascade induced sequentially or simultaneous responses to one or more
metabolic perturbations? If we do not address these questions, it is possible that the long
process of developing new therapeutics will target only one arm of the pathology and
leave the retina open to damaging consequences of the others. Although we think of the
changes detected in diabetes as being pathological, many of them may be an attempt by
the tissue to restore normal function. This is certainly true in inflammatory responses,
and we need to distinguish protective from damaging inflammatory responses.
Although there is much about the biology of the normal and diabetic eye that still needs
to be learned, we also have an urgent need to develop tools that will help in the testing and
application of new therapeutics. We clearly need to define optimal indices of retinal struc-
ture and function that predict development of diabetic retinopathy and vision impairment;
indices that can be used as dynamic parameters for clinical trials of therapeutics.
While the list of outstanding questions is long, the tools to address them are now available
and we can look forward to rapid progress in knowledge and, more importantly, new
scientific approaches that lessen the vision impairment associated with diabetes.
Joyce Tombran-Tink
Colin J. Barnstable
Thomas W. Gardner
Contents
Preface..................................................................................................................... v
Contributors ............................................................................................................ xiii
Part I Living with Diabetic Retinopathy

1 Living with Diabetic Retinopathy: The Patient’s View .................... 3
Heather Stuckey
Part II How Is Diabetic Retinopathy Detected?

2 Diabetic Retinopathy Screening: Progress or Lack of Progress ....... 17
Peter Scanlon
3 Functional/Neural Mapping Discoveries in the Diabetic Retina:
Advancing Clinical Care with the Multifocal ERG .......................... 31
Anthony J. Adams and Marcus A. Bearse Jr.
Part III How Does Diabetes Affect the Eye?

4 Corneal Diabetic Neuropathy ........................................................... 45
Edoardo Midena
5 Clinical Phenotypes of Diabetic Retinopathy ................................... 53
José Cunha-Vaz, Rui Bernardes, and Conceição Lobo
6 Visual Psychophysics in Diabetic Retinopathy ................................ 69
Edoardo Midena and Stela Vujosevic
7 Mechanisms of Blood–Retinal Barrier Breakdown
in Diabetic Retinopathy .................................................................... 105
Ali Hafezi-Moghadam
8 Molecular Regulation of Endothelial Cell Tight Junctions
and the Blood-Retinal Barrier ........................................................... 123
E. Aaron Runkle, Paul M. Titchenell, and David A. Antonetti
9 Capillary Degeneration in Diabetic Retinopathy .............................. 143
Timothy S. Kern
10 Proteases in Diabetic Retinopathy .................................................... 157
Sampathkumar Rangasamy, Paul McGuire, and Arup Das
11 Proteomics in the Vitreous of Diabetic Retinopathy Patients ........... 173
Edward P. Feener
12 Neurodegeneration in Diabetic Retinopathy..................................... 189
Alistair J. Barber, William F. Robinson,
and Gregory R. Jackson
xi
xii Contents
13 Glucose-Induced Cellular Signaling in Diabetic Retinopathy.......... 211

Zia A. Khan and Subrata Chakrabarti
14 IGFBP-3 as a Regulator of the Growth-Hormone/Insulin-Like
Growth Factor Pathway in Proliferative Retinopathies .................... 233
Andreas Stahl, Ann Hellstrom, Chatarina Lofqvist,
and Lois Smith
15 Neurotrophic Factors in Diabetic Retinopathy ................................. 245
Anne R. Murray and Jian-xing Ma
16 The Role of CTGF in Diabetic Retinopathy ..................................... 261
R.J. van Geest, E.J. Kuiper, I. Klaassen, C.J.F. van Noorden,
and R.O. Schlingemann
Part IV How Can Vision Loss Be Limited: Experimental Therapies
17 Ranibizumab and Other VEGF Antagonists for Diabetic

Macular Edema ................................................................................. 289
Ben J. Kim, Diana V. Do, and Quan Dong Nguyen
18 Neurodegeneration, Neuropeptides, and Diabetic Retinopathy........ 307
Cristina Hernández, Marta Villarroel, and Rafael Simó
19 Glial Cell–Derived Cytokines and Vascular Integrity in Diabetic
Retinopathy ....................................................................................... 325
Shuichiro Inatomi, Hiroshi Ohguro, Nami Nishikiori,
and Norimasa Sawada
20 Impact of Islet Cell Transplantation on Diabetic Retinopathy
in Type 1 Diabetes ............................................................................ 339
Iain S. Begg, Garth L. Warnock, and David M. Thompson
Index ......................................................................................................... 367
Contributors
Anthony J. Adams • School of Optometry, University of California,
Berkeley, CA, USA
David A. Antonetti • Departments of Cellular and Molecular Physiology
and Ophthalmology, Penn State College of Medicine, Hershey, PA, USA
Alistair J. Barber • Departments of Ophthalmology and Cellular and Molecular
Physiology, Penn State College of Medicine, Hershey, PA, USA
Marcus A. Bearse Jr. • School of Optometry, University of California,
Berkeley, CA, USA
Iain S. Begg • Department of Ophthalmology and Visual Sciences,
University of British Columbia, Vancouver, BC, Canada
Rui Bernardes • AIBILI, Azinhaga Santa Comba, Celas, Coimbra, Portugal
Subrata Chakrabarti • Department of Pathology, University of Western Ontario,
London, ON, Canada
José Cunha-Vaz • AIBILI, Azinhaga Santa Comba, Celas, Coimbra, Portugal
Arup Das • Division of Ophthalmology, University of New Mexico School
of Medicine, Albuquerque, NM, USA
Diana V. Do • Wilmer Eye Institute, Johns Hopkins University, Baltimore, MD, USA
Edward P. Feener • Joslin Diabetes Center, Boston, MA, USA
Thomas W. Gardner • Department of Ophthalmology and Visual Sciences,
Kellogg Eye Center, University of Michigan Medical School, Ann Arbor, MI, USA
Ali Hafezi-Moghadam • Department of Radiology, Harvard Medical School,
Center for Excellence in Functional and Molecular Imaging Brigham and
Women’s Hospital, Boston, MA, USA
Ann Hellstrom • Department of Ophthalmology, Harvard Medical School,
Children’s Hospital Boston, Boston, MA, USA
Cristina Hernández • Diabetes Research Unit, Institut de Recerca Hospital
Universitari Vall d’Hebron, Barcelona, Spain
Shuichiro Inatomi • Department of Ophthalmology, Sapporo Medical
University School of Medicine, Sapporo, Japan
Gregory R. Jackson • Departments of Ophthalmology and Neural and Behavioral
Sciences, Penn State College of Medicine, Hershey, PA, USA
Timothy S. Kern • Departments of Medicine and Ophthalmology, Case Western
Reserve University, Cleveland, OH, USA
Zia A. Khan • Department of Pathology, University of Western Ontario,
London, ON, Canada
Ben J. Kim • Wilmer Eye Institute, Johns Hopkins University, Baltimore, MD, USA
I. Klaassen • Department of Ophthalmology, Ocular Angiogenesis Group, Academic
Medical Center, University of Amsterdam, Amsterdam, The Netherlands
xiii
xiv Contributors
E.J. Kuiper • Department of Ophthalmology, Ocular Angiogenesis Group,

Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
Conceição Lobo • AIBILI, Azinhaga Santa Comba, Celas, Coimbra, Portugal
Chatarina Lofqvist • Department of Ophthalmology, Harvard Medical School,
Jian-xing Ma • Department of Physiology, University of Oklahoma Health
Sciences Center, Oklahoma City, OK, USA
Paul McGuire • Department of Cell Biology and Physiology, University of New
Mexico School of Medicine, Albuquerque, NM, USA
Edoardo Midena • Department of Ophthalmology, University of Padova, Padova,
Italy and Fondazione GB Bietti per l’Oftalmologia IRCSS, Rome, Italy
Anne R. Murray • Department of Physiology, University of Oklahoma
Health Sciences Center, Oklahoma City, OK, USA
Quan Dong Nguyen • Wilmer Eye Institute, Johns Hopkins University, Baltimore,
MD, USA
Nami Nishikiori • Department of Ophthalmology, Sapporo Medical University
School of Medicine, Sapporo, Japan
Hiroshi Ohguro • Department of Ophthalmology, Sapporo Medical University School
of Medicine, Sapporo, Japan
Sampathkumar Rangasamy • Department of Cell Biology and Physiology,
University of New Mexico School of Medicine, Albuquerque, NM, USA
William F. Robinson • Departments of Ophthalmology, Penn State College
of Medicine, Hershey, PA, USA
E. Aaron Runkle • Department of Pathology,, Penn State College of Medicine,
Hershey, PA, USA
Norimasa Sawada • Department Pathology, Sapporo Medical University
School of Medicine, Sapporo, Japan
Peter Scanlon • Harris Manchester College, University of Oxford, Oxford, UK
R.O. Schlingemann • Department of Ophthalmology, Ocular Angiogenesis Group,
Academic Medical Center, University of Amsterdam, Amsterdam,
The Netherlands
Rafael Simó • Diabetes Research Unit, Institut de Recerca Hospital Universitari
Vall d’Hebron, Barcelona, Spain
Lois Smith • Department of Ophthalmology, Harvard Medical School,
Andreas Stahl • Department of Ophthalmology, Harvard Medical School,
Heather Stuckey • Department of Medicine, Penn State University College
of Medicine, Hershey, PA, USA
David M. Thompson • Department of Medicine, University of British Columbia,
Vancouver, BC, Canada
Paul M. Titchenell • Department of Cellular & Molecular Physiology,,
Penn State College of Medicine, Hershey, PA, USA
Contributors xv
R.J. van Geest • Department of Ophthalmology, Ocular Angiogenesis Group,

Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
C.J.F. van Noorden • Department Cell Biology and Histology, Ocular
Angiogenesis Group, Academic Medical Center, University of Amsterdam,
Amsterdam, The Netherlands
Marta Villarroel • Diabetes Research Unit, Institut de Recerca Hospital
Universitari Vall d’Hebron, Barcelona, Spain
Stela Vujosevic • Department of Ophthalmology, University of Padova,
Padova, ItalyFondazione GB Bietti per l’Oftalmologia IRCSS, Rome, Italy
Garth L. Warnock • Department of Surgery, University of British Columbia,
Vancouver, BC, Canada
Part I
Living with Diabetic Retinopathy
1
Living with Diabetic Retinopathy:
The Patient’s View
Heather Stuckey
CONTENTS
My Patient Experience
Others’ Experiences
Photos of the Meaning of Diabetes
References
Keywords Dark adaptation • Floaters • Insulin-dependent diabetes • Laser treatment • Micro

aneurysm • Quality of life
The men of experiment are like the ant, they only collect and use; the reasoners resemble spiders,
who make cobwebs out of their own substance. But the bee takes the middle course: it gathers
its material from the flowers of the garden and field, but transforms and digests it by a power of
its own. Not unlike this is the true business of philosophy (science); for it neither relies solely or
chiefly on the powers of the mind, nor does it take the matter which it gathers from natural history
and mechanical experiments and lay up in the memory whole, as it finds it, but lays it up in the
understanding altered and digested. Therefore, from a closer and purer league between these two
faculties, the experimental and the rational, much may be hoped.
—Francis Bacon
Although many of us can understand diabetic retinopathy from a scientific, rational
view, this chapter takes us deeper into the personal experience of having diabetic retin-
opathy. It explores some of the fears, uncertainties, and hope from people who have
diabetes, including my own. Like some of you reading this chapter, I am a researcher
motivated by improving diabetes. Not unlike the bee, I am also in the unique posi-
tion of having insulin-dependent diabetes myself since the age of 12. This dual role of
researcher and patient gives me the opportunity to narrate the complex relationship of
living a life with diabetes and a complication of diabetic retinopathy, while maintaining
an active research agenda with diabetes.
From: Ophthalmology Research: Visual Dysfunction in Diabetes

Edited by: J. Tombran-Tink et al. (eds.), DOI 10.1007/978-1-60761-150-9_1
3
4 Stuckey
From this insider patient perspective, diabetes is different than when it is viewed as
only a science. It takes audacity to inject a needle under the skin four or five times a day
or to start an insulin pump. It requires persistence to handle a disease that is relentless.
It takes understanding to put yourself in the place of a patient who crawls on the kitchen
floor while trying to get a cup of juice, trembling in sweat and fuzziness. It takes courage
to accept the news that you have diabetic retinopathy, and you need immediate surgery
to prevent blindness. From a distance, the decisions about medical care and diabetes
treatment look different than when they are happening to you.
Until there is a cure for diabetes and retinopathy, we need to continue to search for
the best advances in medical care, and how our actions are affecting those we serve.
We need to listen to the experiences of our patients to balance our scientific knowledge
about the disease. Rita Charon, a general internist and literary scholar, focuses on the
outcomes of documenting the experiences and narratives of patients, and how these nar-
ratives function in the construction of knowledge [1–3]. Charon [4] said she “came to
understand that I had accrued deep knowledge about my patients that remained unavail-
able” because she had not written down the stories of the patients (p. 404). Sharing what
she has learned with her patients is therapeutic, often deepening their mutual commit-
ment and investment. She went on to say, “I feel privileged to have discovered how to
fortify my medicine with the narrative gifts of perception, imagination, curiosity, and the
indebtedness we listeners accrue toward those we hear.”
The chapter begins with my personal experience of having diabetes and diabetic retin-
opathy. Toward the end of the chapter, there are stories included from other individuals
who’ve mentioned their experiences with diabetic retinopathy. Within the narratives,
there is a common thread of fear of the unknown in the foreground, yet a promise of
hopefulness. There is hope that we will find a cure for diabetes and that we can make the
treatment for retinopathy less destructive.
MY PATIENT EXPERIENCE
It is difficult to imagine a life without eyesight or world without shape and color.
When much younger, I used my eyes to draw, to write, and to see the world through the
imagination. To stare at the clouds and dream of dragons, ships, and explorers across
the blue vastness was one of my favorite hobbies. During my kindergarten years, my
eyesight began to blur—very slowly—until I could no longer see the blackboard clearly
in my classroom, and the teacher moved my seat to the front of the class. Signs looked
fuzzy, and trees no longer looked like they had leaves, but were morphed lumps of green,
yellow, and orange colors. This was my first experience with myopia, corrected with
glasses, and the world was restored. If only all problems in the 1970s could have been
solved with a glass lens and a plastic frame! From that young age, I’ve been wearing
some sort of corrective eyewear and have always respected the power of the eyes.
At the age of 12, I was diagnosed with insulin-dependent diabetes. My mother noticed
the symptoms of diabetes—constant thirst, with my drinking nearly a gallon of milk at
a time, and frequent urination, every hour on the hour. She knew the symptoms because
her mother had lived with type 2 for a number of years before being diagnosed. The time
in the hospital was fuzzy, but friends and teachers would ask what it was like to give
Living with Diabetic Retinopathy 5
myself shots and what foods I was “allowed” to eat. At that time, I didn’t want to talk
about my diabetes. My disease was something I would have rather ignored. I always gave
myself my shots, but didn’t frequently check my blood sugar. It wasn’t something that
seemed that imperative. Certainly, I understood that one of the primary complications of
diabetes was blindness, but I didn’t want to think that it could happen to me. I was young
and felt indestructible, but had no realistic grasp of what the elevated blood sugars were
doing to the tiny vessels in my eyes. I had no idea at all—until my first visit to the office
of ophthalmology in 1995 after my left eye had hemorrhaged.
I had been taking a shower when I first noticed a spider web off to my left. The
black swirl appeared ominous against the white porcelain. Although I tried to whisk it
away, I couldn’t seem to reach the shadowy web. Terrified, I realized it was inside my
eye, not an external web. Hundreds of thoughts burst into my mind. What is it? What’s
happening? Is this a complication of diabetes? Am I going blind? The ophthalmologist,
Dr. Gardner, assured me that he would do his best to prevent blindness, to stop the pro-
gression of the disease. But, that would mean immediate surgery.
At first, it was difficult to understand what having proliferative diabetic retinopathy
meant. Maybe it was the suddenness of the onset or the startled reaction of the diagnosis,
but my memory is somewhat cloudy. In my recollection, it was explained that my blood
vessels were trying to get oxygen, and to maintain adequate oxygen levels, they started
to form smaller blood vessels. Unfortunately, these vessels were much more tenuous
and fragile than the original. They broke easily, and what I was seeing was some of the
blood leaking into the retina and vitreous, causing floaters. It looked like a shadow mov-
ing across my eye, rather than something definitive. It was shapeless, and I watched the
kaleidoscope of blood start as a large woven mass, then slowly break into little parts over
the next few hours, eventually forming a fog which hindered my sight for several months.
At that time, I didn’t understand that the technical name was neovascularization. I simply
knew that things were not as they should be, and that my eyes were calling for help.
On the day of my appointment, I entered a small room with bright cinder block walls.
Humming sounds and drips were ominous, as I waited for the unknown. Dr. Gardner
asked if I had any questions before beginning the hour-long procedure. “No,” I told him.
“But please be careful. I know you’ve done this a 1,000 times before, but I’m scared.”
Clasping my hand in his, he silently communicated trust. He encouraged me to be strong
as he glued the round stabilizer to my eyelid. I tried to blink, but the surrounding metal
resisted motion. He turned his back to prepare a syringe of relaxant solution. “You might
feel a pinch,” he said, as what felt like a 6-in. needle penetrated my bottom-left eyelid.
Wincing, I adjusted the Sony headphones over my ears so I could hear the music of Enya
rather than the chilling drip, drip, drip around me.
With my chin and forehead trapped against steel, Dr. Gardner skillfully aimed the first
laser shot. At first, I didn’t feel pain. Two, three, still nothing. Twenty, thirty, forty, the
back of my eye pinched. Two hundred, three hundred. My eye ached from the sharpness.
As the doctor consoled me with, “You’re doing fine” and “Hang in there,” one strong
emotion surfaced: anger; anger at my eyes for being imperfect, anger at myself for not
keeping my diabetes in control, and anger at my diabetes for being so cruel.
For a day or two, I wore a patch over my eye and slept. As the patch was peeled
away, things appeared brighter than before, but not unbearable. The room felt full of
6 Stuckey
sunbeams, even on the somewhat cloudy day. The white-painted walls mingled with the
space in front of me, and it took a moment to find the dimensions of both, where one
started while the other began. After the adjustment, I could see the shapes of my lamp,
the bedposts, the pillows, all of my personal books, and items within the bedroom. This
familiar sight reassured me that the surgery was successful, and I felt the tension leave
my body. The whiteness and disorientation faded over the next few hours, but the sensi-
tivity to light and reduced peripheral vision remains.
What has helped the most in getting through this complication is the attention of
the ophthalmologist himself, Dr. Gardner. My experience of having a physician who
is soft-spoken and compassionate has soothed my fears and communicated trust. His
ability to give undivided attention, and remembering to ask questions about my family
or a personal situation, has connected me with him. He is attentive and gently touches
my shoulder when he walks in the room to ask how I am doing. His personalized inter-
actions have made the difference in my optimism about the future of my eyesight and
improved quality of life. When my eyes don’t seem quite right, or I am experiencing a
new symptom, such as flashes or unusual coloring, I can call or e-mail him to ask him
whether it is necessary for me to come for a visit, or whether these side effects are “nor-
mal” in patients with diabetic proliferative retinopathy. He is responsive and respects my
value as a patient and as a colleague. These are qualities that have helped me both physi-
cally with my retinopathy as well as psychologically with the anxiety associated with
the complications. I am indebted to his skill as a physician, his vision as a researcher,
and his personal mission to help all patients see to the best of their ability. These are
qualities which help physicians continue to excel in their practice.
The complications of retinal surgery are difficult to adjust to, and it requires a sup-
portive physician and patient interaction to be successful. Even after 15 years of living
with the disease, I’m not used to the difficulty of seeing at night and in bright lights.
This was a complication that I knew would be a probability, but it is very different when
actually going through the experience. One spring, I took a trip to Washington, DC,
with four of my childhood friends. We were amazed at the marble steps and pillars of
the Lincoln Memorial, commemorating the 16th president of the USA. All of us walked
the low steps that led to the central hall, where the solitary figure of Abraham Lincoln
sat. Along the side walls were carved inscriptions of the Inaugural and the Gettysburg
Address, sending us the message of equality and a new birth of freedom. After view-
ing the monument, my friends started to walk down the stairs, as we were planning to
walk around the National Mall. I was still looking at the marble Lincoln, and as I turned
around, I realized I was alone. I walked out to the front of the monument and shaded my
eyes from the glaring sun. As I looked down, all I could see was a white slate, instead of
distinguishable steps. I knew there were steps there—I’d walked up them and my friends
walked down—but where was the next step? My eyes had not adjusted, and I began to
get anxious. I called out to one of my friends, “Tammy,” but she didn’t hear me. I sensed
there were many other people around me, but the world was just so sparkling white
that I couldn’t really see anything. For a moment, I was paralyzed, standing at the top
of the steps, staring blankly. A wave of panic rolled through my forehead. I scrunched
down and walked on four limbs like a crab down the stairs. My friends were laughing
at the bottom of the steps, “What are you doing?” because they thought I was trying to
be funny. I told them I couldn’t see, but I’m sure they didn’t quite understand. Honestly,
I didn’t understand. Now, I’m aware that I need to be careful in places where there is a
shift from dark to bright light. Something simple like walking out onto the patio of my
house on a sunny day requires me to tap the space in front of me to find the concrete step
below. It’s a reminder that I need to be cautious and that my eyes need time to adjust.
This also happens when I go from light to dark areas. I used to be one of those people
who would sneak into a movie theater while the previews were playing, just in time for
the feature presentation. Now, I’m one of the first to sit down while there are still dim
lights in the theater. My 12-year-old son and I were going to the movies, and we were
a few minutes late. He stopped and asked if I was OK. With popcorn in my right hand
and a soda in the other, it was difficult to find another hand to grab onto his coat to make
my way through the aisles. Coming into a poorly lit room makes it impossible for me to
move forward until my eyes adjust. It takes me at least 5 min to begin to see silhouettes
of images or people in the room. I can no longer trust my sense of sight because my eyes
have been damaged by laser surgery and years of high blood sugars; instead, I intently
rely on the sense of feel and memory.
Another simple event that causes difficulty is heading out to see the fireworks at dusk.
I had an experience of following a friend up a road that led to a grassy path. My friend
went ahead, but I wasn’t sure where the road stopped and the grass began. It appeared as
though the terrain had changed, but the road in front of me looked like a dark lake, and
I wasn’t sure I could trust what it was seeing. I could tell that other people were mov-
ing around me, quite quickly, as I stepped quietly, one toe at a time to find my way. My
friend turned around and took my arm, leading me with her across the grass. It’s times
like these that I am keenly aware of my altered vision.
An enjoyment of mine is going to amusement parks, but having reduced vision makes
seeing through the indoor queue lines quite difficult because of the sudden shift from
light to dark. Recently, we were in Disneyland, California, ready to ride “Indiana Jones
Adventure.” The entryway halls were dark for effect, with a strange-looking hologram
on the wall. I squinted, but still couldn’t quite make out the image. It was all I could do to
navigate the left-to-right line to keep up. I held onto my son’s shirt so that I didn’t lose my
way, but I heard the people in back of me grow impatient. They stepped on the back of my
shoes and said, “move forward.” They could see fine, so what was my problem? After all,
I didn’t look blind, and my healthy, strong body shouldn’t have needed assistance.
My vision issues don’t just stop with transitions from dark to light. I’m concerned
about when I’m going to have my next episode of severe floaters in my right eye. I’ve
been bothered by these floaters ever since my surgery. I’m never sure if my sudden loss
of vision is going to be permanent. At the most unfortunate time, when I was trying
to conduct my dissertation work, I developed a large floater in my right eye, making
it impossible to see. The reason and timing for the appearance of floaters seem to be
unpredictable—I was watching television and noticed the fireworks explosion of fluid
filling my eye. As if writing a dissertation isn’t stressful enough, I was trying to meet
the deadlines with only one functioning eye. I tried to look around the web by moving
my head, having to rely on my left eye to read. I think about these floaters often, and
wonder when the next one might hit. The rational I knows it will be a few weeks, or
months, until the cloud dissipates, but a side of me also wonders whether the obstruction
8 Stuckey
will be permanent. As it’s been well over a decade since my last surgery, the floaters
are becoming more sporadic, and my eyes are more stable. I’m also getting used to the
signs and symptoms of a floater, and no longer am surprised by having limited vision.
However, I’m still never certain that they will go away.
The effects of the laser treatment also restrict my driving in unknown places. I am
reluctant to drive at night because I am afraid that I won’t be able to see properly. It’s
difficult to see the transition in the road from highway to ramps, especially in rural areas
that are dimply lit at night. Rainstorms in the dark magnify the problem. Driving on a
snowy, sunny day can be worse because the intense whiteness is simply blinding. It is
the same situation as the fireworks path, where things appear to be a continuous row
without distinction between one terrain and the other. I lose the ability to distinguish
depth, distance, and shading. Now I limit my driving at night to places that are familiar
to me or allow someone else to drive me. My driving record is safe, but it is better to take
a precaution to not drive than find myself in an unknown situation. Because of the eye
damage, I think twice about whether I can go into our local caverns with my son because
of the darkness, or any kind of fun house, haunted house, or darkened museum. It’s not
like being in a dark room, where you can still see shapes and patterns. This is complete
black, like being blindfolded. There’s no depth to anything, so it’s a matter of feeling my
way around the room.
Having had several laser treatments, my peripheral vision is also limited. It hasn’t
affected much of my life, but it is funny when I go for the yearly eye exam, and I real-
ize how much I really can’t see. The technician checking my vision is holding out his
fingers to the right saying, “How many do I have up?” and I’m thinking, “Man, I really
can’t see anything.” It isn’t a real problem, except that I need to remember to look down,
especially in the kitchen where I typically run into the corner of the side table or the cat
dishes on the floor. It’s also common for me to trip over the open dishwasher. Part of this
comes from the fact that I was never considered graceful, but I’m sure having limited
peripheral vision doesn’t help. My experience with having diabetic retinopathy has been
filled with both laughter at my inadequacies and fear at the uncertainties.
OTHERS’ EXPERIENCES
These kinds of uncertainties have also been the experience of others with diabetic
retinopathy. In a qualitative study of ten people with diabetes, we examined how this
group coped, or made meaning of their diabetes. The purpose of the pilot study was
to understand more about the experience of diabetes and its complications, in order to
help adults live more harmoniously with their chronic disease [5,6]. The average age of
the participant was 42, with an age at diagnosis between the years of 4 and 25 (aver-
age = 10.8). They had type 1 diabetes from a minimum of 12 years to a maximum of 52
years (average = 31), with 311 cumulative years of experience with diabetes.
The study began by asking the participants to tell me about their diagnosis of diabe-
tes, which was difficult for most to do as they had not thought about how that diagnosis
may have affected the way that they are currently caring for their disease. My work
did not specifically include the transcripts of the participants’ fears of retinopathy and
other complications. But because the patient’s experience of retinopathy is an important
point to be made for this chapter, I have included their comments (with pseudonyms
used) below.
Six out of the ten participants had at least one retinal surgery, and they found it to
be a difficult experience. In one participant’s story of retinopathy in 2003, Karla said a
floater happened where she least expected it—St. John, US Virgin Islands. She woke
up around 3:00 a.m. in her camp cottage and began to violently dry heave and vomit.
Approximately 30 min later, she woke up, looked around, and realized her vision had
something obstructing it. She tells of her experience in this way:
I blinked to see if I was dreaming, but knew immediately that it was a dreaded “floater.” I had to
turn my head to the side so I could see out of that eye. It was as if I constantly had a bug flying
into my line of vision. Being that it was 3:30 in the morning and not much healthcare available
on the island, I waited until the sun rose to tell my friends I needed to go to the clinic.
She told them her suspicions about a microaneurysm bursting from the force of the
dry heaves, but there was nothing they could do for her at St. John, so she left for the
island of St. Thomas via ferry ride. She arrived at the ER, where the on-call physician
examined her eye and said there was nothing he could do for her, either. He called the
local ophthalmologist to see if she was available, but was not hopeful since it was a
Saturday. Luckily, the ophthalmologist was still in her office, which was only a block
away. She told Karla that she did have a bleed in her eye and that she should avoid scuba
diving, sneezing, coughing, or anything that would put pressure on her eye. Karla was
“so afraid to even fly home to the states.” She was scheduled for laser surgery about a
week later, and says:
I was given the option of having a numbing medicine injected for the procedure, but decided the
needle might be worse than how the doctor described the surgery. Instead, I just took two Advil
an hour prior to surgery. I was led into a pitch dark room and had something placed in my eye to
keep it open. Then I proceeded to see bright green flashes of light and heard sounds like a video
game (like Asteroids, if you are old enough to remember Atari). My doctor warned me when he
got closer to a nerve, because that did cause more discomfort than other areas. It was like a twinge
or someone hitting your funny bone, only in your eyes.
She said her eye felt sore for an hour or so after the procedure, but overall was not
“as bad as I had psyched up myself to expect. The worst part of the whole thing was
having your eye held open when you had an extreme urge to blink.” She is still fright-
ened of the end results if a full retinal detachment were to occur, because she loves
photography and sightseeing, but is no longer afraid of the laser surgery procedure.
She had only one surgery, and so far, it has been successful. She thanks God every day
for the gift of her sight. Having the surgery has been a reminder not to take her sight
for granted. The pictures below are the microaneurysm that bled in her left eye (Figs. 1
and 2).
As another participant described her surgery for diabetic retinopathy, she explained
how it hurt, but also that she was fortunate to have not gone blind. She understands that
the “flip side” of dealing with diabetes is that she could have lost a limb already, or been
blind, and she could have had “so much happened to me that hasn’t.” She could get
through the retinal surgery, knowing that she would be able to watch the sunset, or look
in her garden, and see her children grow up to graduate or to get married. Knowing that
10 Stuckey
Fig. 1. Left eye microaneurysm.
Fig. 2. Left eye subhyaloid

hemorrhage.
she is able to see, having the retinal surgery was not as bad as the alternative. Camilla
summarized her gratitude in this way:
When it comes down to it, I count myself truly blessed because I could have had things so much
worse. I just learned to deal with what I’ve been given, and just think it could be worse. Just be
grateful that this is all you have to deal with.
Because of her retinopathy, Camilla also relies on her husband to do most of the
driving, especially at night and in the rain. Her husband was supportive of her when she
developed retinopathy and had to go to the eye doctor. She called him at work because
she was seeing something in front of her eye. She explained to him,
‘I have this claw-looking thing,’ and he’s like, ‘Can you see it?’ And I say, ‘Yeah, I can see it,’
not thinking he thinks that it’s something that’s protruding out of my eye. So he rushes over to
meet me at the eye doctor, and he says, ‘Well, you look OK. I was thinking I was going to see this
monster.’ [He thought the “claw” was outside, not inside, her eye.]
One of the more ominous thoughts about diabetes for these participants was the
possibility of going blind. Before going into laser surgery for the first time, Camilla
spent some time with her children, and she vividly described her feelings as she spent
the day with them:
The whole time, it was a dreary day, and I was just taking in everything. What the clouds looked
like. They’re so gray, in the dark over here, and trying to keep everything pictured in my mind.
What the trees looked like. What the Dairy Queen sign looked like. My husband’s profile. I just
kept looking at him and the children. I gave the kids a hug, and I tried to remember.
For one participant, it was difficult for her to help other people understand what
it is like to get laser surgery for diabetic retinopathy. She said, “They have no idea,”
but she was grateful to be able to talk to the group, who could relate to her complica-
tions on some level. All she can do is try to “stay ahead of it” on a day-to-day basis
and make the best of the difficult days. Amber was used to dealing with diabetes,
the way that she was “used to” dealing with the blood she has in both her eyes from
retinopathy. She said that the bleeds in her eyes have become a part of her vision,
and she tells herself to keep going. “You know,” she said, “You’ve got to deal with
what you have.”
Like the others in the group, I generally take a positive spin on diabetes. Sometimes
you need to laugh a little. One woman told her daughter, “If I ever go blind, don’t put me
in a polka-dotted shirt.” We sometimes make light of our disease. After several years,
it still requires creativity to figure out where to put an insulin pump on a swimsuit. The
pump does make my life easier and better, especially at night. Before the pump, I would
wake up with multiple low blood sugars while sleeping because the NPH insulin was
peaking. These days, it’s less common to have a low blood sugar at night. I also think
that things could be worse, whether I’m talking about the insulin pump or talking about
my complications. Having diabetes is not as bad as being––and I could finish the sen-
tence a thousand ways––in the intensive care unit, diagnosed with MS or some forms of
cancer, or dead. And yet, we may have some of the same fears and feelings as those who
have a terminal illness.
Marie shared the story of being diagnosed with diabetes in 1984, which serves as
an example of the fears. She has not had retinopathy surgery, but faces the prospect of
blindness as a complication of diabetes:
As I went to get my insulin and syringes from the pharmacy, I cried all the way there. Not only
did I fear shots, but I’ve always been petrified of going blind and here I had a disease that actually
had blindness as a possibility. I never did like anyone messing with my eyes. As a child, I would
‘flip out’ when I got an eyelash in my eye and had to work it out. Just thinking about having any
kind of eye surgery or people invading my eyes is totally stressful. I am also somewhat claustro-
phobic, and blindness is very black, dark and confining… the ultimate in being locked in a car
trunk or trapped in an elevator. My yearly eye exam is always tense, and I breathe a big sigh of
relief when I hear that all is well. I am hoping that my eyes remain healthy because facing retin-
opathy is not anything I could easily deal with (and I’ve been through a lot… breast cancer with
chemotherapy, major reconstructive surgery, carpel tunnel surgery, two broken wrists). None of
these comes close to the fear I have of going blind.
Having diabetes is frightening and confusing, and the fear of going blind is pervasive,
like the humidity of summer. My purpose is to help myself and others make meaning of
diabetes and see how we can find greater strength and wellness with the opportunity for
12 Stuckey
healing, even if not a cure. Even if we don’t understand all the root causes of diabetes or
retinopathy, as patients, we can reflect on what we do know and how we can help others
live more fully with the disease. As medical professionals, researchers, and scientists,
that fear is something we can seek to eliminate.
PHOTOS OF THE MEANING OF DIABETES

To put these thoughts of the diagnosis and the meaning of diabetes in visual form, the
photo below represents the day of my diabetes diagnosis (Fig. 3). It is labeled “unnatu-
ral” because having diabetes meant I would need to take some form of insulin injection
every day for the rest of my life and should avoid sugar. I might go blind when I grow
older or lose my kidney function. These things are unnatural, especially as a young
child, represented by the bright orange slash. The slash appears among the ground and
the grass of the earth, meaning growth and natural life. Although originally, the photo
was about the diagnosis of diabetes, it also relates to its complications, such as retinopa-
thy. Having retinal surgery is unnatural, as some blood vessels are sacrificed in order to
save others and to preserve the site for long term. Although some eye procedures can be
expected at an older age, it is unnatural, and frightening, to have surgery at age 25.
This next photo (Fig. 4) of a cell block also represents my thoughts of having diabetes
and diabetic retinopathy. I took this picture at the Eastern State Penitentiary in Phila-
delphia, Pennsylvania. As the website states (http://www.easternstate.org/), the Peniten-
tiary was once the most famous and expensive prison in the world, but stands today as
a world of crumbling cellblocks and empty guard towers. My eyes used to be unscathed
by disease, but have slowly deteriorated, like the plaster on the floor of the cell and the
table that has fallen down from the weight of gravity over the years. My eyes show
Fig. 3. Unnatural.
Fig. 4. Hydrant.
evident signs of damage in the pin-points of burning laser that penetrated my retina, and
my lack of peripheral vision.
The room (and my sight) is not gone, however, because the building has not collapsed.
The structure remains intact. Although my eyes may be ragged and somewhat worn out,
they still perform the job that they were intended to do. I can see. I realize the room will
not be restored to complete newness, but it can be cleaned and maintained. Keeping my
diabetes under control and my body healthy, there’s hope that I will be able to see for
my lifetime.
It is a wonderful thing to have vision, to experience life in color, to read, to watch the
clouds move mysteriously on an overcast day, and to be able to turn my head and see my
son when he was younger, yelling, “Watch this, mom,” from the playground. As he gets
older, my eyes soak in the shape of his face and the curl of his hair and study the speckles
of light in his eyes. I can see, and my prognosis for continued vision is very good. Each
year, I schedule an appointment with Dr. Gardner, and my eyesight remains stable.
Rather than destroying the retina and damaging vision, we need to find easier, gentler
ways to treat diabetic retinopathy to detect ways of catching the disease earlier so the
fear of blindness is much less. That is what is important to us who have retinopathy. But
scientific research to find a less destructive treatment is only part of the story. Behind
every project or procedure, there’s a human element––a person who is frightened, won-
dering whether he’s going to go blind. He’s giving his eyes, one of his most valuable
possessions to you, the clinician. Besides vessels and fluid, what do you see? Do you see
the way they are looking at you for hope? Do you see how they are afraid that they might
go blind? They don’t want to go through laser treatment. They are afraid there will be
complications with the surgery, and they will go blind. They won’t remember the hue of
the sky or the color of the cornfield. What did snow really look like? And what did the
shadow of my toddler’s head look like at night? This person with diabetic retinopathy
might go blind. And they are looking to you for hope. Regardless of your relationship
14 Stuckey
to research, there is a patient, not a retina, who needs hope. What do you see? How can
you give them that hope? How can you communicate trust to them? The best advice
I can give is to look them with a soft face and tell them that you are going to do whatever
it takes to preserve their sight. Their probability for continued eyesight is going to be
very good. There are other promising methods for treatment, and you will make sure that
they are getting the best treatment possible. This is really seeing. How can you improve
your eyesight, your communication of hope to the patient? If you give me laser surgery
treatment, you’re treating maybe half of my disease. But if you give me hope that I won’t
go blind, you treat the other half.
Perhaps some of you have diabetes, or have loved ones and friends who have a
chronic illness, or have diabetic retinopathy. This personal connection is what stirred
you. Maybe your interest also comes from a deep desire to improve the lives of so many
who suffer with diabetes and its complications or the science of discovering a cure or a
breakthrough in treatment. For me, understanding the experience of diabetes is not only
a research interest, but a personal quest. My hope is that you will see what having diabe-
tes, and diabetic retinopathy, means to someone with diabetes, and you will understand
how very important your work is to those of us who have this chronic illness.
The research in this book is groundbreaking and exciting. Research like this has pre-
served the eyesight of myself and many others and improved our quality of life. Over
the past 20 years, I have seen many outstanding medical achievements in diabetes care:
blood glucose machines, which achieve accurate results in 5 s, short-acting human insu-
lin, needles which come in ultrathin shapes and sizes, and the insulin pump, continuous
glucose monitoring and new advances in knowledge, medication, and technology that
have made it possible for people with diabetes to live long, productive lives.
Ultimately, I hope we will be able to find a cure for diabetes. Diabetes is a demand-
ing, frightening, exasperating disease. I fully support research that finds ways to make
it easier to live with the complications of diabetes. As a fellow researcher, a patient, and
as a friend, I thank all of you reading this chapter who have worked to preserve our eye-
sight, in whatever way. I encourage you to continue to find research to improve the lives
of those with diabetic retinopathy, not only to restore sight but also to give hope.
REFERENCES
1. Charon R, Spiegel M (2006) Reflexivity and responsiveness: the expansive orbit of knowl-
edge. Lit Med 51:vi–xi
2. Charon R (2004) Narrative and medicine. New Engl J Med 350(9):862–865
3. Charon R (2001) Narrative medicine: a model for empathy, reflection and trust. J Am Med
Assoc 286(15):1897–1902
4. Charon R (2004) Physician writers: Rita Charon. Lancet 363(9406):404
5. Stuckey H, Tisdell E (2010) The role of creative expression in diabetes: an exploration into the
meaning-making process. Qual Health Res 20:42–56
6. Stuckey H (2009) Creative expression as a way of knowing in diabetes adult health education:
an action research study. Adult Educ Q 60:46–64
Part II
How Is Diabetic Retinopathy Detected?
2
Diabetic Retinopathy Screening:
Progress or Lack of Progress
Peter Scanlon
CONTENTS
Definitions of Screening for Diabetic Retinopathy
Progress of Lack of Progress in Screening for Diabetic
Retinopathy in Different Parts of the World
References
Keywords Screening • Diabetic retinopathy • Visual Impairment • Blindness • Diabetes control

and complications trial • United Kingdom prospective diabetes study • Early treatment diabetic
retinopathy study • St. Vincent Declaration
DEFINITIONS OF SCREENING FOR DIABETIC RETINOPATHY

The definition of screening that was adapted by the WHO [1] in 1968 was “the
presumptive identification of unrecognized disease or defect by the application of tests,
examinations or other procedures which can be applied rapidly. Screening tests sort out
apparently well persons who probably have a disease from those who probably do not.
A screening test is not intended to be diagnostic. Persons with positive or suspicious
findings must be referred to their physicians for diagnosis and necessary treatment.”
Applying the principles for screening for human disease that were derived from the
public health papers produced by the WHO [1] in 1968 to sight-threatening diabetic
retinopathy raises the following questions [2]:
1. Is there evidence that sight-threatening diabetic retinopathy is an important public
health problem?
2. Is there evidence that the incidence of sight-threatening diabetic retinopathy is going
to remain the same or become an even greater public health problem?
3. Is there evidence that sight-threatening diabetic retinopathy has a recognizable latent
or early symptomatic stage?
4. Is there evidence that treatment for sight-threatening diabetic retinopathy is effective
and agreed universally?

17
18 Scanlon
5. Is a suitable and reliable screening test available, acceptable to both health-care pro-
fessionals and (more importantly) to the public?
6. Are the costs of screening and effective treatment of sight-threatening diabetic
retinopathy balanced economically in relation to total expenditure on health care –
including the consequences of leaving the disease untreated?
Is There Evidence That Sight-Threatening Diabetic Retinopathy

Is an Important Public Health Problem?
Studies Reporting the Prevalence of Diabetic Retinopathy
Reports from North America have shown that diabetic retinopathy continues to be
prevalent in the USA:
1. In 2008–2009, Klein [3] reported the 25-year progression of retinopathy and of macu-
lar edema [4] in persons with type 1 diabetes from the Wisconsin Epidemiological
Study of Diabetic Retinopathy (WESDR study). The 25-year cumulative rate of pro-
gression of DR was 83%, progression to proliferative DR (PDR) was 42%, and im-
provement of DR was 18%. The 25-year cumulative incidence was 29% for macular
edema and 17% for clinically significant macular edema.
2. In 1995, Klein [5] reported the incidence of macular edema over a 10-year period.
This was 20.1% in the younger-onset group, 25.4% in the older-onset group taking
insulin, and 13.9% in the older-onset group not taking insulin.
3. In 2004, Kempen [6] reported that, among an estimated 10.2 million US adults
40 years and older known to have DM, the estimated crude prevalence rates for retin-
opathy and vision-threatening retinopathy were 40.3 and 8.2%, respectively.
Worldwide reports have shown that sight-threatening diabetic retinopathy is prevalent
in both type 1 and type 2 diabetes in the UK [7], India [8], Germany [9], Ethiopia [10],
Australia [11], Denmark [12], Singapore [13], and China [14].
Reports on Blindness and Visual Impairment

In 1994, Moss [15] reported on the 10-year incidence of blindness in the WESDR
study. 1.8, 4.0, and 4.8% in the younger-onset, older-onset taking insulin, and older-
onset not taking insulin groups, respectively. Respective 10-year rates of visual impair-
ment were 9.4, 37.2, and 23.9%.
In 1995, Evans [16] reported on the causes of blindness and partial sight in England
and Wales from an analysis of all BD8 forms for the year April 1990 to March 1991.
Among people of working age (ages 16–64), diabetes was the most important cause
(13.8%) with 11.9% due to diabetic retinopathy. This study was repeated 10 years later
and reported by Bunce [17] in 2006, and diabetic retinopathy was still the commonest
cause of visual loss in the working age group.
In 2001, Cunningham [18] reported that 45 million people worldwide fulfill the
World Health Organization’s criterion for blindness and the cause of one-quarter of
all blindness, which affects people in both developed and developing nations, includes
diabetic retinopathy and macular degeneration. In 2002, Kocur [19] reported that in
people of working age in Europe, diabetic retinopathy is the most frequently reported
causes of serious visual loss.
Diabetic Retinopathy Screening 19
Zhang [20] reported results from the national health and nutrition examination survey
in the USA. People with diabetes were more likely to have uncorrectable VI than those
without diabetes.
Is There Evidence That the Incidence of Sight-Threatening Diabetic

Retinopathy Is Going to Remain the Same or Become an Even Greater
Public Health Problem?
Numerous studies have shown that there is a rising incidence of diabetes and its com-
plications in all age groups, both in the UK and worldwide.
In 1997, Amos [21] estimated that 124 million people worldwide have diabetes,
97% NIDDM, and that by 2010, the total number with diabetes is projected to reach
221 million.
In 2000, Sorensen [22] reported that the World Health Organization has recognized
that there is a “global epidemic of obesity,” and the prevalence of type 2 diabetes is ris-
ing in parallel.
In 2001, Boyle [23] estimated the number of Americans with diagnosed diabetes is
projected to increase from prevalence of 4.0% in 2000 to a prevalence of 7.2% in 2050.
The International Diabetes Federation estimated the prevalence of diabetes in 2003 in
20–79 age groups and projected this to an estimate in 2025. They predicted rises in num-
bers of people with diabetes of 7.07–15.04 million in Africa, of 19.24–39.41 million in
Eastern Mediterranean and Middle East Region, of 48.38–58.64 million in Europe, of
23.02–36.18 million in America, of 14.16–26.16 million in South and Central American
Region, of 39.3–81.57 million in Southeast Asian Region, and of 43.02–75.76 million
in Western Pacific Region.
Is There Evidence That Sight-Threatening Diabetic Retinopathy Has a

Recognizable Latent or Early Symptomatic Stage?
Numerous reports from the Wisconsin Epidemiological Study [24, 25] have shown
that sight-threatening diabetic retinopathy in both type 1 and type 2 diabetes has a rec-
ognizable latent or early symptomatic stage. In patients with type 1 diabetes, Klein [3]
reported that the 25-year cumulative rate of progression of DR was 83%, progression to
PDR was 42%, and improvement of DR was 18%.
The Early Treatment Diabetic Retinopathy [26] documented all the photographic lesions
of diabetic retinopathy and the risks of progression of DR relating to those lesions.
The United Kingdom Prospective Diabetes Study [27] documented the incidence and
progression of diabetic retinopathy over 6 years from diagnosis of type 2 (non-insulin-
dependent) diabetes.
Is There Evidence That Treatment for Sight-Threatening Diabetic

Retinopathy Is Effective and Agreed Universally?
The Evidence That Diabetic Retinopathy Can Be Prevented or the Rate of
Deterioration Reduced by Improved Control of Blood Glucose, Blood Pressure
and Lipid Levels, and by Giving Up Smoking
Evidence for the link between poor glucose control and greater progression of dia-
betic retinopathy (DR) was provided by numerous early studies [28, 29]. The study that
20 Scanlon
confirmed that intensive blood glucose control reduces the risk of new-onset DR and
slows the progression of existing DR for patients with IDDM was the Diabetes Control
and Complications Trial (DCCT) [30].
Similarly, for type 2 diabetes, the United Kingdom Prospective Diabetes Study
(UKPDS) [31] demonstrated that intensive blood glucose control reduces the risk of new-
onset DR and slows the progression of existing DR for patients with type 2 diabetes.
Control of systemic hypertension has been shown [32, 33] to reduce the risk of new-
onset DR and slow the progression of existing DR.
There is evidence [34, 35] that elevated serum lipids are associated with macular exu-
dates and moderate visual loss, and partial regression of hard exudates may be possible
by reducing elevated lipid levels.
There is some evidence that smoking may be a risk factor in progression of diabetic
retinopathy in type 1 diabetes as described by Muhlhauser [36] and Karamanos [37].
However, in type 2 diabetes, the evidence is controversial [27].
The Evidence that Laser Treatment Is Effective

Evidence for the efficacy of laser treatment for diabetic eye disease has been shown
from the Diabetic Retinopathy Study [38] and the Early Treatment Diabetic Retinopathy
Study [39]. In 1976, the organizers of the Diabetic Retinopathy Study [40] modified the
trial protocol and recommend treatment for control eyes with “high-risk characteristics.”
In 1981, they reported [41] that photocoagulation, as used in the study, reduced the
2-year risk of severe visual loss by 50% or more.
In 1985, a report [42] from the Early Treatment Diabetic Retinopathy Study showed
that focal photocoagulation of “clinically significant” diabetic macular edema (CSMO)
substantially reduced the risk of visual loss.
Further studies that have shown evidence for the longer-term efficacy of laser treat-
ment for diabetic eye disease have been reported by Blankenship [43] and Chew [44].
The Evidence That Vitrectomy for More Advanced Disease Is Effective

Smiddy [45], he noted that, according to the Early Treatment Diabetic Retinopathy
Study, at least 5% of eyes receiving optimal medical treatment will still have progressive
retinopathy that requires laser treatment and pars plana vitrectomy. He also noted that,
although vitrectomy improves the prognosis for a favorable visual outcome, preventive
measures, such as improved control of glucose levels and timely application of pan reti-
nal photocoagulation, are equally important in the management.
There have been reports of improving visual results during the last 20 years following
vitrectomy, the most recent being from Yorston [46].
Is a Suitable and Reliable Screening Test Available, Acceptable

to Both Health-Care Professionals and (More Importantly) to the Public?
There is an increasing acceptance that, in population-based screening programs,
digital photography offers the best method of screening for sight-threatening diabetic
retinopathy. Digital photography has been shown to provide higher sensitivities and spe-
cificities across large numbers of operators than examination techniques such as direct
ophthalmoscopy [47, 48], or slit lamp biomicroscopy [49, 50]. Digital photography also
has the advantage that a percentage of images can be reexamined for quality assurance
purposes.
The acceptance of digital photography for population-based screening does not imply
that this replaces the comprehensive eye examination as pointed out by Chew [51].
In screening studies, far more controversial than the use of digital photography has
been the use of mydriasis or nonmydriasis and the number of fields photographed.
There have been strong proponents [52] of nonmydriatic photography for many
years. However, it has been recognized in more recent years that ungradable image
rates for nonmydriatic digital photography in a predominantly white Caucasian popula-
tion [53, 54] are of the order of 19–26%. Scotland has developed a national screening
program based on one-field nonmydriatic photography following a report [55] from
the Health Technology Board for Scotland. Other proponents of nonmydriatic digital
photography have attempted to capture three-fields [56], five-fields [57], and remark-
ably Shiba [58] excluded the over 70 years age group and attempted 9× overlapping
nonmydriatic 45° fields.
Mydriatic digital photography studies [49, 53] have shown that consistently good
results can be achieved, with sensitivities of >80% and high levels of specificity. In these
studies, specificity does vary depending on whether ungradable images are regarded as
test positive, but levels of >85% are consistently achieved. England has developed a
national screening program [7] based on two-field mydriatic photography.
In 2004, Williams produced a report [59] for the American Academy of Ophthalmology
summarizing the use of single-field fundus photography for diabetic retinopathy screening.
In 2007–2008, reports of diabetic retinopathy screening were published from
France [60], Spain [61], the Canary Islands [62], Western Cape [63], the USA [64], and
England [7].
The debate over whether mydriasis should be used for screening and the number of
fields used has continued around the world with two of the recent studies coming to very
different conclusions [60, 61].
Are the Costs of Screening and Effective Treatment of Sight-Threatening

Diabetic Retinopathy Balanced Economically in Relation to Total
Expenditure on Health Care – Including the Consequences of Leaving
the Disease Untreated?
In 1982, Savolainen [65] reported on the cost-effectiveness of photocoagulation for
sight-threatening diabetic retinopathy in the UK. There have been reports of computer
simulation models of diabetic retinopathy screening by Javitt [66, 67], Dasbach [68],
Caro [69], and Fendrick [70], based on the health systems in the USA and Sweden, that
concluded that screening for sight-threatening diabetic retinopathy was cost-effective.
James et al [71]. reported results for an organized screening program in the UK using
35-mm retinal photography and demonstrated this to be more cost-effective than the
previous system of opportunistic screening.
Meads [72] reviewed published studies of the costs of blindness and compared
Fould’s 1983 estimate [73] inflated to £7,433 in 2002 costs, Dasbach’s 1991 estimate
[68] inflated to £5,391 in 2002 costs, and Wright’s 2000 estimate [74] inflated to £7,452
(4,070–£11,250) in 2002 costs. He concluded that much of the uncertainty in any
22 Scanlon
sensitivity analysis of the cost of blindness in older people is associated with the cost
of residential care and that the excess admission to care homes caused by poor vision is
impossible to quantify at the present time.
Only four studies have been published that assess the costs of screening using dig-
ital photography. The first was from a telemedicine program in Norway [75] where,
at higher workloads, telemedicine was cheaper. The second compared an optometry
model with a digital photographic model in the UK [76]. However, in this study, there
were poor compliance rates in the newly introduced screening program in both models.
A cost-effectiveness analysis [77] of use of a telemedicine screening program in a prison
population in Texas concluded that teleophthalmology holds great promise to reduce the
cost of inmate care and reduce blindness caused by diabetic retinopathy in type 2 diabetic
patients. Tung [78] concluded that screening for DR in Chinese with type 2 diabetes is
both medically and economically worthwhile and recommended annual screening.
PROGRESS OF LACK OF PROGRESS IN SCREENING FOR DIABETIC

RETINOPATHY IN DIFFERENT PARTS OF THE WORLD
In 1990, the St. Vincent Declaration [79] recognized diabetes and diabetic retinopa-
thy to be a major and growing European health problem, a problem at all ages and in
all countries. The first of the five-year targets that were unanimously agreed by govern-
ment health departments and patient’s organizations from all European countries was to
reduce new blindness due to diabetes by one-third or more. In 2005 in Liverpool UK,
a conference took place to review progress in the prevention of visual impairment due
to diabetic retinopathy since the publication of the St. Vincent Declaration. Delegates
attended as representatives from 29 European countries, and there were invited experts
from Europe and the US. It was clear from this meeting that the health-care systems in
Europe were at very different stages of development, and the funding of those health-
care systems varied considerably. For example, if the population did not have access
to adequate treatment facilities, there was little point in concentrating on screening for
diabetic retinopathy until adequate treatment facilities were established.
Hence, the conference recommended the following steps in the development of sys-
tematic screening programs for sight-threatening DR:
Step 1
Access to effective treatment
• Minimum number of lasers per 100,000 population
• Equal access for all patient groups
• Maximum time to treatment from diagnosis, 3 months
Step 2
Establish opportunistic screening
• Dilated fundoscopy at time of attendance for routine care
• Annual review
• National guidelines on referral to an ophthalmologist
Step 3
Establish systematic screening
• Establish and maintain disease registers
• Systematic call and recall for all people with diabetes
• Annual screening
• Test used has sensitivity of ³80% and specificity of ³90%
• Coverage ³80%
Step 4
Establish systematic screening with full quality assurance and full coverage
• Digital photographic screening
• All personnel involved in screening will be certified as competent
• 100% coverage
• Quality assurance at all stages
• Central/regional data collection for monitoring and measurement of effectiveness
The European countries that were most advanced in development of national
screening programs were those that had nationalized health systems that facilitated the
development of public health screening programs. Iceland, England, Scotland, Wales,
and Northern Ireland had all developed national screening programs, whereas Denmark,
Finland, and Sweden had regional programs, all with good coverage. At that time, these
countries had an estimated overall prevalence of diabetes in Europe approximating 4%.
The wealthier European countries that had private health-care systems (e.g., Eire,
France, Germany, Greece, Israel, Italy, Luxembourg, the Netherlands, Portugal, Spain)
had developed local screening programs, many of which are based upon the initiatives of
individual persons. However, there was a lack of uniformity between different centers on
screening methodology and classification of diabetic retinopathy. More recently, there have
been attempts within some of these countries to standardize [80] their screening systems
and to develop a framework [81] for the development of a national screening program.
With respect to Eastern Europe (Czech Republic, Turkey, Hungary, Romania, and
Serbia and Montenegro), the Czech Republic introduced diabetic retinopathy screen-
ing and treatment guidelines published in 2002; Hungary, Romania, and Turkey have
local or regional screening programs. Turkey reported that 7.2% of their population
was known to have diabetes. Serbia and Montenegro reported that they did not have a
formalized screening program, but had taken steps to introduce protocols. In parts of
Serbia, there was a lack of available lasers.
Posters were also presented from the following countries—Albania, Bulgaria, Georgia,
Kazakhstan, Lithuania, Uzbekistan, and St. Petersburg. Bulgaria has 17 lasers, but there
are insufficient in the other countries: Uzbekistan appears to have none and Kazakhstan
only one or two. Lasers are available for the “general” population in Lithuania, with one in
Albania, one in St. Petersburg, and some in Bulgaria. Other lasers are in private offices.
In Australia, there are local screening programs that have developed to serve indi-
vidual populations such as the aboriginal [82] population and rural Victoria [83].
Similarly, localized screening programs have developed in the Western Cape [63],
India [8], Japan [58], and China [14].
24 Scanlon
A recent study [84] by Boucher from Canada attempted to increase uptake of diabetic
retinopathy screening by locating mobile screening imaging units within pharmacies.
This produced further communication within the same journal to which Boucher replied
[85], “Despite efforts to educate both patients and physicians about the importance of
routine diabetic screening and despite the publication of Canadian screening guidelines,
a large percentage of the diabetic population continues to receive inadequate retinopathy
screening. This has led to the search for strategies to better detect vision-threatening
retinopathy and reduce the incidence of complications and blindness from diabetic retin-
opathy.”
In America, health-care delivery is chiefly driven by market forces, and the key to any
new preventive health program is reimbursement. Provision of medical care is based on
private insurance for those who can pay for it and a patchwork of Federal programs for
the indigent and the elderly. It is estimated that there are more than 43 million Ameri-
cans who have no health-care insurance whatsoever.
The Center for Medicare and Medicaid Services (CMS) sets reimbursement standards
for Federal programs and also influences private insurers’ reimbursement policies. Cur-
rently, CMS does not offer reimbursement for image-based diabetic retinopathy screen-
ing, and only a few private insurers do so.
Hence, screening programs in America have usually been developed by enthusiasts
such as the Vine Hill program [64] where digital retinal imaging is undertaken in an
inner-city primary care clinic, in the Joslin Diabetes Center [56], or in a Veterans Affairs
Medical Center [86].
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3
Functional/Neural Mapping Discoveries
in the Diabetic Retina: Advancing Clinical
Care with the Multifocal ERG
Anthony J. Adams and Marcus A. Bearse Jr.
CONTENTS
Introduction
Diabetes and an Unresolved Diabetic Eye Management Problem
The Need to Go Beyond Visual Acuity and Beyond Foveal Function
How Is the mfERG Measured and What is it Measuring?
The Horizon for Patient Care of Diabetes Retina and Research Agenda
References
Keywords Multifocal electroretinogram • Non proliferative diabetic retinopathy • Neuropathy

• Microvascular disease
INTRODUCTION
Diabetes, now an epidemic, has devastating effects on the eye and vision. The treatments
of the eye complications are currently limited to relatively advanced stages and primarily
to slow down the progressive retinal vasculopathy (diabetic retinopathy). New, nonfoveal
measures of early retinal function abnormalities, including neural abnormalities, could
change the focus of patient research and management to a more preventative agenda.
We have found that multifocal electroretinogram implicit time (mfERG IT) delays are
spatially associated in the retina with sites containing nonproliferative diabetic retinopa-
thy (NPDR) and edema. These delays also occur, albeit to a lesser extent, in the retinas
of patients with diabetes and no retinopathy. More important, we have shown that the
mfERG IT, in combination with other risk factors such as blood glucose concentration
and duration of diabetes, combines to provide remarkably accurate predictors of new
retinopathy development at specific locations within the central 45° of the retina. Very
recently, we showed that these mfERG IT delays are also predictive of the onset (ini-
tial appearance) of NPDR in adults. The importance and value of these local measures
of neural retina function and health seems obvious. Understanding their relationship to

31
32 Adams and Bearse
systemic factors that are known to be associated with type 2 diabetes before and after the
appearance of NPDR and using other known risk factors to further increase an already
excellent predictive model, are the next logical research steps. Both offer promise of
improved patient care and more personal patient management options.
DIABETES AND AN UNRESOLVED DIABETIC

EYE MANAGEMENT PROBLEM
The Diabetes Epidemic
In the United States, 17.9 million people, 5.9% of the population, have diabetes [1].
There are also an estimated 5.7 million who have undiagnosed diabetes and 57 million
who are prediabetic [1]. Diabetic retinopathy, the vascular eye complication, is the lead-
ing cause of blindness in the US among adults aged 20–74 years [1].
Current Treatment Focus

Treatments of the potentially devastating retinal complications are currently aimed
at slowing the progression of vision loss after vascular-related structural damage within
the retina which is funduscopically obvious. Laser photocoagulation, an invasive treat-
ment that destroys retinal tissue, is used in cases of clinically significant macular edema
(CSME). In cases of advanced retinopathy, panretinal laser treatment is applied to as many
as thousands, or more, of retinal locations to destroy tissue and consequently reduce the
retina’s demand for oxygen, thereby slowing progression of neovascularization. Although
these gold-standard treatments significantly reduce the loss of visual acuity, they have
side effects, including loss of paracentral vision (important for reading and other tasks)
and peripheral and night vision, and they are also associated with many adverse events
[2]. Furthermore, despite these treatments, vision loss still continues at a disturbing rate
[3–5]. Additional treatments are emerging, including intraocular and retrobulbar injection
of steroids, anti-VEGF agents, PKC inhibitors, PEDF (pigment endothelium-derived fac-
tor) inducers, and several indirect growth factor modulators. These therapies are targeted
at reducing macular edema, treating advanced disease, or reducing the risks of neovas-
cularization. These important treatment improvements remain focused on the relatively
advanced stages of vision loss produced by diabetes complications.
Vasculopathy and Neuropathy of the Retina

Increasing attention is being paid to the fact that there are both neural and vascular
components involved in very early stages of diabetic retinopathy. The concept that diabe-
tes directly affects the neurosensory retina, independent of clinically observed vascular
changes, has been proposed for decades [6]. Bresnick proposed, almost 25 years ago, to
redefine diabetic retinopathy as a neurosensory disorder resulting from both metabolic
and systemic insults to the retina, in addition to the clinically apparent vascular changes
[7]. Many sensitive human electrophysiological measurements of retinal neural function
and psychophysical measurements of visual function now indicate that there are early
abnormalities that appear before the clinical signs of diabetic retinopathy (vasculopathy)
[8–10]. Consistent with this, results obtained in animal models of diabetes show that
Functional/Neural Mapping Discoveries 33
there are increased inflammatory factors, structural changes of the glia, and ganglion
cell apoptosis in the retina before there are overt vascular changes associated with clini-
cal retinopathy [11].
THE NEED TO GO BEYOND VISUAL ACUITY

AND BEYOND FOVEAL FUNCTION
The Early Efforts
For almost three decades, research in our laboratory has involved the pursuit of retinal
function and vision markers early in, or preceding, the diabetes complications of the
retina. Quite clearly, visual acuity and visual fields are poor candidates, being quite late
consequences of retinal vascular complications. Indeed, visual acuity is reduced only
with edema in the foveal area of the macula, or as a result of fairly obstructive retinal/
vitreous hemorrhages. For more than a century, there had been clinical reports of blue–
yellow color vision changes in diabetes, even with foveal testing with fairly traditional
clinical tests. Based on this, we began our first studies trying to isolate the vision func-
tion underlying specific cone photoreceptor types using a suprathreshold variation of the
“two-color threshold” technique known to allow individual populations of cone receptor
activity to be manifest in vision measures. In the early 1980s, we found quite dramatic
reductions in the blue cone (S cone) sensitivity when deep violet patches of light were
detected only by S cones against a bright yellow background [12, 13]. These losses of
blue cone system sensitivity were even present prior to the clinically observable onset of
the vascular retinopathy of diabetes. Later, we developed a method to make these same
measurements across the retina and found losses in localized areas across the central 50°
of the retina [14, 15]. [Parenthetically, our work on this followed on with Chris Johnson,
then at UC Davis and led to the development of “blue-cone” (S cone) automated perim-
etry [16], which later was referred to as SWAP perimetry [17] with many applications in
glaucoma patient management.]
In patients with diabetes, we much later reported that blue-cone perimetry revealed
about 40% of central visual field zones as abnormal in the patients who had mild to
moderate retinopathy and even 20% abnormal in the retinas of those with diabetes and
no retinopathy [18]. However, disappointingly, we found little correlation of these field
abnormalities with the locations of visible retinopathy.
Some Breakthroughs
By marked contrast, our first efforts with measuring local neural function across the
retina with a newly emerging tool, the multifocal electroretinogram (mfERG), provided
clear association of abnormal neural function (observed as delays in the local mfERG
responses) with visible retinopathy [19]. This encouraged us to pursue the measures
further with both cross-sectional and longitudinal studies. With evidence of association
of neural dysfunction and visible retinopathy, the correlation between abnormality and
retinopathy severity and the observation that many patches of retina without retinopathy
had abnormal mfERG responses [19], we enrolled patients without retinopathy and with
minimal retinopathy. Our goal was to see if the abnormal mfERG delays were present in
34 Adams and Bearse
eyes that had not yet shown clinical retinopathy and to explore whether abnormal neural
function measures might be predictive of new retinopathy development.
Our studies over the 4–5 years that followed confirmed the initial promise of this
measure, and we now know that the neural latency abnormalities (mfERG delays)
observed in the earlier studies are not only present prior to retinopathy onset [19, 20]
and correlated with the severity of the retinopathy at the local site of the retinal vascu-
lar signs of retinopathy [19–21], but are also predictive (precedes) retinopathy onset
at locations in eyes that already have some retinopathy [20, 22–24]. Our longitudinal
studies over 1, 2, and 3 years have shown that predictive models based on mfERG
delays revealed remarkable potential clinical and research tools with high sensitivity
and specificity [20, 23, 24]. In confirmation studies, the high sensitivity (prediction of
retinopathy onset in a specific location) and specificity (prediction of normal retina at
specific locations) remain high [24]. One of our recent publications also reveals that
the mfERG measures are predictive of the onset of retinopathy in eyes that had no prior
retinopathy [25].
These research results with early stage emergence of neural dysfunction measures in
the retina are in striking contrast to the natural history of change in visual acuity. Visual
acuity loss occurs many years after retinopathy appears, and then only with severe retin-
opathic events or edema that impact the fovea. By that time, the vascular events are very
apparent to the clinician. So, as a functional outcome measure, visual acuity is primarily
useful as a measure of success in slowing late-stage retinopathy, or for assessing the
impact of treatments applied at that late stage. It is not useful to signal imminent retinal
problems, early retinopathy progression, or the efficacy of any preventative treatments.
In contrast, the implicit time (delay) measure of the mfERG has emerged as an exciting
future clinical tool in the management of patients at earlier stages and for the exploration
of new candidate treatments and interventions. With it, we have produced formal predic-
tive models. It is the critical component of predictive models of retinopathy onset over a
relatively short time frame and, as such, is an obvious candidate as an outcome measure
for relatively brief clinical trials of proposed pharmaceutical preventatives at the earliest
stages of diabetic retinal complications.
Predictive Models of Visible Retinopathy Onset at Specific Locations

Using multivariate logistic regression techniques, we formulated models incorporat-
ing mfERG IT and risk factors such as duration of diabetes and blood glucose control
that predict the development of retinopathy in new retinal locations with high sensitivity
and specificity (approx. 80–90%) [20, 23, 24]. Recently, we formulated another mul-
tifactor model, based on mfERG IT, that predicts the initial clinical onset of diabetic
retinopathy [25].
HOW IS THE MFERG MEASURED AND WHAT IS IT MEASURING?

So, what is the mfERG and how is it actually measured? The mfERG is a noninvasive
technique for measuring neural function in up to hundreds of contiguous retinal areas
within the central retina [26, 27]. The implicit time (IT) of the P1 component of the local
mfERG response waveform is a highly reproducible and sensitive indicator of neural
function in the retina. Figure 1 provides a brief overview of the stimulus and response
outputs across the central 45° of human retina [18–30].
Briefly, 103 local retinal responses to 200 cd/m2 flash stimulation (actually, first-order
response kernels) are recorded from the central ~45° of the retina during an ~8 min ses-
sion using a 75 Hz frame rate and 10–100 Hz filtering. The responses are recorded using
a bipolar contact lens electrode, and a ground electrode is clipped to the right earlobe.
Fixation is monitored using an in-line infrared video camera. The session is broken into
16 segments for subject comfort.
The first prominent positive peak (P1) of the mfERG response (Fig. 1D) that our
group has investigated is the easiest to measure, and the implicit time measure of P1 is
far less variable than the amplitude measure (one-tenth of the coefficient of variation of
the amplitude measure in healthy control subjects) [20].
Where Are These Neural Signals Generated in the Retina?

It is generally believed that mfERG IT delay, in the absence of reduced response
amplitude, reflects abnormality of the outer plexiform layer and bipolar cells, as it does
for the conventional full-field flash ERG. The P1 component of the mfERG waveform,
from which we measure mfERG IT, is generated primarily by the opposing electrical
polarities of the ON and OFF bipolar cell responses in the middle layers of the retina
[31–33]. The retina is particularly susceptible to the early pathological vascular changes
associated with type 2 diabetes because of its high metabolic demand, minimal retinal
vascular supply, and low oxygen tension of the inner retinal layers [8]. It has been pro-
posed that mfERG IT delays in the absence of mfERG response amplitude reductions
represent the effects of reduced perfusion and resulting hypoxia/ischemia [19, 20, 22,
23, 30, 34]. Recently, more direct evidence supporting this view has been reported. In
diabetic patients with enlarged foveal avascular zones, the area of the vascular-free zone
has been shown to be correlated with increasing mfERG IT delay, but not mfERG ampli-
tude reduction, in and adjacent to the fovea [34].
Some Key Results

Before highlighting the evolution of our predictive models, since 2004, it is illustra-
tive to look at a single patient example of the way in which the local mfERG implicit
time delay predicted subsequent retinopathy in a patient (Fig. 2).
In one of our first publications, we reported the sensitivity and specificity of the
mfERG implicit time as part of a “one-year” predictive model. It certainly included what
we later learned were both retinopathy that was transient and retinopathy that was likely
to be persistent. Based on our data then, primarily for study patients with mild diabetic
retinopathy, we found relatively high sensitivity (86%) and specificity (84%) [23].
This quantitative model was the first to make predictions of diabetic retinopathy
lesions in discrete retinal areas. The study involved only one follow-up visit and thus
could not examine whether the lesions that were evidenced were transient or sustained
in nature. More recently, our review included new data that extended the study by Han
et al. [23] for another year [20].
Two years later, we reported on a 3-year prediction model with similarly high sen-
sitivity and specificity for patients who already had some retinopathy [24]. Eighteen
36 Adams and Bearse
Fig. 1. Stimulus array of 103

scaled hexagons (A), its
relationship with the retinal area
tested (B), an example array of the
103 local mfERGs (C), and the
mfERG implicit time (IT) measure
from the stimulus flash to the P1
peak (D).
Fig. 2. Shows an example of the predictive power of the mfERG IT. The baseline mfERGs
are shown in (A). At baseline, this patient had no retinopathy. The mfERG implicit time was,
however, abnormally delayed (P < 0.023) in many of the 103 locations (red hexagons in (B)) and
many of the 35 retinal zones used for analysis (red patches in (D)). On follow-up 1 year later,
new patches of retinopathy and edema had developed, as indicated in the fundus photograph (C)
and as black dots (D). As can be seen in (D), four of the five new lesions are associated with
significantly delayed mfERG IT one year earlier, and the fifth lesion is very close to a delayed
zone. (Fig. 2 from Bearse et al. [20]).
diabetic patients were examined at baseline and at three annual follow-ups. Again, 35
retinal zones were constructed from the 103-element stimulus array, and each zone was
assigned the maximum IT z-score within it based on 30 age-similar control subjects.
Logistic regression was used to investigate the development of retinopathy in relation
to baseline mfERG IT delays and additional diabetic health variables. Again, receiver
operating characteristic (ROC) curves were used to evaluate the models.
38 Adams and Bearse
Fig. 3. (from Ng et al. [24]) ROC curves for the multivariate model (right) that predicts
recurring retinopathy over the course of 3 years in a local retinal area. The area under the ROC
curve (AUC) of 0.95 provides an overall measure of the model’s discrimination accuracy (95%).
Even a model containing only the mfERG implicit time, and no other factors (left), provided
surprisingly good sensitivity (84%) and specificity (73%) along with good discrimination
(AUC = 0.83) [24].
Here, we were interested in the prediction of persistent retinopathy onset at two suc-
cessive annual visits. We looked separately at what we had learned was a common occur-
rence of transient initial retinopathy. A retinal area that shows retinopathy lesions over
a longer period represents more significant pathophysiological alterations—increased
vascular permeability and hypoxia. We argue that these areas are clinically more impor-
tant than transient retinal lesions. (It is well known that the very earliest clinical signs of
diabetic retinopathy wax and wane. For example, Hellstedt and Immonen reported that
over a 2-year period, 52% of microaneurysms show spontaneous resolution [35]. )
Retinopathy developed in 77 of the 1,208 retinal zones of which 25 retinal zones
had recurring retinopathy. The multivariate analyses showed baseline mfERG IT, dura-
tion of diabetes, and blood glucose concentration as the most important predictors of
recurring retinopathy but were not at all predictive of transient retinopathy. ROC curves
revealed sensitivity of 88% and specificity of 98% for the recurring retinopathy we were
interested in (see Fig. 3). A tenfold cross-validation confirmed the high sensitivity and
specificity of the model.
In a recent publication, we report on the onset of diabetic retinopathy in a study
group of patients with diabetes but no clinically visible signs of retinopathy [25].
Again, the predictive multivariate models incorporating mfERG IT delay and other risk
variables showed excellent ability to predict the onset of retinopathy with high sensitiv-
ity and specificity. Seventy-eight eyes from 41 diabetes patients were tested annually
for several years. The presence or absence of DR at the last study visit was the outcome
measure, and measurements of risk factors from the previous visit were used for predic-
tion. Nearly 40% of the 78 eyes developed retinopathy for a total of 80 of 2,730 retinal
zones. In short, mfERG IT was again a good predictor of diabetic retinopathy onset,
1 year later, even in patients without any prior retinopathy. It can be utilized to assess
the risk of DR development in these patients and may be a valuable outcome measure in
evaluation of novel prophylactic therapeutics directed at impeding DR.
Adolescents and Adult Diabetes

Are the mfERG abnormalities we see in adult diabetic subjects also present in ado-
lescent patients with diabetes?
In 2005, the Center for Disease Control (CDC) in the US estimated that there are
206,000 people under the age of 20 that have diabetes, and approximately one in six
overweight adolescents have prediabetes (CDC, 2005). Type 2 diabetes now accounts
for up to 20% of all newly diagnosed adolescent cases [36].
In 2008, we reported that indeed, adolescents with type 2 diabetes do have abnormal
neural function in the retina [37]. We also noted early indications of abnormal dilation
of venules and abnormal thinning of the retina. Adolescents with type 2 diabetes often
present with comorbidities such as obesity, hyperinsulinemia, hypertension, and hyper-
lipidemia. All of these conditions can impact both the vascular and neurologic health
of the patient. Our study was the first of its kind to examine the neural retinal function,
structure, and retinal vascular health in adolescents with type 2 diabetes.
Fifteen adolescents diagnosed with type 2 diabetes, aged 13–21 years with a mean
diabetes duration of 2.1 ± 1.3 years, were examined. Twenty-six age-matched control
subjects were also tested. The mfERGs of the type 2 diabetic patients were significantly
delayed ( p = 0.03). The diabetic group also showed significant retinal thinning and sig-
nificant venular dilation.
Type 1 vs. Type 2: Differences in Retinal Function

In a recent paper, we noted differences in type 1 and type 2 adults with diabetes [25].
Neural function in the retina was distinctly poorer in the type 2 patients. We have noted
this same difference when comparing adolescents with type 1 and type 2 diabetes [38].
This raises questions about possible underlying differences in pathophysiology of the
retina (and beyond). Type 2 diabetes patients typically have more numerous cardiovascular
risk factors and comorbidity factors than type 1 patients. Our current research is looking
at this more carefully.
THE HORIZON FOR PATIENT CARE OF DIABETES

RETINA AND RESEARCH AGENDA
The early neural changes in the retina of eye, produced by diabetes well before
clinical signs of vascular retinopathy, have quite significant implications for patient
care and management of eye complications as we look to the horizon. The mfERG
implicit time, measured with clinical instrumentation, clearly identifies almost 20% of
the central retina of patients with diabetes as functioning abnormally prior to visible
retinopathy. This “neuropathy” is consistent with the changing view of the retinal com-
plications of diabetes that has previously had almost entirely a “vascular” label; it still
does with most clinicians. Regardless of the perspective of neural preceding vascular or
vice versa—the debate will likely hinge on whichever new technical assessment tools
40 Adams and Bearse
are most sensitive—it is clear that the identification of functional deficits, early in the
disease complication process of the eye, provides new opportunities for the development
of new therapies and assessment tools for the staging of retinal changes.
Clinicians have primarily been limited to assessment of visual acuity at one central
and tiny location of the retina, and to visual fields with relatively insensitive markers
in diabetes. In fact, both visual acuity and visual fields by conventional perimetry are
characteristic of fairly late stage vasculopathy of the retina—well after any prophylactic
treatments could be applied. The early “warning signals” of the mfERG, coupled with
an apparently powerful predictive ability for future retinopathy within a year or two, are
an exciting advance in the potential management of the diabetic complications of the
retina. New candidate interventions, aimed at preventing or slowing the path of retinopa-
thy progression at early stages, may now be contemplated with biological and objective
markers of functional improvement. With visual acuity loss typically occurring only
after many years, it becomes a most unattractive outcome measure for any early inter-
vention efficacy studies.
In management, it is conceivable that patient monitoring, based on the progression of
neural abnormality, will be a valuable tool in the hands of eye care practitioners. Oph-
thalmologists and optometrists could have the ability to gauge both the severity of neural
dysfunction and the likelihood of incipient local retinopathy and use this information to
stage an appropriate and timely intervention.
Looking even further ahead, it is conceivable that as other functional measures of the
retina, known to be altered at early stages of the diabetic complications (e.g., alterations
in the retinal pigment epithelium function, or systemic serum markers or indices known
to be risk factors) that might make the predictive models of incipient damage in the
retina even more powerful than they already are. It is important to examine the potential
relationships between the mfERG IT delays in diabetes and to look at systemic markers
of glycemic control, diabetes-related inflammation, microvascular damage, and dysli-
pidemia (abnormal concentrations of lipids in the blood). These systemic markers are
associated with diabetes and microvascular disease including diabetic retinopathy.
Taken a step further, as research links systemic serum risk factors to particular reti-
nal structure changes, whether neural or vascular, it is conceivable that personalized
treatment and management options will evolve for diabetic retinal health. Certainly, the
opportunities for research to unveil those relationships and the underlying mechanisms
provide an exciting opportunity in clinical research.
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1. American diabetes association web site. Diabetes statistics; 2010.
2. Aiello LM. Perspectives on diabetic retinopathy. Am J Ophthalmol. 2003;136:122–35.
3. Early Treatment Diabetic Retinopathy Study research group. Photocoagulation for diabetic
macular edema. Early treatment diabetic retinopathy study report number 1. Arch Ophthal-
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4. Hansson-Lundblad C, Holm K, Agardh CD, Agardh E. A small number of older type 2
diabetic patients end up visually impaired despite regular photographic screening and laser
treatment for diabetic retinopathy. Acta Ophthalmol Scand. 2002;80:310–5.
5. Vine AK. The efficacy of additional argon laser photocoagulation for persistent, severe pro-
liferative diabetic retinopathy. Ophthalmology. 1985;92:1532–7.
6. Wolter JR. Diabetic retinopathy. Am J Ophthalmol. 1961;51:1123–41.

7. Bresnick GH. Diabetic retinopathy viewed as a neurosensory disorder. Arch Ophthalmol.
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8. Antonetti DA, Barber AJ, Bronson SK, Freeman WM, Gardner TW, Jefferson LS, Kester M,
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IA. Diabetic retinopathy: seeing beyond glucose-induced microvascular disease. Diabetes.
2006;55:2401–11.
9. Jackson GR, Barber AJ. Visual dysfunction associated with diabetic retinopathy. Curr Diab
Rep. 2010;10:380–4.
10. Tzekov R, Arden GB. The electroretinogram in diabetic retinopathy. Surv Ophthalmol.
1999;44:53–60.
11. Kern TS. Contributions of inflammatory processes to the development of the early stages of
diabetic retinopathy. Exp Diabetes Res. 2007;2007:95103.
12. Adams AJ. Chromatic and luminosity processing in retinal disease. Am J Optom Physiol
Opt. 1982;59:954–60.
13. Adams AJ, Zisman F, Rodic R, Cavender JC. Chromaticity and luminosity changes in glau-
coma and diabetes. Doc Ophthalmol Proc Series. 1982;33:413–8.
14. Heron G, Adams AJ, Husted R. Foveal and non-foveal measures of short wavelength sensitive
pathways in glaucoma and ocular hypertension. Ophthalmic Physiol Opt. 1987;7:403–4.
15. Heron G, Adams AJ, Husted R. Central visual fields for short wavelength sensitive pathways
in glaucoma and ocular hypertension. Invest Ophthalmol Vis Sci. 1988;29:64–72.
16. Johnson CA, Adams AJ, Lewis RA. Automated perimetry of short-wavelength-sensitive
mechanisms in glaucoma and ocular hypertension; preliminary findings. In: Heijl A, editor.
Proceedings of the VIIIth international perimetric society meeting. Amsterdam: Kuglrer &
Ghedini Publications; 1989. p. 31–7.
17. Sample PA, Johnson CA, Haegerstrom-Portnoy G, Adams AJ. Optimum parameters for
short-wavelength automated perimetry. J Glaucoma. 1996;5:375–83.
18. Han Y, Adams AJ, Bearse Jr MA, Schneck ME. Multifocal electroretinogram and short-
wavelength automated perimetry measures in diabetic eyes with little or no retinopathy.
Arch Ophthalmol. 2004;122:1809–15.
19. Fortune B, Schneck ME, Adams AJ. Multifocal electroretinogram delays reveal local retinal
dysfunction in early diabetic retinopathy. Invest Ophthalmol Vis Sci. 1999;40:2638–51.
20. Bearse Jr MA, Adams AJ, Han Y, Schneck ME, Ng J, Bronson-Castain K, Barez S.
A multifocal electroretinogram model predicting the development of diabetic retinopathy.
Prog Retin Eye Res. 2006;25:425–48.
21. Schneck ME, Bearse Jr MA, Han Y, Barez S, Jacobsen C, Adams AJ. Comparison of mfERG
waveform components and implicit time measurement techniques for detecting functional
change in early diabetic eye disease. Doc Ophthalmol. 2004;108:223–30.
22. Han Y, Bearse Jr MA, Schneck ME, Barez S, Jacobsen CH, Adams AJ. Multifocal elec-
troretinogram delays predict sites of subsequent diabetic retinopathy. Invest Ophthalmol Vis
Sci. 2004;45:948–54.
23. Han Y, Schneck ME, Bearse Jr MA, Barez S, Jacobsen CH, Jewell NP, Adams AJ. Formula-
tion and evaluation of a predictive model to identify the sites of future diabetic retinopathy.
Invest Ophthalmol Vis Sci. 2004;45:4106–12.
24. Ng JS, Bearse Jr MA, Schneck ME, Barez S, Adams AJ. Local diabetic retinopathy predic-
tion by multifocal ERG delays over 3 years. Invest Ophthalmol Vis Sci. 2008;49:1622–8.
25. Harrison WW, Bearse MA, Jr., Ng JS, Jewell N, Barez S, Burger D, Schneck ME, Adams
AJ. Multifocal electroretinograms predict onset of diabetic retinopathy in adult patients with
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26. Bearse Jr MA, Han Y, Schneck ME, Adams AJ. Retinal function in normal and diabetic
eyes mapped with the slow flash multifocal electroretinogram. Invest Ophthalmol Vis Sci.
2004;45:296–304.
27. Bearse Jr MA, Sutter EE. Imaging localized retinal dysfunction with the multifocal elec-
troretinogram. J Opt Soc Am A Opt Image Sci Vis. 1996;13:634–40.
28. Han Y, Bearse Jr MA, Schneck ME, Barez S, Jacobsen C, Adams AJ. Towards optimal filter-
ing of “standard” multifocal electroretinogram (mfERG) recordings: findings in normal and
diabetic subjects. Br J Ophthalmol. 2004;88:543–50.
29. Harrison WW, Bearse Jr MA, Ng JS, Barez S, Schneck ME, Adams AJ. Reproducibility of
the mfERG between instruments. Doc Ophthalmol. 2009;119:67–78.
30. Palmowski AM, Sutter EE, Bearse Jr MA, Fung W. Mapping of retinal function in diabetic
retinopathy using the multifocal electroretinogram. Invest Ophthalmol Vis Sci. 1997;38:
2586–96.
31. Hare WA, Ton H. Effects of APB, PDA, and TTX on ERG responses recorded using both
multifocal and conventional methods in monkey. Effects of APB, PDA, and TTX on monkey
ERG responses. Doc Ophthalmol. 2002;105:189–222.
32. Hood DC. Assessing retinal function with the multifocal technique. Prog Retin Eye Res.
2000;19:607–46.
33. Horiguchi M, Suzuki S, Kondo M, Tanikawa A, Miyake Y. Effect of glutamate analogues
and inhibitory neurotransmitters on the electroretinograms elicited by random sequence
stimuli in rabbits. Invest Ophthalmol Vis Sci. 1998;39:2171–6.
34. Tyrberg M, Ponjavic V, Lovestam-Adrian M. Multifocal electroretinogram (mfERG) in
patients with diabetes mellitus and an enlarged foveal avascular zone (FAZ). Doc Ophthalmol.
2008;117:185–9.
35. Hellstedt T, Immonen I. Disappearance and formation rates of microaneurysms in early dia-
betic retinopathy. Br J Ophthalmol. 1996;80:135–9.
36. CDC. National diabetes fact sheet: General information and national estimates on diabetes in
the United States. US Department of health and human services, centers for disease control
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37. Bronson-Castain KW, Bearse Jr MA, Neuville J, Jonasdottir S, King-Hooper B, Barez S,
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38. Bronson-Castain KW, Bearse Jr MA, Neuville J, Jonasdottir S, King-Hooper B, Barez S,
Schneck ME, Adams AJ. Early neural and vascular changes in the adolescent type 1 and type 2
diabetic retina. Retina. 2011; Aug 30. [Epub ahead of print.]
Part III
How Does Diabetes Affect the Eye?
4
Corneal Diabetic Neuropathy
Edoardo Midena
CONTENTS
Introduction
Corneal Confocal Microscopy
Corneal Nerves and Diabetes
Conclusion
References
Keywords Sub-basal corneal nerve plexus • Corneal nerve fibers • Corneal confocal microscopy
• Peripheral diabetic neuropathy
INTRODUCTION
The prevalence of diabetes mellitus is dramatically increasing worldwide, and con-
sequently, the prevalence of chronic complications due to diabetes will increase in the
near future [1]. The most common cause of chronic disability in diabetic patients is dia-
betic neuropathy, mainly, peripheral diabetic neuropathy. Peripheral diabetic neuropathy
affects 50% of diabetic patients within 25 years of diagnosis [2]. Long-term effects of
undetected and untreated peripheral diabetic neuropathy can lead to foot infections that
do not heal, as well as foot ulcers. Patients may require subsequent amputation of the foot
and digits, which can lead to a decreased quality of life and increased mortality [3].
The effective and reliable diagnosis and quantification of peripheral diabetic neuropathy
are relevant in defining at risk patients, decreasing patient morbidity, and assessing new
therapies [4, 5]. The clinical diagnosis of peripheral diabetic neuropathy is often missed
or peripheral neuropathy is lately diagnosed, mainly because a simple noninvasive method
for early detection of peripheral diabetic neuropathy is not yet available [6]. Clinical diag-
nosis is commonly made only when patients with peripheral diabetic neuropathy become
symptomatic. Early diagnosis is currently based on electrophysiological tests or on skin
biopsy, probably the gold standard in identifying small fiber peripheral diabetic neuropa-
thy. Electrophysiological tests cannot detect the minute fiber nerve fiber damage in patients
with diabetes [7]. Although skin biopsy may detect the minute damage in small peripheral
nerve fibers, it has a major limitation because skin biopsy is an invasive test [8, 9].

45
46 Midena
Recently, a new approach to the detection of very early small fiber peripheral diabetic
neuropathy has been proposed and validated. It involves the detection and quantifica-
tion of the alteration of corneal nerves in diabetes, mainly the subbasal corneal nerve
plexus [10]. This is a monolayer of nerve fibers located at the border between corneal
epithelium and stroma, which may be detected in vivo even in a noninvasive way (see
below) and probably represents the best model to have clinical information on diabetic
peripheral neuropathy.
CORNEAL CONFOCAL MICROSCOPY

Corneal confocal microscopy (CCM) is a diagnostic test used to investigate at a
microscopic level the different layers of the cornea. It is based on the same physical
principle of any confocal microscope, allowing to have in focus just one layer of the
examined tissue. Light reflected by any layer out of focus is eliminated allowing to
have a high magnification, sharp image of the layer under investigation. Using corneal
confocal microscope, the individual structures of any corneal layer may be easily docu-
mented: from the endothelium through the stroma (containing keratocytes, nerve fibers,
and sometimes Langherans cells) up to the epithelium (with each layer) and tear film.
The procedure may be a contact or noncontact one. The noncontact procedure allows
to repeat CCM in a safe way, as much as necessary and with high reliability [10]. In
our studies, CCM was performed by using Confoscan 4.0 (Nidek, Gamogori, Japan)
equipped with an Achroplan nonapplanating ×40 immersion objective lens (Zeiss,
Oberkochen, Germany) and with a Z-ring adapter system. Each examination is per-
formed according to a standard procedure, as previously described [11]. Briefly, before
the examination, a drop of topical anesthetic (0.4% oxybuprocaine chlorohydrate) is
instilled in the lower conjunctival fornix of the eye. One drop of 0.2% polyacrylic gel
is applied onto the objective tip to serve as an immersion fluid. The patient is positioned
in the chin and forehead rest, and when an image of stroma appears on the monitor of the
confocal microscope, the recording button is pressed and a micrometric motor-driven
system automatically completes the alignment. The focal plane is automatically moved
to reach the anterior chamber and begins recording several scans of the entire depth of
the cornea. The Z-ring device is used for all examinations, and only the central cornea is
analyzed. Illumination intensity is kept constant in all cases. The images collected using
this procedure are analyzed in a qualitative and/or quantitative way. The endothelium
is automatically analyzed using a dedicated software available with the machine. Both
stromal and epithelial cells may be quantified in a semiautomatic way. The analysis of
corneal sub-basal nerve plexus (CSNP) has been recently validated in a large group of
normal and pathological eyes (Figs. 1 and 2) [10].
The assessment of CSNP was performed according to the following standard-
ized procedure. The standard dimension of each image produced was 340 × 255 mm
(area = 0.132 mm2) with an optical section thickness of 5.5 mm. For each examined cor-
nea, the best sharp focus frame of CSNP was chosen. For each frame of the CSNP
images, five parameters were analyzed: nerve fiber length (NFL), number of fibers (NF),
number of branching (NBr), number of beadings (NBe), and fiber tortuosity (FT) (Fig. 3).
NFL was calculated using an image processing computer tool, the Neuron J© program to
Corneal Diabetic Neuropathy 47
Fig. 1. Corneal subbasal nerve plexus (CSNP) in a normal subject, as shown by corneal
confocal microscopy (CCM). It appears as a monolayer of straight nerve fibers with hyperreflec-
tive spots along the nerve (nerve beadings).
Fig. 2. CSNP in diabetes, examined with CCM. The most evident aspect is the reduction of
nerve beadings (colored in red) along the nerve fibers.
outline nerve fibers from each CSNP frame. NFL for each image was calculated as the
total length of the nerves (micrometers) divided by the area of the image (0.132 mm2)
and expressed as micrometers per square millimeters (mm/mm2). NF was manually cal-
culated and defined as the total number of principal nerve trunks and their branches per
image. NBr was manually calculated and defined as the total NBr per image. NBe was
defined as the number of hyperreflective points manually calculated considering 100 mm
48 Midena
Fig. 3. Normal nerve tortuosity in the corneal subbasal nerve layer.
of one fiber. The fiber was randomly chosen by the operator between all the best focused
fibers. The same standard magnification was kept for all the images during the counting.
The score system proposed by Oliveira-Soto and Efron [12] was used to analyze FT.
CORNEAL NERVES AND DIABETES

The cornea is the most densely innervated tissue in the body and is richly supplied
by sensory and autonomic nerve fibers [13, 14]. Nerve bundles enter the cornea at the
periphery in a radial manner parallel to the corneal surface. The nerve bundles lose their
perineurium and myelin sheaths approximately 1 mm from the limbus and continue into
the cornea surrounded by Schwann cell sheaths, and then subdivide several times into
smaller branches. Stromal nerve trunks move from the periphery toward the corneal
center and eventually turn 90°, proceeding toward the corneal surface and penetrating
Bowman’s layer. After penetrating Bowman’s layer, the large nerve bundles divide into
several smaller bundles, which turn another 90° and continue parallel to the corneal
surface between Bowman’s layer and the basal epithelial cell layer, creating the sub-
basal corneal nerve plexus. The CSNP is characterized by local axon enlargements, or
beading, which are accumulations of mitochondria and glycogen particles located at
the periphery of the bundle. Corneal nerve fibers exert important trophic influences on
the corneal epithelium and contribute to the maintenance of a healthy ocular surface [13].
Corneal abnormalities caused by diabetes include superficial punctuate keratopathy,
recurrent epithelial defects, neurotrophic keratopathy, and corneal ulcer [15–19]. These
abnormalities have been reported to occur in 50–74% of patients with diabetes who
never underwent surgery, and many of these patients are asymptomatic [18, 19]. Corneal
sensation is reduced in diabetic patients and progresses with the severity of neuropathy,
suggesting that corneal nerve fiber damage accompanies diabetic somatic nerve fiber
damage [20–22], one of the most important and invalidating diabetic chronic complica-
Fig. 4. Altered (increased) tortuosity of the subbasal nerve plexus in diabetes. This image
is classified as stage 4 tortuosity.
tions [23]. A growing interest in corneal morphology in diabetic patients, especially in

CSNP, is documented [21, 24–27]. Corneal nerve changes secondary to diabetes mellitus
have been recently analyzed with CCM using a multiparametric approach and termed
corneal diabetic neuropathy (CDN) [21].
CDN, as defined using CCM, is characterized by relevant modifications (vs. con-
trol subjects) of CSNP parameters which may be summarized as follows: decrease in
the number of fibers, branching pattern and number of beadings, and increase in nerve
tortuosity in diabetic patients (Fig. 4) [21]. Rosenberg et al. [22] found a reduction in
long nerve fiber bundle in patients with mild to moderate neuropathy, and a reduction in
corneal mechanical sensitivity only in patients with severe neuropathy, suggesting that
decrease in nerve fiber bundle counts precede impairment of corneal sensitivity and that
reduction in neurotrophic stimuli in severe neuropathy may induce a thin epithelium that
may lead to recurrent erosions. Chang et al. [24] defined diabetic alterations in the cor-
neal innervations using CCM, finding a decrease in nerve fiber density and nerve branch
density and an increase of tortuosity, demonstrating that reduced density in basal epithe-
lial cell is correlated with changes in innervations. Malik et al. [26] showed a progres-
sive reduction in the number of corneal nerve fibers in diabetes, suggesting enhanced
degeneration, and showed reduction in the number of corneal nerve branches, suggest-
ing a reduction in regenerative capacity, with a progression of neuropathic severity.
Quattrini et al. [27] quantified nerve fiber pathological changes using CCM and found
a progressive reduction in corneal nerve fiber and branch density, but the latter was
significantly reduced even in diabetic patients without neuropathy. Kallinikos et al. [25]
demonstrated that tortuosity coefficient of nerve fibers was significantly greater in the
severe diabetic neuropathic group than in control subjects and in the mild and moderate
neuropathic groups, suggesting that this morphologic abnormality relates to the sever-
ity of somatic neuropathy and may reflect an alteration in the degree of degeneration in
50 Midena
diabetes. Moreover, Mehra et al. [28] demonstrated, using CCM, a significant improve-
ment in corneal nerve fiber density and nerve fiber length within 6 months after pancreas
transplantation in patients with type 1 diabetes, indicating an early repair process with
the restoration of euglycemia. Regeneration of CSNP was demonstrated after refrac-
tive surgery [29, 30]. In diabetes, nerve fiber damage is caused by hyperglycemia and
oxidative stress [31–33] and not by fiber axotomy, as in refractive surgery [29, 30]. Neu-
rons are obligate glucose users, and whereas some neurons express glucose transport-
ers, glucose may enter the cell solely based on concentration gradient [32]. This makes
neurons of the peripheral nervous system particularly vulnerable to hyperglycemia [32].
Vincent et al. [31] reviewed the evidence that indicates that glucose-mediated oxidative
stress is an inciting event in the development of diabetic neuropathy. In a pilot study on
CSNP regeneration in diabetic patients under topical antioxidant therapy, we observed
an increase in NF, NFL, NBe, and nerve sprouting.
CONCLUSION
CCM is currently the key diagnostic technique in evaluating and monitoring CSNP
and CDN in vivo. Quantification of CSNP parameters allows a correct, reproducible,
and objective in vivo, noninvasive approach to CDN, allowing to characterize peripheral
diabetic neuropathy, a potentially highly disabling complication of diabetes, and CCM
may represent a valid tool in monitoring CSNP regeneration, which may have important
implications for corneal healing and health.
REFERENCES
1. Mokad A, Ford ES, Bowman BA, Nelson DE, Englegau MM, Vinicor F, et al. Diabetes
trends in the US: 1990–1998. Diabetes Care. 2000;23:1278–83.
2. Gooch C, Podwall D. The diabetic neuropathies. Neurologist. 2004;10:311–22.
3. Partanen J, Niskanen L, Lehtinen J, Mervaala E, Siiitonen O, Uusitupa M. Natural history
of peripheral diabetic neuropathy in patients with non-insulin-dependent diabetes mellitus.
N Engl J Med. 1995;333:89–94.
4. Park TS, Park JH, Beak HS. Can diabetic neuropathy be prevented? Diabetes Res Clin Pract.
2004;66:S53–8.
5. Boucek P. Advanced diabetic neuropathy: a point of no return. Rev Diabet Stud. 2006;3:
143–50.
6. Rahman M, Griffin SJ, Rahtmann W, Wareham NJ. How should peripheral neuropathy be
assessed in people with diabetes in primary care? A population based comparison of four
measures. Diabet Med. 2003;20:368–74.
7. Daube JR. Electrophysiologic testing in diabetic neuropathy. In: Dyck P, Thomas P, editors.
Diabetic neuropathy. Philadelphia: WB Saunders; 1999. p. 213–5.
8. Smith AG, Howard JR, Kroll R, Ramachandaran P, Hauer P, Singleton JR, et al. The reli-
ability of skin biopsy with measurement of intraepidermal nerve fiber density. J Neurol Sci.
2005;228:65–9.
9. Umapathi T, Tan WL, Cheong Loke S, Cheow Soon P, Tavintharan S, Huak Chan Y.
Intraepidermal nerve fiber density as a marker of early diabetic retinopathy. Muscle Nerve.
2007;35:591–8.
10. Midena E, Cortese M, Miotto S, Gambato C, Cavarzeran F, Ghirlando A. Confocal micros-
copy of corneal sub-basal nerve plexus: a quantitative and qualitative analysis in healthy and
pathologic eyes. J Refract Surg. 2009;25:S125–9.
11. Brugin E, Ghirlando A, Gambato C, Midena E. Central corneal thickness. Z-ring corneal
confocal microscopy versus ultrasound pachimetry. Cornea. 2007;26:303–7.
12. Oliveira-Soto L, Efron N. Morphology of corneal nerves using confocal microscopy. Cor-
nea. 2001;20:374–84.
13. Muller LJ, Pels L, Vrensen GFJM. Ultrastructural organization of human corneal nerves.
14. Muller LJ, Marfurt CF, Kruse F, Tervo TMT. Corneal nerves: structure, contents and func-
tion. Exp Eye Res. 2003;76:521–42.
15. Ohashi Y. Diabetic keratopathy. Nippon Ganka Gakkai Zasshi. 1997;101:105–10.
16. Creuzot-Garcher C, Lafontaine PO, Gualino O, D’Athis P, Petit JM, Bron A. Study of ocular
surface involvement in diabetic patients. J Fr Ophtalmol. 2005;28:583–8.
17. Rao GN. DR P Siva Reddy Oration. Diabetic keratopathy. Indian J Ophthalmol. 1987;35:16–36.
18. Schultz RO, Peters MA, Sobocinski K, et al. Diabetic corneal neuropathy. Trans Am Oph-
thalmol Soc. 1983;81:107–24.
19. Didenko TN, Smoliakova GP, Sorokin EL, et al. Clinical and pathogenetic features of neu-
rotrophic corneal disorders in diabetes. Vestn Oftalmol. 1999;115:7–11.
20. Tavakoli M, Kallinikos PA, Efron E, Boulton AJM, Malik RAM. Corneal sensitivity is
reduced and relates to the severity of neuropathy in patients with diabetes. Diabetes Care.
2007;30:1895–7.
21. Midena E, Brugin E, Ghirlando A, Sommavilla M, Avogaro A. Corneal diabetic neuropathy:
a confocal microscopy study. J Refract Surg. 2006;22:S1047–52.
22. Rosenberg ME, Tervo TMT, Immonen IJ, Muller LJ, Gronhagen-Riska C, Vesaluoma H.
Corneal structure and sensitivity in type 1 diabetes mellitus. Invest Ophthalmol Vis Sci.
2000;41:2915–21.
23. Boulton AJ, Vinik AI, Arezzo JC, et al. Diabetic neuropathies: a statement by the American
Diabetes Association. Diabetes Care. 2005;28:956–62.
24. Chang PY, Carrel H, Huang JS, et al. Decreased density of corneal basal epithelium and sub-
basal corneal nerve bundle changes in patients with diabetic retinopathy. Am J Ophthalmol.
2006;142:488–90.
25. Kallinikos P, Berhanu M, O’Donnel C, Boulton AJM, Efron N, Malik RA. Corneal nerve
tortuosity in diabetic patients with neuropathy. Invest Ophthalmol Vis Sci. 2004;45:418–22.
26. Malik RA, Kallinikos P, Abbott CA, et al. Corneal confocal microscopy: a non-invasive sur-
rogate of nerve fibre damage and repair in diabetic patients. Diabetologia. 2003;46:683–8.
27. Quattrini C, Tavakoli M, Jeziorska M, et al. Surrogate markers of small fiber damage in
human diabetic neuropathy. Diabetes. 2007;56:2148–54.
28. Mehra S, Tavakoli M, Kallinikos PA, et al. Corneal confocal microscopy detects early nerve
regeneration after pancreas transplantation in patients with type 1 diabetes. Diabetes Care.
2007;30:2608–12.
29. Cavillo MP, McLaren JW, Hodge DO, Bourne WM. Corneal reinnervation after LASIK.
Prospective 3-year longitudinal study. Invest Ophthalmol Vis Sci. 2004;45:3991–6.
30. Erie J, McLaren JW, Hodge DO, Bourne WM. Recovery of corneal subbasal nerve density
after PRK and LASIK. Am J Ophthalmol. 2005;140:1059–64.
31. Vincent AM, Russel JW, Low P, Feldman EL. Oxidative stress in the pathogenesis of dia-
betic neuropathy. Endocr Rev. 2003;25:612–8.
32. Sullivan KA, Feldman EL. New developments in diabetic neuropathy. Curr Opin Neurol.
2005;18:586–90.
33. McHugh JM, McHugh WB. Diabetes and peripheral sensory neurons: what we don’t know
and how it can hurt us. AACN Clin Issues. 2004;15:136–49.
5
Clinical Phenotypes of Diabetic Retinopathy
José Cunha-Vaz, Rui Bernardes, and Conceição Lobo
CONTENTS
Natural History
MA Formation and Disappearance Rates
Alteration of the Blood–Retinal Barrier
Retinal Capillary Closure
Neuronal and Glial Cell Changes: Retinal Thickness Measurements
Multimodal Macula Mapping
Clinical Retinopathy Phenotypes
Relevance for Clinical Trial Design
Relevance for Clinical Management
Targeted Treatments
References
Keywords Blood–retinal barrier • Retinal vascular endothelium • Macular edema • Retinal

leakage analyzer • Multimodal macula mapping • Microaneurysm turnover • Retinopathy pro-
gression
Diabetic retinopathy is characterized by gradually progressive alterations in the reti-

nal microvasculature and is the leading cause of new cases of legal blindness among
Americans between the ages of 20 and 74 years [1].
Diabetic retinopathy occurs in both type 1 (also known as juvenile-onset or insulin-
dependent diabetes) and type 2 (also known as adult-onset or noninsulin-dependent dia-
betes) diabetes. All the features of diabetic retinopathy may be found in both types of
diabetes, but characteristically the incidence of its major complications and main causes
of vision loss, macular edema, and retinal neovascularization is quite different for each
type of diabetes [1]. Diabetic retinopathy in type 1 diabetes induces vision loss mainly
due to the formation of new vessels in the eye fundus and development of proliferative
retinopathy, whereas in type 2 diabetes, vision loss is most commonly due to macular
edema and proliferative retinopathy is relatively rare.

53
54 Cunha-Vaz et al.
It is apparent, from the data available from a variety of large longitudinal studies,
that the evolution and progression of diabetic retinopathy vary between the two types of
diabetes involved and between different patients even when belonging to the same type
of diabetes, and does not necessarily progress to clinically significant macular edema
(CSME) or proliferative retinopathy leading to vision loss.
NATURAL HISTORY
Diabetic retinopathy shows initially minimal fundus abnormalities and progresses over
time to more and more advanced microvascular changes. The main alterations occurring in
the diabetic retina are: breakdown of the blood–retinal barrier (BRB), evidenced by abnor-
mal vascular leakage and capillary closure leading to progressive tissue ischemia. These
two main alterations lead, as they progress, to the two major complications of diabetic reti-
nal disease which are associated with vision loss: CSME and proliferative retinopathy.
The retinal changes that result from diabetes before the development of the two main
complications referred above are conventionally described under the name of nonprolif-
erative diabetic retinopathy (NPDR).
The initial stages of NPDR are, therefore, characterized by the presence of micro-
aneurysms (MA), hemorrhages, hard exudates or cotton-wool spots, indirect signs of
vascular hyperpermeability, and capillary closure.
These are the alterations that dominate the initial stages of NPDR, and it is crucial to
analyze their development and progression, in order to clarify their relative importance
in the progression of diabetic retinopathy [2]. They are not present in every patient in the
same way nor at the same rate.
It is fundamental to realize that the course and rates of progression of the retinopathy
vary between patients. MA, for example, may come and go. Once you get an MA, you
do not necessarily continue to have that MA. MA may disappear due to vessel closure,
which is an indication of worsening of the retinopathy because of progressive vascular
closure [3]. Hemorrhages will obviously come and go as the body heals them. Fre-
quently, there is apparent clinical improvement with fewer lesions visible, but in reality,
it masks worsening of the disease.
A prominent feature of diabetic retinopathy, focal edema, can spontaneously resolve
itself. Indeed, it is resolved in approximately a third of patients over a period of 6 months,
without any intervention [4].
The initial pathological changes occurring in the diabetic retina are characteristically
located in the small retinal vessels of the posterior pole of the retina, i.e., in the macular
area. The structural changes in the small vessels include endothelial cell and pericyte
damage and thickening of basement membrane [2, 5].
Retinal vascular endothelium is a fundamental part of the BRB, which has many simi-
larities with the blood–brain barrier. It functions as a selective barrier which has shown
to be altered in experimental and human diabetes [6]. It is altered in the early stages of
diabetic retinal disease.
Pericyte damage has also been reported as one of the earliest findings in diabetic
retinal disease since the introduction of retinal digest studies [7]. However, pericyte
damage may be more prominent just because it is more readily detectable than endothe-
lial cell damage, because the pericytes are encased in basement membrane and thus less
Clinical Phenotypes of Diabetic Retinopathy 55
accessible to the clearing effect of blood flow, whereas dying endothelial cells slough off
into the capillary lumen and are rapidly cleared by the blood stream.
The simplest paradigm that explains the initial retinal microvascular changes in diabetes,
capillary hyperpermeability, and capillary closure is damage to the vascular endothelium.
In the retina, endothelial cells are the site of the BRB, a specific blood–tissue barrier, and,
as in all vessels, provide a nonthrombogenic surface for blood flow. Both these properties
are compromised by diabetes from the initial stages of diabetic retinal disease.
In addition, diabetes also affects the neural and glial cells of the retina. Consequently,
we have an initial pathological picture characterized by endothelial and pericyte altera-
tions associated with basement membrane thickening and MA formation, together with
retinal tissue changes.
These alterations when seen as a whole are characteristic for NPDR, particularly the
alteration of the BRB, the pericyte damage, and the MA formation, but they also occur
in a variety of retinal diseases unrelated to diabetes. There is clear site specificity, not
disease specificity [2].
Which are then the features of the retinal circulation which are specific to the retina
and may be responsible for the site specificity of diabetic retinopathy? They are the BRB
and the autoregulation of retinal blood flow. Both serve the needs of the neuronal and
glial cells of the retina.
An abnormality of the BRB, demonstrated both by vitreous fluorometry and fluores-
cein angiography, has repeatedly been demonstrated to be an early finding both in human
and in experimental diabetes [6, 8, 9]. Loss of retinal blood flow autoregulation contrib-
utes to capillary closure that ultimately leads to retinal ischemia and to one of the two
major complications of diabetic retinal disease, proliferative retinopathy, which causes
the most tragic outcomes: vitreous hemorrhage, rubeosis iridis, retinal detachment, etc.
It is becoming apparent that at least three processes can contribute to retinal capillary
occlusion and obliteration in diabetes: proinflammatory changes, microthrombosis, and
apoptosis [10].
MA FORMATION AND DISAPPEARANCE RATES

MA and hemorrhages are the initial changes seen on ophthalmoscopic examination
and fundus photography (FP). MA counting has been suggested as an appropriate marker
of retinopathy progression [11, 12].
It must be realized that MA formation and disappearance are dynamic processes.
During a 2-year follow-up of 24 type 1 diabetics with mild background diabetic retin-
opathy using fluorescein angiography, Hellstedt and Immonen [13] observed 395 new
MA and the disappearance of 258 previously identified.
Generally, the disappearance of an MA is not a reversible process and indicates vessel clo-
sure and progressive vascular damage. Therefore, to assess progression of retinopathy, MA
counting should take into account every newly developed MA identified in a new location.
We have developed software for MA counting in fundus-digitized images where the
location of each MA is taken into account and registered [14]. In a follow-up study
with repeated fundus images obtained at regular intervals, all MAs in the fundus were
counted and added as they became visible in new locations in the retina. The results of
MA counting using this method, in a 2-year follow-up study of a series of eyes with
56 Cunha-Vaz et al.
Fig. 1. Microaneurysm analysis.
mild nonproliferative retinopathy in subjects with type 2 diabetes, maintaining a stable

metabolic control during the period of the study, suggested that MA counting may be a
good marker of disease progression in the initial stages of NPDR [15].
In order to improve the identification and counting of MA on color fundus images,
the software included algorithms for eye movement compensation, color correction, and
identification of each MA by its coordinates.
Using the software’s ability to identify each MA as a single entity, in a specific loca-
tion with identifiable coordinates, the following parameters were assessed: cumulative
number of MA, MA formation rate, and MA disappearance rate.
In a study involving 50 eyes/patients over a period of 2 years, with examinations per-
formed every 6 months, using the traditional procedure, the total amount of MA detected
at every visit remained stable. However, using the software to identify MA location, the
cumulative number of MA rose from 115 at the first visit to 505 at the last visit, showing
a marked increase in new MA. It is now obvious that there were many more new MA
in the fundus in this 2-year time period than expected using data for each examination
separately.
One of the advantages of the method used is the ability to count the number of real
new MA appearing at every visit (MA formation rate) (Fig. 1). The rate of formation
(MA/year) ranged from 0 to 22. The results showed that eyes in the same retinopathy
stage from different patients show very different MA formation rates. Values for MA
formation rate higher than 3 MAs/year correlated well with increased fluorescein leak-
age measured by vitreous fluorometry and capillary closure identified by a damaged
foveal avascular zone (FAZ), demonstrating a direct correlation with faster retinopathy
progression [16].
The MA disappearance rate ranged from 0 to 16 MAs/year. MA disappearance

rates also varied quite markedly in eyes from different patients and showed similar
correlations.
MA formation represents particularly well diabetic retinopathy because MAs are
associated with localized proliferation of endothelial cells, loss of pericytes, and altera-
tions of the capillary basement membrane, alterations that occur in the initial stages of
diabetic retinal disease and have been considered to be directly involved in its patho-
physiology [2, 17, 18].
MA closure and their disappearance are most probably due to thrombotic phenomena
leading to subsequent rerouting of capillary blood flow and progressive remodeling of
the retinal vasculature in diabetes [19]. These thrombotic changes are probably enhanced
by changes in the red and white cells occurring as a result of diabetes.
MA counting on fundus photographs and MA counting on fluorescein angiography
have been proposed as predictive indicators of progression of diabetic retinopathy [20,
21]. The software developed by our research group allows the identification of the exact
location of each MA in successive fundus photographs performed in each eye. The iden-
tification of the exact location of an individual MA is considered particularly important
because a new MA is considered to develop only once in a specific location, its disap-
pearance being generally associated with capillary closure, leaving in its place mainly
remnants of basement membrane [2, 18].
Our studies demonstrated a steady turnover of MAs in the diabetic retina, even in the
initial stages of retinopathy. In fact, most MAs show a lifetime of less than 1 year, with
new ones being formed and disappearing at rates which vary between different patients,
confirming previous reports [22].
Most interestingly, however, is the observation that some patients show much higher
rates of MA formation and disappearance, suggesting that they may represent specific
phenotypes of diabetic retinopathy. These eyes showed also faster progression in other
retinal lesions, with increased fluorescein leakage, i.e., alterations of BRB, and progres-
sion in capillary closure.
Using this new methodology, we have recently analyzed data from a group of 113
type 2 diabetic patients with mild-to-moderate NPDR, followed up for 2 years as con-
trols in diabetic retinopathy clinical trials, and thereafter, by usual care at the same insti-
tution for a period of 10 years [23].
MA turnover from the initial 2 years was correlated with the occurrence of CSME
during the following 8 years.
Patients were maintained under acceptable metabolic control during this period, and
underwent ophthalmological examinations (including color fundus photography) every
month.
At baseline, all patients showed mild-to-moderate retinopathy and were classified
as levels 20 (MA only) or 35 (MA/hemorrhages and/or hard exudates) according to the
Early Treatment of Diabetic Retinopathy Study (ETDRS) grading scale.
At the end of the 10-year follow-up period, 17 out of the 113 patients developed
CSME needing photocoagulation.
When counting the total number of MA over the first 2 years of the follow-up, a sig-
nificant increase in the number of MA was found for the CSME eyes ( p = 0.002), while
for the non-CSME eyes, the number of MA remained relatively constant ( p = 0.647).
58 Cunha-Vaz et al.
Fig. 2. Boxplot for the microaneurysm formation rate for clinically significant macular
edema (CSME) and non-CSME eyes, and number of eyes for the different values of the micro-
aneurysm formation rate.
When computing the MA turnover for the same period of time, a higher MA turnover
was found in the group of patients/eyes that developed CSME (higher MA formation
and disappearance rates). Formation and disappearance rates of 9.2 ± 18.2 and 7.5 ± 16.6
MAs/year, respectively, were found for the eyes that developed CSME, while rates of
0.5 ± 1.2 and 0.5 ± 1.2 MAs/year were found for the non-CSME eyes ( p < 0.001).
A MA turnover of at least 2 MAs/year was found in 12 of the 17 eyes that developed
CSME (70.6%), whereas this was only found in 8 of the 96 eyes that did not develop
CSME during the 10-year follow-up period (8.3%) (Fig. 2).
This study shows that in the initial stages of diabetic retinopathy, higher MA counts
and MA turnover obtained from color fundus photography are good indicators of retin-
opathy progression and development of CSME needing photocoagulation.
We also found that MA turnover is more reliable than simple MA counts and that
there was much better agreement between graders when determining MA turnover than
MA counts.
Recently, Sharp et al. [24] found that the MA turnover varied widely between eyes of
the same retinopathy level. This is also consistent with our findings. MA turnover has
been shown in this study to vary between patients that were classified with the same
retinopathy level. Particularly relevant is the finding that the patients who have higher
MA turnover values are the ones that go on to develop CSME within a period of 10 years
and show a more rapid retinopathy progression, particularly in association with poor
metabolic control demonstrated by higher HbA1C values.
It appears that it is possible to use MA turnover computed from noninvasive color

fundus photographs as a biomarker to identify eyes/patients at risk of progression to
CSME.
ALTERATION OF THE BLOOD–RETINAL BARRIER

Fluorescein angiography confirmed most of what was known of the initial pathologi-
cal picture of diabetic retinopathy and showed in the initial stages of the disease focal
leaks of fluorescein, demonstrating, in a clinical setting, the existence of focal break-
downs of the BRB.
In 1975, vitreous fluorometry, a clinical quantitative method for the study of the
BRB, was introduced by our group [6], showing that an alteration of the BRB could
be detected and measured in some diabetic eyes presenting clinically normal fundi.
These results were confirmed by Waltman et al. [9] and demonstrated that breakdown
of the BRB plays an important initiating role in the development of the diabetic
retinopathy.
One major limitation of the available commercial instrumentation for vitreous fluor-
ometry was associated with the fact that the permeability of the BRB is measured as an
average over the posterior pole. Accurate mapping of localized changes in the perme-
ability of the BRB would be beneficial for early diagnosis, to explain the natural history
of retinal disease, and to predict its effect on visual acuity.
We have recently developed a new method of retinal leakage mapping, the retinal
leakage analyzer (RLA), which is capable of measuring localized changes in fluores-
cein leakage across the BRB while simultaneously imaging the retina (Fig. 3). The
instrument is based on a confocal scanning laser ophthalmoscope that was modified
into a confocal scanning laser fluorometer [25]. Two types of information are obtained
simultaneously, distribution of fluorescein concentration (retina and vitreous) and
Fig. 3. Macula from a patient with diabetes type 2. Fluorescein angiography obtained by
scanning laser ophthalmoscope (left). Retinal leakage analyzer (RLA) blood–retinal barrier
(BRB) permeability map (RLmap) in a false color-code map (right).
60 Cunha-Vaz et al.
morphology of the eye fundus. This simultaneous acquisition is crucial because it

allows a direct correlation to be established between the maps of permeability and the
morphological information.
RETINAL CAPILLARY CLOSURE

Retinal ischemia due to vascular closure develops relatively early in the course of
diabetic retinopathy and is attributed to changes in vascular autoregulation and micro-
thrombosis formation. Retinal blood flow changes are considered to lead to the develop-
ment of poor perfusion facilitating microthrombosis formation [19].
Alterations in retinal blood flow have been identified in the different stages of the pro-
gression of retinopathy, but a major problem associated with these measurements is their
technical complexity and variability. Our observations indicate that in some diabetic
eyes, even before the development of visible retinopathy, there is (probably due to local
factors) a marked increase in retinal capillary blood flow with maximal utilization of the
retinal capillary net, whereas other eyes do not show this circulatory response, suggest-
ing individual variations in the response to the altered metabolic status. This increase
in retinal blood flow may contribute to localize endothelial damage and establish the
appropriate conditions for microthrombosis formation.
NEURONAL AND GLIAL CELL CHANGES: RETINAL

THICKNESS MEASUREMENTS
We have stated previously that the simplest paradigm to explain increased capillary
permeability and the advent of capillary closure centers on vascular endothelial damage.
There are, however, a number of reports showing changes in the neuronal and glial cells
of the retina in diabetes very early in the course of the disease [26]. This is clearly of
major potential importance, and it may indicate at least a contributory role in the devel-
opment of the microangiopathy.
Recent evidence suggests that retinal glial and Muller cells, in particular, are affected
early in the course of both experimental and human diabetes.
Retinal edema is a frequent alteration occurring in the initial stages of diabetic retinal
disease. As the disease progresses, it may cause CSME, one of the two major complica-
tions of disease associated with loss of vision. Based on WESDR data, it was estimated
(as of 1993) that of approximately 7,800,000 people with diabetes, about 84,000 North
Americans would develop proliferative retinopathy and about 95,000 would develop
sight loss from macular edema over a 10-year period [11, 12].
Edema of the retina is any increase of water of the retinal tissue resulting in an increase
in its volume, i.e., because of the structural organization of the retina, an increase in its
thickness.
This increase in water content of the retinal tissue may be initially intracellular or
extracellular. In the first case, also called cytotoxic edema, there is an alteration of the
cellular ionic exchanges with an excess of Na+ inside the cell. In the second case, also
called vasogenic edema, there is predominantly extracellular accumulation of fluid
directly associated with the alteration of the BRB [27].
Fig. 4. Multimodal macula mapping of an eye with mild NPDR showing localized increases
in leakage and retinal thickness. The background represents the leakage using a false color code.
Units are × 10−7 cm/s (left). The gray areas represent increased retinal thickness (shown in white
dots on the left image) (right).
It is now possible to objectively measure retinal thickness. Optical coherence tomog-

raphy (OCT, Carl Zeiss Meditec, Dublin, CA, USA) is a powerful tool for the objective
assessment of macular edema.
Measurements of retinal thickness show that localized areas of retinal edema are
a frequent finding in the diabetic retina in the initial stages of NPDR in subjects with
diabetes type 2 and allow to follow its progression to CSME.
MULTIMODAL MACULA MAPPING

The initial changes occurring in the diabetic retina involve the macula, and an altera-
tion of the macula will, sooner or later, affect visual acuity.
There are a variety of diagnostic tools and techniques to examine the macular region
and to obtain information on its structure and function. The different methods available
offer different perspectives and fragmentary information. It has been our objective, in
recent years, to combine different methodologies and to obtain maps of the alterations
occurring in the macular region of the retina (Fig. 4).
Our research group has been developing methods to combine and integrate data from
fundus photography, angiographic images (scanning laser ophthalmoscope–fluorescein
angiography), maps of fluorescein leakage into the vitreous (scanning laser ophthalmo-
scope–retinal leakage analyzer), and maps of retinal thickness of the macular area to
achieve multimodal macula mapping [25, 28, 29].
CLINICAL RETINOPATHY PHENOTYPES

It is well recognized that duration of diabetes and level of metabolic control are
important risk factors for development of diabetic retinopathy.
However, these risk factors do not explain the great variability that characterizes the
evolution and rate of progression of the retinopathy in different diabetic individuals.
There is clearly great individual variation in the course of diabetic retinopathy.
62 Cunha-Vaz et al.
There are many diabetic patients who after many years with diabetes never develop
sight-threatening retinal changes and maintain good visual acuity. There are also other
patients that after only a few years of diabetes show a retinopathy that progresses rapidly
developing one of the two major complications.
To characterize the clinical picture and progression of the retinal changes in the ini-
tial stages of NPDR, we performed a prospective 3-year follow-up study of the macular
region, in 14 patients with type 2 diabetes mellitus and mild nonproliferative retinopa-
thy, using multimodal macula mapping combining data from fundus photography, fluo-
rescein angiography, retinal leakage analysis, and retinal thickness measurements [30].
In a span of 3 years, eyes with minimal changes at the start of the study (levels 20 and
35 of ETDRS-Wisconsin grading) were followed at 6-month intervals in order to moni-
tor progression of the retinal changes.
The most frequent alterations observed were, by decreasing order of frequency MA,
leaking sites on the RLA and areas of increased retinal thickness.
Increased rates of MA formation were found in eyes that showed more MA at base-
line and higher values of BRB permeability during the study.
RLA-leaking sites were a very frequent finding and reached very high BRB perme-
ability values in some eyes. These sites of alteration of the BRB, well identified in RLA
maps, maintained, in most cases, the same location on successive examinations, but their
BRB permeability values fluctuated greatly between examinations, indicating revers-
ibility of this alteration.
There was, in general, a correlation between the BRB permeability values and the
changes in HbA1C levels occurring in each patient. This correlation was particularly
clear when looking at eyes that showed, at some time during the follow-up period, BRB
permeability values within the normal range. A return to normal levels of BRB perme-
ability was, in this study and in each patient, always associated with a stabilization or
decrease in HbA1C values.
Areas of increased retinal thickness were another frequent finding in these eyes. They
were present in every eye at some time during the follow-up and were absent, at base-
line, in only 2 of the 14 eyes. This confirms previous observations by our group [25] and
by others [31]. However, the areas of increased retinal thickness varied in their location
over subsequent examinations and did not correlate with changes in HbA1C levels. They
may represent a delayed response in time to other changes occurring in the retina, such
as increased leakage [25]. They certainly represent in most cases zones of extracellular
edema, an interpretation supported by the frequent shift observed in their location in
subsequent examinations.
Multimodal imaging of the macula made apparent three major evolving patterns
occurring during the follow-up period of 3 years: Pattern A includes eyes with a slow
rate of MA formation, relatively little abnormal fluorescein leakage, and a normal FAZ.
This group appears to represent eyes presenting slowly progressing retinal disease.
Pattern B includes eyes with persistently high leakage values, indicating an important
alteration of the BRB, high rates of MA formation, and a normal FAZ. All these features
suggest a more rapid and progressive form of the disease. This group appears to identify
a “wet” form of diabetic retinopathy. Pattern C includes eyes with high rates of MA
formation and disappearance, variable leakage, and an abnormal FAZ. This group is less
Fig. 5. Multimodal images from three different patients, at yearly intervals, showing for each
visit the foveal avascular zone (FAZ) contour, RLA results, and retinal thickness analyzer results.
(A) Pattern A. Note the little amount of retinal leakage over the four represented visits and the
normal FAZ contour. This patient showed a slow rate of microaneurysm formation. (B) Pattern B.
Note the high retinal leakage showing a certain degree of reversibility and the normal FAZ con-
tour. This patient showed a high rate of microaneurysm accumulation over the 3-year follow-up
period. (C) Pattern C. Note the reversible retinal leakage and the development of an abnormal
FAZ contour. This patient showed a high rate of microaneurysm formation.
well characterized considering the small number of eyes that showed an abnormal FAZ.
It may be that abnormalities of the FAZ may occur as a late development of groups A
and B or progress rapidly as a specific “ischemic” form (Fig. 5).
We have now extended our observations after following for 2 years 59 patients with
diabetes type 2 and mild NPDR. In this larger study, these three different phenotypes
were again clearly identified. The discriminative markers of these phenotypes were MA
formation and disappearance rates, degree of fluorescein leakage, and signs of capillary
closure in the capillaries surrounding the FAZ [23].
It must be realized that levels of hyperglycemia and duration of diabetes, i.e., expo-
sure to hyperglycemia, are expected to influence the evolution and rate of progression
tentatively classified in these three major patterns.
If diabetic retinopathy is a multifactorial disease—in the sense that different fac-
tors or different pathways may predominate in different groups of cases with diabetic
retinopathy—then it is crucial that these differences and the different phenotypes are
identified.
64 Cunha-Vaz et al.
Diabetes mellitus is a familial metabolic disorder with strong genetic and environ-
mental etiology. Familial aggregation is more common in type 2 than in type 1 diabetes.
Rema et al. [32] reported that familial clustering of diabetic retinopathy was 3 times
higher in siblings of type 2 subjects with diabetic retinopathy. Presence or absence of
genetic factors may play a fundamental role in determining specific pathways of vas-
cular disease and, as a consequence, different progression patterns of diabetic retinal
disease. It could be that certain polymorphisms would make the retinal circulation more
susceptible to an early breakdown of the BRB (pattern B) or microthrombosis and cap-
illary closure (pattern C). The absence of these specific genetic polymorphisms would
lead to an evolving pattern of pattern A.
It is clear from this study and from previous large studies such as DCCT [33]
and UKPDS [34] that hyperglycemia plays a determinant role in the progression of
retinopathy. It is interesting to note that HbA1C levels are also largely genetically
determined [35].
An interesting perspective of our observations, analyzed under the light of availa-
ble literature, depicts diabetic retinopathy as a microvascular complication of diabetes
mellitus conditioned in its progression and prognosis by a variety of different genetic
polymorphisms and modulated in its evolution by HbA1C levels, partly genetically deter-
mined and partly dependent on individual diabetes management. The interplay of these
multiple factors and the duration of this interplay would finally characterize different
clinical pictures or phenotypes of diabetic retinopathy.
RELEVANCE FOR CLINICAL TRIAL DESIGN

It is crucial in order to design an appropriate clinical trial to test the efficacy of a drug,
to identify not only the meaningful clinical endpoints but also the surrogate endpoints
that may demonstrate efficacy of a drug in a realistic and feasible period of time [36].
It is clear that such process implies the validation of surrogate endpoints by the asso-
ciated occurrence of hard clinical outcomes such as significant visual loss. It is here that
the problem lies. Diabetic retinopathy progresses to irreversible stages of the disease
with relatively little visual loss, and when macular edema or proliferative retinopathy is
present, it becomes ethically mandatory to perform photocoagulation treatment.
The development of an effective drug must take into account the need to demonstrate
efficacy on the earliest and reversible stages of diabetic retinal disease by demonstrating
its effect on surrogate endpoints which can be followed for shorter periods of time. The
assumption would be that those surrogate endpoints would ultimately be validated by
association with more hard clinical outcomes.
It is therefore an urgent priority to identify endpoints which can be accepted as sur-
rogates and be validated in longer natural history studies.
The candidates for surrogate endpoints in the initial stages of the retinal disease are
not many: mean differences on the ETDRS retinopathy scale, reduction in fluorescein
leakage, reduction in macular thickening, and microaneurysm turnover.
The problem of using the ETDRS retinopathy scale lies in the fact that in the initial
stages of the retinopathy, even a two-step eye change means that we have to wait for an
important worsening of the retinopathy and the presence of irreversible changes.
The second possibility, reduction in fluorescein leakage, evaluates one of the two
main factors in the progression of the retinopathy, the alteration of the BRB permeabil-
ity. It has, however, a major drawback; it involves intravenous fluorescein administration
and is technically difficult.
The third candidate, reduction in macular thickening by measuring the mean change
with dedicated instrumentation, has been shown to correlate poorly with visual acuity
loss, and changes in retinal thickness do not necessarily correlate with progression of
the retinopathy [29].
Finally, the fourth possibility, calculation of MA turnover from fundus photographs,
taking into account every new MA according to their specific location in the eye fundus
is noninvasive and has the potential to become an extremely informative marker of the
overall progression of diabetic retinal vascular disease. By calculating MA turnover on
digital fundus images, using appropriate software to identify the specific location of
each MA, we may be able to measure the rate of progression of diabetic vascular retinal
disease [23]. Our studies suggest that MA turnover may contribute decisively to design
feasible clinical trials to test the efficacy of new drugs.
Another fundamental step in this procedure is the characterization of the different
phenotypes of diabetic retinal disease.
The design of future clinical trials should consider only groups of patients character-
ized by their homogeneity: patients presenting a specific retinopathy phenotype (wet/
leaky or ischemic), with similar duration of diabetes and at similar levels of blood pres-
sure and metabolic control (HbA1C values). Patients that have retinopathy characterized
by low progression with low values of MA turnover, which are the majority, should not
be included in relatively short-term clinical trials.
RELEVANCE FOR CLINICAL MANAGEMENT

It is accepted that in the initial stages of diabetic retinopathy when the fundus altera-
tions detected by ophthalmoscopy or slit-lamp examination are limited to MA, hemor-
rhages and hard or soft exudates, i.e., mild or NPDR, an annual examination is indicated
to every patient with 5 or more years of duration of their diabetes. This is the recom-
mendation of the American Academy of Ophthalmology Guidelines for Diabetic Retin-
opathy [37].
Our observations and the identification of different diabetic retinopathy phenotypes
in the initial stages of diabetic retinopathy, i.e., mild or moderate NPDR, character-
ized by different rates of progression of the retinopathy suggest that specific approaches
should be used when managing these different retinopathy phenotypes.
A patient with mild or moderate NPDR, presenting retinopathy phenotype B (wet/
leaky), characterized by marked breakdown of the BRB, identified by high MA forma-
tion rates and increased values of fluorescein leakage into the vitreous, registered during
a period of 1–2 years of follow-up, and indicating rapid retinopathy progression, should
be watched more closely and examined at least at 6-month intervals. Furthermore, blood
pressure values and metabolic control should be closely monitored at least at 3-month
intervals and paying close attention to HbA1C levels. Communication channels should be
rapidly established between ophthalmologist and their diabetologist, internist, or general
66 Cunha-Vaz et al.
health care provider. Information should be given indicating that the chances of rapid
retinopathy progression to more advanced stages of disease are in these patients rela-
tively high, calling for immediate tighter control of both glycemia and blood pressure.
A patient with mild or moderate NPDR presenting retinopathy phenotype C, ischemic,
characterized by high MA formation and disappearance rates and signs of capillary clo-
sure would similarly indicate the need for shorter observation intervals than 1 year with
particular attention for other systemic signs of microthrombosis. Here, however, control
of hyperglycemia and blood pressure must be addressed with some degree of caution.
Improved metabolic and blood pressure control must be progressive and less aggressive
than with phenotype B. It is realized that the ischemia that characterizes phenotype C
may become even more apparent in eyes submitted to rapid changes in metabolic con-
trol, and lowering rapidly the blood pressure may increase the retinal damage associated
with ischemia.
Finally, a patient with mild or moderate NPDR, presenting phenotype A, identified
by low levels of fluorescein leakage, no signs of capillary closure, low MA formation
rates, and with a diabetes duration of more than 10 years, all signs indicating a slowly
progression subtype of diabetic retinopathy, may be followed at intervals longer than
1 year. If the examination performed at 2-year intervals confirms the initial pheno-
type characterization, the patient and his diabetologist, internist, or general health care
provider should be informed of the good prognosis associated with this retinopathy
phenotype.
TARGETED TREATMENTS
It would be of great benefit to have a drug available which would prevent the need for
destructive photocoagulation of the retina. Furthermore, many diabetic patients are not
well controlled, they do not come to the doctor often, and they become blind because
they do not get medical attention in time for photocoagulation.
The major large clinical trials have shown that tight glycemic control slows the devel-
opment and progression of diabetic retinopathy. But the constantly increasing incidence
of type 2 diabetes and the evidence that retinal damage begins early on underscore the
need for a medical treatment that is targeted to the initial retinal alterations.
Several key pathways have been incriminated in the process of triggering diabetic
retinal disease, and they may play specific roles in the development of specific retin-
opathy phenotypes. Four candidates, the polyol pathway, nonenzymatic glycosylation,
growth factors, and protein kinase C, may be playing leading roles in the development
of diabetic retinal disease.
It is possible that all these different mechanisms of disease play complementary roles
in the progression of diabetic retinal disease.
The identification of different retinopathy phenotypes characterized by different rates
of progression and different dominant retinal alterations may indicate that different dis-
ease processes predominate in specific retinopathy phenotypes.
Identification of well-defined retinopathy phenotypes may be an essential step in the
quest for a successful treatment of diabetic retinopathy. After the characterization of
specific retinopathy phenotypes, the predominant disease mechanisms involved may be

identified, and drugs directly targeted at the correction of these disease mechanisms may
be used with greater chances of success.
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6
Visual Psychophysics in Diabetic Retinopathy
Edoardo Midena and Stela Vujosevic
CONTENTS
Introduction
Visual Acuity
Color Vision
Contrast Sensitivity
Macular Recovery Function (Nyctometry)
Perimetry
Microperimetry (Fundus-Related Perimetry)
Conclusion
References
Keywords Visual acuity • Snellen chart • Color vision dysfunction • Contrast sensitivity
• Macular recovery function • Perimetry
INTRODUCTION
Irreversible and severe visual loss may represent the end of long lasting diabetic retin-
opathy. The progression of visual impairment and the quantification of final residual
visual function are currently determined by means of diagnostic tests which rely on the
physiological and mathematical principles of psychophysics. The best known among
these tests is the quantification of visual acuity: a classic visual function psychophysical
test. Visual psychophysical tests are the cornerstone of visual function investigation, and
any physical or pharmacological therapy for the treatment of diabetic retinopathy still has
the maintenance (or improvement) of visual function as primary endpoint. More recently,
subtle and precocious neurosensory visual abnormalities have been quantified in diabetic
patients in order to detect early visual dysfunction, even before the onset of clinically
detectable retinopathy. The aim of these investigations is to try to identify among diabetic
subjects a population at higher risk of developing vision-threatening retinopathy [1].
Psychophysics is a science which developed as a way to measure the internal sensory
and perceptual responses to external stimuli [2]. Psychophysical visual function testing

69
70 Midena and Vujosevic
may reflect the neural activity of the whole visual pathway, but it is known that these
tests are valuable clinical indicators of retinal function derangements induced by the
metabolic changes secondary to diabetes mellitus. In fact, in diabetic patients, impaired
vision in dim light and difficulties in recognizing the contour of objects in low-contrast
conditions are common complaints even with good visual acuity and full visual fields
[3]. Moreover, health-related quality of life can become affected in diabetics even prior
to vision loss due to anxiety about the future and emotional reaction to diagnosis and
treatment of retinopathy [4].
Visual acuity is still considered the gold standard in clinical practice of vision testing,
but it does not entirely reflect functional vision. Functional vision describes the impact
of sight on quality of life that represents the patient’s point of view [5, 6]. This approach
is better quantified using available psychophysical tests (visual acuity, color vision, con-
trast sensitivity, macular recovery function, perimetry, and microperimetry).
VISUAL ACUITY
The quantification of visual acuity (VA) is the best known and most widely used test
for assessing the integrity of the visual function in clinical settings. It represents the
ability to discriminate, at high contrast (black symbols/letters on a white background),
two separated stimuli. The Snellen chart is the most widely used tool for VA assessment,
and it is routinely used in any clinical setting worldwide. The prototype of this chart
was developed in 1862 by the Dutch ophthalmologist Hermann Snellen. He defined
“standard vision” as the ability to recognize one of his optotypes at a visual angle of
1 min of arc. Later, the original chart was modified and became what is now known as
a standard Snellen chart. This chart has well-documented limits owing to design flaws,
such as inconsistent progression of letter size from one line to another, unequal legibility
of letters used, unequal and unrelated spacing between letters and rows, and large gaps
between acuity levels at the lower end of the chart [7–10]. Variability in background
ambient illumination and contrast and poor reliability during test–retest evaluation
make, in some cases, Snellen measurements clinically inadequate and prevent reliable
evaluation of data obtained from different studies [11–13].
Therefore, new and standardized charts with logMAR (logarithm of the minimal angle
of resolution) progression have been developed and introduced into clinical practice,
based on design suggested by Bailey and Lovie in 1976, lately described in detail by
Ferris et al., and adopted for the Early Treatment Diabetic Retinopathy Study (ETDRS
chart) [14, 15]. The major advantages of this chart are regular geometric progression
of the size and spacing of the letters, following a logarithmic scale with 0.1 log units
steps, equal number of letters in each row, five Sloan optotypes, comparable legibility
of the sans serif letters, high accuracy, and reliability for both high and low levels of VA
[14–17]. Thus, the ETDRS chart has become the gold standard for measuring VA at least
in clinical trials.
In diabetic patients, the full functional impact of macular edema (diabetic macular
edema, DME) and the functional effects of its treatment on visual function are still
poorly documented and understood [18]. Ang et al. found that VA was a poor predictor
of presentation and type of DME and that its usefulness as a sole screening tool is lim-
ited [19]. On the contrary, Sakata et al. [20] reported a correlation of VA with macular
Visual Psychophysics in Diabetic Retinopathy 71
microcirculation characteristics (perifoveal capillary blood flow velocity and severity of

perifoveal capillary occlusion) and central foveal retinal thickness in diabetics.
Since the ETDRS study demonstrated that focal macular laser photocoagulation
prevents moderate vision loss in approximately 50% of cases, visual acuity has been
considered the primary endpoint in all clinical trials evaluating both the natural his-
tory as well as the efficacy of any treatment strategy in clinically significant diabetic
macular edema (CSME) [21–26]. But in clinical practice, DME is currently assessed
not only with VA but also with optical coherence tomography (OCT), a retinal structure
test. Therefore, the correlation between these two investigations, one functional and one
structural, has been widely, even if not definitively, investigated. Recently, the Diabetic
Retinopathy Clinical Research Network reported only modest correlation between VA
and OCT-measured center point retinal thickness with a possible wide range of VA for a
given degree of retinal edema. These authors also found modest correlation of changes
in retinal thickening and VA after focal laser treatment for DME [27]. Browning et al.
[28] found no correlation between the extension of DME by OCT and changes of VA
after laser photocoagulation, during 12 months follow-up. These results suggest that
OCT measurement alone may not be a good surrogate for VA as a primary outcome in
studies of DME. Moreover, VA data needs to be integrated with more comprehensive
visual function information.
COLOR VISION
As a predominantly macular function, color discrimination may be impaired by any
degenerative process affecting the central retina [29]. In diabetes, the underlying mecha-
nism of color dysfunction is uncertain and may relate to metabolic derangement in the
neural retina other than to microvascular disease [30]. Several hypotheses have been
proposed such as (a) osmotic distortion of the retina caused by the fluid shifts inside
the retina, followed by distortion and dysfunction of the neural cells and (b) disorders
of metabolisms of neural cells caused by direct diabetes damage or mediated by the
alterations of the retinal microcirculation [31–35]. Dean et al. [36] suggested a major
role of retinal hypoxia showing that color vision deficits in diabetics with retinopathy
can be partially reversed by inhalation of pure oxygen. Different tests are available to
assess color vision; unfortunately, most of them are negatively affected by lens opacities
[37]. Moreover, approximately 10% of male population and 0.5% of female population
show varying degree of congenital color deficiency. Therefore, studies evaluating color
vision in diabetics should account for all these factors. One of the most widely known
and reported test is the Farnsworth–Munsell 100-Hue Test (FM 100 Hue Test); this is
also the most time-consuming diagnostic procedure [38].
Since the first report (in 1905) describing the association between abnormalities
in color vision and diabetes mellitus, many researchers have reported the relationship
between diabetic retinopathy and color vision dysfunction [39–43]. The first control-
led study of color vision in diabetics was reported by Kinnear et al. [44] and Lakowski
et al. [29] who showed in a large group of subjects that blue-yellow and blue-green
color vision losses were found significantly more among diabetic patients with retin-
opathy than in normal controls. Other studies confirmed that the blue-yellow axis
(the short-wavelength-sensitive cone system) is more vulnerable to diabetes than the

green and the red axes [45, 46]. But this conclusion is not unanimously accepted. Hue
discrimination in diabetics without retinopathy or with only microaneurysms has been
reported not to significantly differ from controls, whereas other studies concluded that
diabetics show abnormal results in color vision tests and a tritanopic reduction in a
chromatic-contrast threshold when compared with normal controls [47–50] (Table 1).
Different studies showed deficits in blue-yellow color discrimination in both adults
and adolescents with type 1 diabetes mellitus who had no evidence of retinopathy [41,
44, 51–60]. Hardy et al. [61] found in young patients with insulin-dependent diabetes
mellitus (IDDM) that FM 100 Hue Test was more sensitive and specific in detecting
dysfunction of the visual pathway than both flash and pattern electroretinogram, and
proposed this test for the early visual dysfunction evaluation without success. In the
ETDRS, the FM 100 Hue Test was performed in 2,701 patients and showed abnormal
hue discrimination in approximately 50% of cases when compared with published data
on normal subjects [62]. Macular edema severity, age, and the presence of new vessels
were the factors most strongly associated with impaired color discrimination, especially
the tritan-like defect [62].
Green et al. [63] examined the FM 100 Hue Test as a screening device for sight-
threatening diabetic retinopathy and reported sensitivity of 73% and specificity of 66%,
concluding that the test was not sensitive enough for screening of sight-threatening dia-
betic retinopathy. In a similar study, Bresnick et al. [41] reported sensitivity of 65% and
specificity of 59%. Therefore, new color vision tests have been proposed and evalu-
ated. The Mollon–Reffin “Minimalist” test showed sensitivity of 88.9% and specificity
of 93.3% in detecting DME [64]. An automated tritan contrast threshold showed 94%
sensitivity and 95% specificity in screening for sight-threatening diabetic retinopathy,
mainly for DME before the onset of visual loss [65, 66]. Although more advanced stages
of retinopathy and DME show greater effect on color vision, subtle specific spectral
losses, especially related to blue-yellow discrimination, seem widespread in patients
with diabetes, irrespective of the presence of retinopathy and duration of diabetes. More-
over, decreased hue discrimination is present after successful panretinal laser photoco-
agulation for proliferative DR [67]. These data are also confirmed by studies on contrast
sensitivity, and they should be considered in the evaluation and counseling of patients
with diabetic retinopathy.
CONTRAST SENSITIVITY
Perhaps the chief merit of the human contrast sensitivity function is that it provides
considerably more information than visual acuity: The contrast sensitivity function is
a description of the visual system’s sensitivity to course-scale detail and medium-scale
detail as well to fine detail, while visual acuity quantifies sensitivity to fine detail only.
For any given spatial frequency, contrast sensitivity is the reciprocal of contrast detec-
tion threshold. The contrast sensitivity function is a plot of the reciprocal of the contrast
detection threshold for a grating vs. the spatial frequency of that grating. Contrast sensi-
tivity (CS) function may be quantified using different laboratory and clinical tests [68].
CS determines the person’s contrast detection threshold, the lowest contrast at which
Table 1. Studies which have investigated color vision in patients with diabetic retinopathy
Principal
investigator/
year of Types Age in years:
publication of study Sample size mean/range DR status and VA Nature of stimulus Conclusions
Roy et al. [54] Case-control 12 Pts (23 45.33 (36–56) 7-Mild Farnsworth–Munsell There was significant difference
eyes) 5-Moderate 100-Hue Test (FM between mild and moderate group
retinopathy 100 Hue Test) in CV defects; but there was not
More than 25 years significant difference from normal
of diabetes subjects’ CV
VA: 20/20
Bresnick et al. Case-control Cases-90 pts Median: 36 12-No/mild/ FM 100 Hue Test Tritanlike axis was comparable with
[41] (and eyes) (19–68) moderate DR scores of normal population;
Controls- 29-Severe DR yellow-blue hue discrimination
published 49-PDR defect correlated significantly
age norms VA: – with severity of retinopathy and
data maculopathy, and with fluorescein
leakage in the macula
Green et al. Case-control Cases-126 pts – 115 (eyes)-No DR FM 100 Hue Test CV deteriorated with increasing
[63] (small (232 eyes) 55-bDR severity of diabetic retinopathy
number of Controls-16 42-PDR
controls) subjects 20-Exudative
(18 eyes) maculopathy
VA: –
Roy et al. [37] Case-control Cases-51 pts Cases: Mild retinopathy Lanthony desaturated Diabetic pts showed significantly
(95 eyes) 37.0 ± 10.5 (only five or fewer D-15 test more CV defects than controls on
Controls-41 Controls: microaneurysms) FM 100 Hue Test all three tests. Among diabetic pts
pts (81 33.9 ± 11.8 VA: 20/20 Gunkel no significant differences were
eyes) chromograph test found correlating to age, dura-
tion of diabetes or glycosylated
hemoglobin
(continued)
Table 1. (continued)
Principal
investigator/
year of Types Age in years:
publication of study Sample size mean/range DR status and VA Nature of stimulus Conclusions
Greenstein Case-control Cases-24 pts Cases: 45.8 From no DR to FM 100 Hue Test No correlation was found between
et al. [95] and eyes (24–68) severe NPDR; + Two-color increment Farnsworth’s result and levels
Controls-age- from no macular threshold test of DR; S-cone pathway, meas-
similar edema to center ured by Two-Color Increment
normal involving edema Threshold Test showed significant
data from VA: 20/30 or better correlation with level of both
Verriest retinopathy and maculopathy
et al. [124]
Hardy et al. Case-control Cases-38 Cases: 26.1 No DR FM 100 Hue Test Diabetic pts had significant abnor-
[55] (pts) (16–40) VA: 6/9 or better mal results compared with normal
Controls-36 subjects; no significant correlation
was found between CV abnor-
malities and diabetes duration or
glycosylated hemoglobin values
Maár et al. Case-control Cases-10 Cases: Cases + controls: Lanthony desaturated Highly significant correlation was
[64] (pts) with 33.7 ± 7.75 12-No DR D-15 test found between the tritan value of
CSME Controls: 18-Mild DR Mollon–Reffin the Mollon test and the presence
Controls-29 28.07 ± 5.67 4-Moderate DR Minimalist test of CSME; Lanthony test did not
without 3-Severe DR version 6.0 show a significant correlation
CSME 2-PDR with presence/absence of CSME
Cases-VA:
0.07 ± 2.01
logMAR
Controls-VA:
−0.06 ± 0.17
logMAR
Giusti [60] Case-control Cases-39 pts 17.14 ± 8.2 Cases-No DR; VA: Standard SPP2 and Roth tests did not show
Controls-39 18.1 ± 3.1 1.08 ± 0.15 log- Pseudoisochromatic differences between cases
pts MAR Plates (SPP2) and controls; Farnsworth and
Controls-VA: Roth 28-Hue test Lanthony tests showed significant
1.07 ± 0.24 log- FM 100 Hue Test difference between diabetic pts
MAR Lanthony D-15 Hue and normal subjects
test
Ong et al. Cross- 510 pts: NSTDR: NSTDR: VA: Automated Tritan Sensibility of 94% and specificity
[65] sectional 493- 60.9 ± 13.9 0.06 ± 0.09 Contrast Threshold of 95% were found in detecting
study NSTDR STDR: 383 no DR (TCT) STDR; no association was found
17-STDR 60.4 ± 11.3 110 bDR between abnormal values of TCT
STDR: VA: 0.1 ± 0.11 and clinical parameters (HbA1c,
3 Pre-proliferative duration of diabetes, micro-albu-
DR minuria)
2 PDR
12 Maculopathy
Wong et al. Case-control Cases-35 (pts 60 (median) CSME (cases)-35; ChromaTest Statistically significant results were
[125] and eyes) VA: 0.20 (median) found between NPDR group and
Controls-115 NPDR (con- CSME group for both tritan and
trols)-115; VA: protan color contrast threshold;
0.20 (median) sensitivity and specificity of
ChromaTest were respectively of
71 and 70% in detecting CSME
in diabetic pts
Pts patients; VA visual acuity; DR diabetic retinopathy; NPDR non proliferative diabetic retinopathy; bDR background diabetic retinopathy; PDR pro-
liferative diabetic retinopathy; CV color vision; STDR sight-threatening diabetic retinopathy; NSTDR non sight-threatening diabetic retinopathy; CSME
clinically significant diabetic macular edema
a certain pattern can be seen. An assumption which often underlies the clinical use of
the CS function is that it predicts whether a patient is likely to have difficulty in see-
ing visual targets typical of everyday life. A contrast sensitivity assessment procedure
consists of presenting the observer with a sine-wave grating target of a given spatial
frequency (i.e., the number of sinusoidal luminance cycles per degree of visual angle).
The contrast of the target grating is then varied while the observer’s contrast detection
threshold is determined. Typically, contrast thresholds of this sort are collected using
vertically oriented sine-wave gratings varying in spatial frequency from 0.5 (very wide)
to 32 (very narrow) cycles per degree of visual angle.
Whereas standard visual acuity testing is a high-contrast test by definition and it
measures only size, it does not provide full information about visual function in the
everyday life activities. Contrast sensitivity measures the two major variables: size and
contrast, offering a more realistic quantification of visual impairment. There are differ-
ent types of chart tests to capture the different aspects of the CS function (charts with
white and black bars of decreasing contrast, charts with letters). Among them, the Pelli–
Robson chart is the most commonly used chart in clinical trials. It consists of letters of a
single (large) size (low spatial frequency). The chart is arranged by triplets of letters and
each triplet is 0.15 log units higher in contrast than the preceding triplet.
Both hue discrimination and contrast sensitivity may reflect (if the lens is clear) mac-
ular function, but their exact physiological relationship has not yet been fully explained.
Some data suggest that the CS function more significantly correlates to DR grading
than color vision and macular recovery function [69, 70]. Unfortunately, data about CS
function in diabetics are still controversial. This difference in clinical results may be,
at least methodologically, explained by the different methods used to quantify CS, as
well as the lack of homogeneity in the examined groups (type of diabetes, age, criteria,
and methods for DR evaluation). This fact points to the importance of developing a
standardized test to accurately and reliably quantify contrast sensitivity function in both
clinical practice and clinical trials. Diabetic patients with retinopathy and good visual
acuity frequently show spatial resolution defects, which can be detected measuring CS
function. The reductions in CS involve mainly the intermediate and medium-high spatial
frequencies in relation to the severity of retinopathy and previous laser photocoagula-
tion; nevertheless, some patients show losses at the medium-low spatial frequencies
[71–74]. In DME, Arend et al. [75] found that loss of CS correlates with the enlarge-
ment of the foveal vascular zone. Midena et al. [76] studied the effect of both focal and
grid laser photocoagulation on CS of patients with DME and found that CS function
improved after treatment, but it never normalized. The same finding was reported by
Talwar et al. [77] who found improved CS and stabilization of visual acuity after focal
argon laser photocoagulation for CSME.
Farahvash et al. described the early improvement of CS at midfrequencies after macu-
lar laser photocoagulation. This benefit appeared only in patients with resolved CSME,
suggesting that CS is probably a more sensitive parameter than visual acuity for early
monitoring of CSME after laser photocoagulation [78]. The significant reduction in CS
function documented in diabetics with retinopathy is not confirmed when a subject has
no retinopathy: There is still not strong evidence of significant difference in CS between
diabetics without retinopathy and normal controls. According to Arend et al., there
was no difference in CS function between diabetics without retinopathy and controls,

whereas Ghafour et al. [71], using the same test, found that diabetics without retinopathy
were abnormal at 3.2 and 6.3 c/deg. Using the Vision Contrast Test System in patients
with little or no retinopathy, Trick et al. [69] found reduced mean CS at each spatial fre-
quencies when compared to controls; however, a post hoc analysis yielded no statistical
difference between the groups. Sokol et al. studied separately insulin- and non-insulin-
dependent diabetes mellitus (IDDM and NIDDM) patients and found that patients with
IDDM and no DR had normal CS function, whereas patients with NIDDM, normal VA,
and no DR had abnormal CS at high spatial frequencies. If background retinopathy
was present, abnormal CS at all spatial frequencies was found [73]. Della Sala et al.
[72], using the Cambridge low-contrast sensitivity charts, showed abnormal CS in 9 of
22 patients without diabetic retinopathy and in only 6 of 20 patients with background
retinopathy (Table 2). Therefore, the contrast sensitivity losses in IDDM and NIDDM
patients may not be similar, and further studies are needed to substantiate this hypoth-
esis. Contrast sensitivity testing, as color vision testing, shows significant changes in
diabetics and there is some correlation with glycemic control, although prospective stud-
ies are required to assess this relationship over a longer time period. Although both tests
show similar patterns in diabetics, direct comparisons of the two tests seem to indicate
the CS function test as more sensitive and specific.
MACULAR RECOVERY FUNCTION (NYCTOMETRY)

Macular recovery function (nyctometry) is a dynamic measure of the initial 2-min
course of macular recovery function following preadaptation to a strong uniform illu-
mination of a large area of the retina. It is a standardized technique, which lasts only
6.5 min. It quantifies not only the dark adaptation of the cone system but also the mac-
ular sensitivity to glare [79]. Gliem and Schulze reported a progressive reduction in
macular recovery related to deterioration of DR [80]. Midena et al. [79] showed, in a
well-defined series of patients, that reduced nyctometry is directly and strongly related
to the progression of retinal (functional and anatomical) derangement due to diabetes
mellitus. Different authors suggested, but never definitively proved, that nyctometry can
be used to predict the progression of background DR to proliferative DR. They sug-
gested the use of nyctometry as a screening method in selecting patients at high risk for
proliferative DR [81–83]. Verrotti et al. [84] found altered nyctometry in microalbu-
minuric diabetic children vs. normoalbuminuric and normal controls. Reported values
were independent of both the level and the fluctuations of glycemia. However, Lauritzen
et al. [85] found improved performance of nyctometry in the first year in patients on a
intensive insulin regimen. In two separate studies, Andersen et al. [86] and Frost-Larsen
et al. [87] found significant improvement in macular recovery function in newly diag-
nosed juvenile diabetics after a 10-day period of superregulation in the biostator. This
indicates that in metabolic dysregulation, the results of nyctometry are reversible to a
certain extent provided the reduced values of nyctometry are mainly due to functional
changes in the retina [83].
In CSME, 1 week after macular laser photocoagulation, nyctometry was shown to
decrease significantly, followed by slow improvement toward the initial value [76].
Table 2. Studies which have investigated contrast sensitivity in patients with diabetic retinopathy
Principal
investigator/ Types Age in years:
year of publication of study Sample size mean/range DR status and VA Nature of stimulus Conclusions
Ghafour et al. [71] Case-control Cases-93 Cases-47 (27–70) 42-No DR Arden grating test Diabetic pts without DR
Controls-80 Controls-46 (24–68) 22-Background DR have increased thresh-
29-PDR olds at the higher spatial
VA: 6/5 to 6/36 frequencies. Significative
difference CS threshold
found between each
group (controls-no
DR-background-PDR)
Hyvärinen et al. Case-control Cases-19 Cases-32 (19–59) 5-Micro±hemorrhages Sinusoidal grating CS seems to correlate better
[3] Controls-from but normal vision (cathode-ray- with DR status then with
Virsu et al. (20/20) display) VA. Diabetic pts without
[127] 5-bDR DR has no significant
6-PDR reduction of CS in com-
3-PDR + central cataract parison to normal sub-
jects. In the third group
(cataract) CS was better
than expected
Regan and Neiman Case-control Cases-15 Cases-49 (24–75) 6-VA ³6/7.5 or better Regan chart Diabetic pts had significa-
[128] Controls-40 9-VA <6/7.5 tive CS loss
Sokol et al. [73] Case-control Cases-64 – 31-IDDM and no DR; Sinusoidal grating Pts with NIDDM, normal
Controls-117 VA: 20/25 or better (microproces- VA and no DR had
33-NIDDM and no sor-controlled abnormal CS at high
(n = 16) or back- video system) spatial frequencies. Pts
ground (n = 17) DR; with NIDDM and bDR
VA: 20/30 or better had abnormal CS at all
spatial frequencies. Pts
with IDDM and no DR
had normal CS
Della Sala et al. Case-control Cases-42 Cases-12–75 22-No DR Cambridge Diabetic pts showed
[72] Controls-84 Controls-14–68 19-bDR low-contrast decreased CS
1-PDR sensitivity
VA: 1.0 or better charts
Trick et al. [69] Case-control Cases-57 No DR-36.9 ± 11.1 37-No DR Vistech VCTS All diabetic pts showed
Controls-35 bDR-37.9 ± 8.6 20-bDR 6500 distance decreased CS, par-
Controls-33.3 ± 9.3 18-NIDDM chart ticularly with mid-spatial
39-IDDM frequency gratings.
VA: 20/30 or better No difference between
IDDM and NIDDM pts
Khosla et al. [129] Case-control Cases-38 eyes No DR-50.0 ± 11.8 22 (eyes)-No DR Cambridge low- Significant decreased CS in
(22 pts) bDR-47.1 ± 10.3 16-bDR contrast sensi- the retinopathy group.
Controls-20 Controls-47.2 ± 13.5 VA: 6/6 tivity charts No significant difference
eyes (10 in CS between non retin-
pts) opathy group and normal
subjects
Midena et al. [76] Prospective 30 Diabetic 55 (40–70) Minimal- to mild-bDR Arden grating test CS improved after photo-
non com- pts CSME coagulation, with a sig-
parative VA: 1.0 nificant difference after
study 3 months, but did not
reach normal values
Bangstad et al. Case-control Cases-30 pts Micro-albuminuria Micro-albuminuria Vistech VCTS Micro-albuminuric pts
[130] with micro- group: 19 (14–29) group: 6500 distance showed worse CS at
albuminuria Normo-albuminuria 12 pts-No DR chart middle and high spatial
Controls-27 group: 19 (14–24) 18 pts-bDR frequencies, but signifi-
pts with Normo-albuminuria cantly only for 18 cpd
normo- group:
albuminuria 12 pts-no DR
15 pts-bDR
(continued)
Principal
Arend et al. [75] Case-control Cases-20 pts Cases-42 ± 12 6-No DR CSV-1000 (Vector Diabetic pts had signifi-
Controls- 8-Only microaneurisms vision; Dayton, cantly lower CS at 6 and
Normal 4-Mild retinopathy OH) 12 c/deg than control
subjects 1-Severe retinopathy subjects. Foveal avascu-
from data- 1-PDR lar zone and perifoveal
base (arch VA: 20/25 or better intercapillary area cor-
ophth related significantly with
75;610) CS at 12 cpd
De Marco [131] Case-control Cases-66 Cases: No DR Conel CST auto- No difference was found
IDDM 30–10 ± 1.22 years VA: 1.0 or better matic (Roma, between diabetic aretino-
Controls-66 36–16.07 ± 2.3 ITA) (sinusoi- patic pts and controls.
years dal gratings) CS was not correlated
Controls: with sexual maturity or
30–9.93 ± 2.02 duration of diabetes
years
36–17 ± 3.16 years
Verrotti et al. Case-control Cases-40 + 20 Cases-16.9 ± 4.9 20-No DR CSV-1000 (Vector Diabetic pts showed a sig-
[132] Controls-20 Controls-16.9 ± 4.6 30-bDR vision; Dayton, nificative decrease of
10-Preproliferative/PDR OH) CS at 12 and 18 c/deg;
preproliferative and PDR
pts had decreased CS at
all frequencies, and sig-
nificative lower than CS
of aretinopathic pts
Mackie et al. [133] Case-control Cases-90 Cases: VA: 0.3 or better Pelli–Robson There was a progressive
Controls-50 Young pts- chart reduction of CS thresh-
33.2 ± 7.9 old through the five
Older pts- groups of diabetic pts (no
65.5 ± 8.2 DR, bDR, PPR, treated
Controls: retinopathy, treated mac-
Young pts- ulopathy), significative
30.8 ± 7.9 between groups in which
Older pts- there was a difference
66.6 ± 10.1 of at least two adjacent
degrees of retinopathy.
No significative differ-
ence was found between
controls and aretino-
pathic pts
Lövestam-Adrian Case control Cases-20 Cases-32 (15–27) Cases-Treated PDR or Precision Vision Pts treated with panretinal
et al. [134] Controls-19 Controls-30 (20–42) severe NPDR; VA: chart (Preisler photocoagulation had
0.9 (0.4–1.0) instrument AB, significative higher
Controls-No DR or non Illinois, USA) contrast threshold than
treated mild bDR; untreated diabetic pts
VA: 1.0 (0.5–1.0)
Talwar et al. [77] Prospective 14 Eyes with 47–60 years CSME Cambridge low- The CS improved signifi-
noncom- untreated VA: 0.49 (1.0–0.1) contrast sensi- cantly after photocoagu-
parative CSME tivity charts lation treatment
study
Stavrou et al. Case-control Cases-20 pts Cases-62.67 ± 11.21 12-No/minimum DR Pelli–Robson CS was lower in diabetic
[135] Controls- Controls-67.36 ± 7.35 4-Mild DR chart pts than CS of controls,
24 pts 4-Moderate/severe DR but significative differ-
VA: 6/9.5 or better ence was observed only
8 Pts had macular between no/minimum
edema DR group and controls.
(continued)
Principal
Presence/absence of
macular edema was
correlated to decreased
CS, but there was no
significative difference
between the two groups
Farahvash et al. Prospective 17 Diabetic – 26 Eyes-diffuse macu- Metrovision with CS had a significative
[78] noncom- pts (34 lar edema a high resolu- improved after photoco-
parative eyes) 8 Eyes-focal macular tion cathodic agulation treatment only
study edema ray tube stimu- in the frequency of 6.4
VA pre-treatment: 0.21 lator cpd
VA post-treatment: 0.24
Pts patients; VA visual acuity; CS contrast sensitivity; DR diabetic retinopathy; bDR background diabetic retinopathy; PDR proliferative diabetic retinopa-
thy; CSME clinically significant diabetic macular edema; IDDM insulin-dependent diabetes mellitus; NIDDM non insulin-dependent diabetes mellitus; cpd
cycles per degree
Frost-Larsen et al. [83] demonstrated a close correlation of the oscillatory potential and
nyctometry in IDDM patients, suggesting a common retinal mechanism responsible for
the changes of both parameters in DR. Macular recovery function is a complex phenom-
enon consisting of photochemical, neural receptor, and network adaptation, the resultant
achievement being an optimized interaction of all three mechanisms [88]. Although the
mechanisms responsible for the increased recovery time in the initial phase of this test
are unknown, the phenomenon appears related to disturbances primarily in the neural
network adaptation. The site of the neuronal mechanisms of this test is likewise believed
to be located to the inner nuclear layer, and it might be influenced by the same functional
disturbances which suppress the generation of the oscillatory potential [83, 89]. Unfor-
tunately, the technology to perform this test is no more available and a new electronic
version is under investigation.
PERIMETRY
Perimetry represents a systematic measurement of visual field sensitivity function. It
encompasses the assessment of differential light threshold of retinal locations from the
fovea to the preplanned periphery. The two most commonly used types of perimetry are
Goldmann kinetic perimetry and (threshold) static automated perimetry. Kinetic perim-
etry is particularly useful for obtaining the outline of extensive defects and identifying
major scotomas. Static perimetry is particularly useful for detailed probing in carefully
selected areas and represents the current cornerstone of visual field testing. Standard
threshold static automated perimetry quantifies the differential light threshold required
to detect a static white light stimulus in the visual field. Since standard threshold perim-
etry uses a static achromatic stimulus, it is thought to nonselectively evoke both major
groups of retinal ganglion cells: (1) the parasol ganglion cells of the magnocellular vis-
ual pathway subserving motion perception, low spatial resolution, high contrast sensitiv-
ity, and stereopsis and (2) the midget ganglion cells of the parvocellular visual pathway
subserving central visual acuity, color perception, low contrast sensitivity, high spatial
resolution, static stereopsis, pattern recognition, and shape. There is considerable over-
lap in the receptive fields of these cell types; therefore, a nonselective, white-on-white
stimulus cannot detect the earliest loss of retinal ganglion cells, and standard threshold
perimetry therefore may not detect visual field loss until the whole population of reti-
nal ganglion cells is significantly damaged. In addition to new algorithms, visual field
testing is becoming more sophisticated with the development of new perimetric tech-
nologies. New technologies are aimed at earlier detection of subtle deficits and enhanc-
ing diagnostic accuracy. The sensitivity to short-wavelength stimuli can be measured
in different regions of the visual field by blue-on-yellow perimetry (short-wavelength
automated perimetry, SWAP). It is accomplished by determining the sensitivity to blue
stimuli (thus stimulating the short-wavelength cone system) on a bright yellow back-
ground. In this way, long- and medium-wavelength cone system sensitivity is reduced
and rods are saturated.
In DME, visual acuity loss is quite relevant and irreversible when long lasting edema
involves the center of the macula; in these cases, the outcome of laser treatment is
poor. But before the loss of visual acuity is reported by patients, they may suffer from
other disturbances of visual function such as waviness, blurring, relative scotoma, and
decrease of contrast sensitivity which are not assessed and quantified in routine exami-
nation. Therefore, a visual function test aimed at identifying vision-threatening retin-
opathy before visual acuity is affected would be of great value. One possible approach
may be to identify decreased sensitivity in paracentral areas using perimetry.
It has been reported that patients with diabetic retinopathy show sensitivity loss in
the midperipheral field by white-on-white perimetry (WWP) and that this sensitivity
loss is correlated with the retinal areas of nonperfusion [90–92]. The sensitivity loss
was closely associated with microangiopathy and was greater in the midperipheral area
than in the paracentral area. Bek and Lund-Andersen evaluated with Humphrey Field
Analyzer retinal sensitivity over cotton wool spots in patients with diabetic retinopathy
and reported localized nonarcuate scotomata in the visual field, which may persist even
when the funduscopic lesions resolve [93]. A selective loss of short-wavelength sensitive
pathway has been demonstrated in diabetic patients with minimal or no diabetic retin-
opathy [94–97]. SWAP has been suggested as a useful tool for defining visual function
loss in diabetic patients with early ischemic damage of the macula or clinically signifi-
cant macular edema [98, 99]. Decreased blue-on-yellow sensitivity has also been dem-
onstrated in diabetic children without clinically detectable retinopathy [100] (Table 3).
When comparing SWAP and WWP in diabetics, SWAP seems superior for macu-
lar localized field loss determination and early ischemic macular damage evaluation.
Uncertainty remains about its use in macular edema. Moreover, SWAP showed to be
highly lens opacity–dependent [98, 99, 101]. On the other hand, WWP correlates better
with the ETDRS severity scale than SWAP or visual acuity determination, and it might
be better in separating groups with different levels of retinopathy [102]. As elegantly
stated by Sunness et al. [103], conventional visual field examination is inadequate for
the accurate functional evaluation of macular diseases and detection of small scotoma,
particularly when foveal function is compromised and the patient may have unstable and
extrafoveal fixation. Accuracy of the conventional visual field rests on the assumption
that fixation is foveal and stable. Moreover, the detection of the site and stability of reti-
nal fixation (foveal or extrafoveal) and the quantification of retinal threshold over small
and discrete retinal lesions are beyond the possibilities of conventional, automatic, and
nonautomatic perimetry [2].
MICROPERIMETRY (FUNDUS-RELATED PERIMETRY)

The integration of retinal details with function has been achieved by fundus-related
perimetry, more widely known as microperimetry. Microperimetry allows for the exact
topographic correlation between fundus abnormalities and corresponding functional
alterations by integration, with different methods, of differential light threshold (more
commonly known as retinal sensitivity) and fundus imaging. It also allows to quantify
fixation characteristics, by exactly defining location and stability of any foveal or extra-
foveal (PRL, preferred retinal locus) fixation site, as well as determination of size, site,
and shape of scotoma. Moreover, the possibility of an automatic follow-up examina-
tion (using the microperimeter MP-1, Nidek Co, Japan) which allows the evaluation of
exactly the same retinal points tested at baseline, regardless of any change in fixation
Table 3. Studies which have investigated perimetry in patients with diabetic retinopathy
Principal
investigator/
year of Age in years: Nature
publication Types of study Sample size mean/range DR status and VA of stimulus Conclusions
Bek et al. [136] Cross-sectional 20 Pts – Hard exudates and/or Humphrey field No topographical correlation was
localized leakage of analyzer found between barrier leakage
fluorescein and decreased light sensitivity
VA: 6/18 or better
Lutze et al. Case-control Cases-31 pts 30 (Median) No DR-6 Humphrey field S-cone sensitivity and achromatic
[137] Controls-50 pts (19–59) Mild retinopathy-10 analyzer sensitivity were not significantly
Moderate retinopathy-4 reduced in diabetic pts, but they
Severe retinopathy-4 showed localized sensitivity
PDR-7 losses in visual fields in diabetic
VA: 20/80 or better pts. Localized sensitivity losses
of SWAP were significantly cor-
related to the level of DR
Hudson et al. Case-control Cases-24 pts 59.75 (45–75) CSME (Early Treatment Humphrey field SWAP test showed greater sensitiv-
[99] and eyes 48 (18–84) Diabetic Retinopathy analyzer ity than WWP test in detecting
Controls-400 Study (ETDRS)) visual field defects. The position
pts VA: 0.25 or better of localized field loss assessed by
SWAP corresponded with clinical
mapping of the area of DME
Nomura et al. Case-control Cases-31 pts Cases: No No DR-21 Humphrey field No significant correlation was found
[138] Controls-11 pts DR 50.9 bDR-10 analyzer 750 between level of DR and FM 100
(40–59) VA: 20/20 Hue Test. The SWAP sensitivity
bDR 51.3 of the upper half of the central
(40–59) 20–30° area was significantly
Controls: 51.7 reduced in bDR group; no signifi-
(40–59) cant sensitivity loss was detected
with WWP
(continued)
Principal
investigator/
Remky et al. Case-control Cases-31 pts 35 ± 12 No DR-9 Humphrey field SWAP thresholds were significantly
[98] and eyes Only microaneurysms-5 analyzer 750 correlated with increasing size of
Controls-31 Mild retinopathy-13 FAZ and PIA; WWP thresholds
Moderate retinopathy-1 and VA were not correlated with
Severe retinopathy-2 diabetic changes of the perifoveal
VA: 20/25 or better capillary area
Verrotti [139] Prospective Cases-60 pts 15.9 (14–18) No DR Humphrey field The probability of retinopathy devel-
study VA: 1.0 or better analyzer 640 opment after 8 years of follow-
up was significantly higher in
subgroups of patients with mean
sensitivity in areas 2 and 3 below
cut-off
Afrashi et al. Case-control Cases-43 pts 31.03 (16–38) No DR Humphrey field There was no difference in sensi-
[140] Controls-30 pts 30.13 (21–35) VA: 20/20 analyzer 750 tivity between the diabetic and
the control group. The values
of mean deviation by blue-on-
yellow perimetry in diabetic pts
were significantly higher than in
the control group. WWP did not
show this difference
Remky et al. Case-control Cases-45 pts 37.2 ± 10.4 No/mild macular Humphrey field SWAP thresholds were signifi-
[141] and eyes 37.2 ± 14.1 changes (not edema) analyzer 750 cantly more reduced in pts with
Controls-58 pts No DR-13 advanced DR than those of
Only microaneu- WWP. In pts with no DR sensi-
rysms-11 tivity was not affected
Advanced DR-21
Cases-VA: 0.015 ± 0.042
Controls-VA:
0.013 ± 0.034
Han et al. [142] Case-control Cases-22 pts 52.4 (32–59) Cases-mild (20) or mod- Humphrey field Both groups showed reduced sensi-
and eyes 43.5 (26–64) erate (2) DR analyzer tivity at SWAP test. Also mfERG
Controls-18 pts Controls-no DR showed similar number of signifi-
VA: 20/25 cant abnormalities. In diabetic pts
with DR SWAP and mfERG also
showed some spatial agreement
Bengtsson et al. Cross-sectional 59 Pts and eyes 50.6 (20–69) – Humphrey field WWP was correlated with degree of
[102] analyzer 750 peripheral DR better than VA or
SWAP test. SWAP was superior
to both WWP and VA in measur-
ing effects caused by enlarged
FAZ and PIAs
Agardh et al. Cross-sectional 59 Pts and eyes 50.6 (20–69) DME-20 Humphrey field VA was correlated to the thickness
[101] No DME-39 analyzer 750 of macula when edema involved
VA: −0.04 (median) the center of the macula. SWAP
(−0.22 to +0.82) was able to detect macular
edema, WWP was not. SWAP
and WWP were correlated to
FAZ and PIA. Visual field defects
reflected ischemic damage of
the macula rather than macular
edema per se
(continued)
Principal
investigator/
Nitta et al. [143] Case-control Cases-33 pts 41.7 ± 6.8 No DR Humphrey field There was a correlation between
and eyes 41.2 ± 6.3 VA: 20/20 or better analyzer 750 decreasing of mean deviation and
Controls-33 increasing clinical data (duration
of diabetes, fructosamine concen-
tration, glycatet hemoglobin) with
SWAP test, with not in WWP test
Lobefalo et al. Case-control Cases-50 pts 13.3 (10.1– No DR Humphrey field Mean perimetric sensitivity of
[100] (100 eyes) 16.3) VA: 0.8 or better analyzer 640 SWAP showed significant lower
Controls: 50 values in micro-albuminuric
pts group than values of normo-albu-
minuric group. Mean perimetric
sensitivity of WWP did not show
significant differences between
micro-albuminuric and normo-
albuminuric diabetic pts, either
between diabetic pts and controls
Pahor [144] Case-control Cases-32 eyes 51.2 (22–71) Moderate DR-17 eyes Humphrey field There was a significant correlation
(25 pts) 48.3 (17–64) Severe DR-15 analyzer between visual field defects and
Controls-30 VA: 6/9 or better areas of reduced retinal perfusion
eyes
Pts patients; DR diabetic retinopathy; VA visual acuity; bDR background diabetic retinopathy; PDR proliferative diabetic retinopathy; CSME clinically
significant diabetic macular edema; DME diabetic macular edema; FAZ foveal avascular zone; PIA Perifoveal Intercapillary Area; WWP white-on-white
perimetry; SWAP short-wavelength automated perimetry; mfERG multifocal electroretinogram
characteristics, is a valuable tool of this technique, mainly in the evaluation of treatment

outcome. Microperimetry offers several advantages vs. standard perimetry in the quan-
tification of macular sensitivity, such as direct real-time fundus control, direct correla-
tion between sensitivity and fundus details, detection of central microscotomata, and
continuous monitoring of fixation.
The original Scanning Laser Ophthalmoscope (SLO, Rodenstock, Germany) was the
first instrument combining static perimetric testing and simultaneous observation of the
fundus. SLO allowed a real-time examination by an infrared (IR) source of the retina and
allowed the manual projection of visual stimuli of different shapes, sizes, and intensities
over selected retinal areas. The sensitivity map, obtained according to the stimulation
pattern (in dB or pseudocolors), was available at the end of the examination. This map
contained the fixation area, the fixation target, and the threshold data. This instrument is
no more commercially available.
With the introduction of a new microperimeter, a liquid crystal display (LCD) micro-
perimeter (MP-1) coupled with a color fundus camera, visualization of color fundus
details allows to directly report functional data onto clinical fundus image, and auto-
matic tests are also obtained. MP-1 microperimeter has both an infrared and a color
fundus camera, as well as an automatic real-time tracking system that allows for a full
automatic retinal fixation and threshold determination as well as automatic follow-up
and differential maps determination, independently from fixation characteristics. The
main technical characteristics of this instrument have been previously described in detail
[104–106]. Rohrschneider et al. compared MP-1 and SLO microperimeters and found
that both instruments analyzed retinal sensitivity and fixation characteristics, and the
results obtained from both instruments were directly comparable. However, MP-1 is
superior to SLO due to the automatic real-time alignment system, a larger field of (fun-
dus) view (44° × 36° MP-1 vs. 33° × 2° SLO) and color image [107].
The most relevant characteristics of advanced microperimetry performed with the
MP-1 microperimeter may be briefly summarized as follows:
• Exact fundus-related stimulation
• Automatic eye-tracking system
• Automatic static and kinetic stimulation (with standardized or customized grids and
centration)
• Normative age-related database [108]
• Age-related differential maps (local defect determination, shallow defects determina-
tion, etc.)
• Automatic follow-up and differential maps
• Screening tests (short test duration: <5 min)
• Morpho/functional relationship investigation (overlapping of sensitivity maps over
different types of fundus images)
MP-1 microperimetry is a mesopic test that requires a 5–10-min dark light adaptation
before starting the examination.
In the last 15 years, microperimetry has been successfully used in the diagnosis and
follow-up of different macular disorders, including: age-related macular degeneration,
myopic maculopathy, macular dystrophies, and diabetic macular edema [105, 109–117].
Fig. 1. Microperimetry map (in decibels) superimposed onto the color fundus image in a
case of clinically significant diabetic macular edema (CSME). Decrease of retinal sensitivity is
shown on the temporal side of the macular region.
In DME, microperimetry has been used for the quantification of macular sensitivity;
the correlation of macular sensitivity to macular thickness, visual acuity, and fundus
autofluorescence data; and the fixation patterns determination in different stages and
types of edema.
Different studies report the correlation between retinal sensitivity, determined with
microperimetry, and VA in patients with CSME [102, 108, 118]. Moreover, reduced
retinal sensitivity is related to increasing retinal thickness [102, 114, 118] (Table 4). In a
study published by Vujosevic et al. [104], a significant inverse relationship was found in
patients with CSME, between retinal sensitivity and normalized retinal thickness values
obtained with OCT, with a decay of 0.83 dB (p < 0.0001) for every 10% of deviation of
retinal thickness from the normal values (Fig. 1). This means that normalized macular
thickness better copes with macular function than any absolute value [104]. Microper-
imetry seems to represent a better functional testing than BCVA for quantifying visual
function in diabetic patients, because it incorporates a functional measure that may
potentially supplement the predictive value of OCT and visual acuity [104, 118, 119].
Besides retinal sensitivity, microperimetry allows to quantify retinal fixation character-
istics. Fixation characteristics (location and stability) are relevant parameters for under-
standing patient’s quality of vision, especially reading ability, and its knowledge may be
important in planning laser treatment [110, 119–121]. Reading ability better correlates
with subjective quality of vision rather than distant visual acuity [110]. Whereas different
studies agree that macular sensitivity deteriorates in patients with DME, data about fixa-
tion characteristics are quite contrasting [104, 109, 110, 114, 118, 122] (Table 4). Kube
et al. [114] found decreased fixation stability in patients with DME using SLO micro-
perimetry. Carpineto et al. [122] found that all eyes with eccentric or unstable fixation
had cystoid DME. Vujosevic et al. [119] found that fixation patterns are not significantly
Table 4. Studies which have investigated microperimetry in patients with diabetic retinopathy
Principal
investigator/
year of Sample Age in years: Nature
publication Types of study size mean/range DR status and VA of stimulus Conclusions
Rohrschneider Prospective 30 Pts and 63 (37–81) CSME SLO 101 In ten eyes VA significantly improved
et al. [110] eyes VA: From 20/200 to Rodenstock after laser photocoagulation, in nine
20/20 eyes it decreased. Fifteen eyes showed
improving in mean light sensitivity
after treatment, seven showed decreas-
ing. Nine eyes improved in fixation
stability, five eyes demonstrated a
deterioration. There was no significant
correlation between stability of fixa-
tion and visual acuity or subjective
patient changes
Mori et al. Cross- 19 Pts and 63 (45–78) CSME with: SLO 101 Significant difference was found between
[111] sectional eyes Dense scotoma-4 Rodenstock the three groups VA. There were sig-
Relative scotoma-10 nificant differences in the prevalence
No scotoma-5 of cystoid changes, diffuse edema,
VA: 0.7 (−0.2 to 2) unstable fixation among the three
logMAR groups. Group with dense scotoma
showed a great association with all
these three clinical characteristics,
group with no scotoma did not show
any of these characteristics
(continued)
Principal
investigator/
Moller and Prospective 24 Pts and 66.9 (38–85) CSME treated with SLO 101 A significant negative correlation was
Bek [145] eyes standard argon Rodenstock found between the changes in VA and
laser treatment the changes in the retinal areas covered
(ETDRS protocol) by hard exudates. In four pts hard exu-
VA: dates covered fovea at baseline, and
I group: −0.05 the site of fixation was at the border of
to 0.2 the exudate. After laser treatment, in
II group: 0.21–0.4 two eyes hard exudates reduced, result-
III group: 0.41–0.6 ing in an increased VA and a shift of
IV group: 0.61–0.8 the site of fixation, in one eye hard
exudates increased, followed by a VA
impairment and a more peripheral site
of fixation
Kube et al. Case-control Cases-27 54 (17–81) Presence of diabetic SLO 101 Fixation stability was significantly
[114] pts 45 (18–85) maculopathy Rodenstock decreased in diabetic pts in comparison
Controls-61 Cases-VA: 0.6 ± 0.32 to controls. Macular light sensitivity
Controls-VA 1.0 ± 0.1 was worse in diabetic pts than in con-
trols, and temporal parts of the macula
were the most affected. No correlation
was found between VA and foveal
light sensitivity nor foveal fixation
Vujosevic Cross- 61 Eyes 56.1 ± 12.5 Non edema (NE)-16; MP-1 Nidek VA and central macular sensitivity cor-
et al. [104] sectional (32 pts) VA: −0.07 ± 0.18 related significantly in the NCSME
logMAR group, but not in the NE or in the
NCSME-30; VA: CSME group. There was a significant
0.12 ± 0.48 correlation between retinal sensitiv-
CSME-15; VA: ity and normalized macular thickness
0..33 ± 0.36 detected by OCT scans
Okada et al. Retrospective Cases-32 Cases-58.8 CSME MP-1 Nidek Mean sensitivities in diabetic pts were
[118] case-con- eyes (25 (25–76) VA: 0.7 (0.1–0.7) lower than in healthy controls. VA and
trol pts) Controls-42–76 Controls: −0.1 (−0.2 macular sensitivities were significantly
Controls-17 to −0.1) correlated. A significant negative cor-
pts relation was also found between foveal
thickness (by OCT) and the mean reti-
nal sensitivities at central 2° and 10°
Carpineto Cross- Cases: 84 66.35 (45–81) CSME (67% cystoid) MP-1 Nidek VA, central retinal sensitivity, foveal
et al. [122] sectional pts and VA: 0.60 ± 0.29 log- thickness, duration of symptoms,
eyes MAR HbA1c levels and the presence of cyst-
oid macular edema were significantly
associated with fixation impairment.
The three groups (stable vs. unstable
and central vs. eccentric fixation)
showed statistically differences in VA,
central retinal sensitivity, and foveal
thickness. Cystoid macular edema
was significantly more frequent in the
eccentric and unstable group
(continued)
Principal
investigator/
Unoki et al. Prospective 20 Eyes 62.9 (43–78) Severe NPDR-11 MP-1 Nidek Areas of capillary nonperfusion detected
[146] cross-sec- (17 pts) PDR-9 by FA were associated with the loss of
tional All showed a nonper- retinal sensitivity. The average sensitivity
fused area in the of the next nearest points from the area of
temporal macula capillary nonperfusion was significantly
VA: 0.28 ± 0.30 log- reduced compared with that of the other
MAR areas. OCT scans showed morphological
changes of the nonperfused areas
Grenga et al. Prospective 20 Eyes 65.7 ± 13.3 Chronic diffuse macu- MP-1 Nidek Three months after injection of intravitreal
[147] lar edema triamcinolone, VA, macular thickness
VA: 0.13 ± 0.09 deci- and mean retinal sensitivity improved
mal units significantly. At 6 months after injection
follow-up of the data were similar to
those at baseline
Vujosevic Prospective 179 Eyes 58.4 ± 11.2 NCSME-32 MP-1 Nidek Site and stability of fixation were associ-
et al. [119] (98 pts) CSME-147 ated. A significant association was
VA: from worse than found between fixation characteristics
20/200 to 20/25 or and visual acuity, but they were not
better influenced by edema characteristics
(diffuse, focal, cystoid, spongelike
edema, with or without neuroretinal
detachment). Subfoveal hard exudates
were significantly associated with
eccentric and unstable fixation, juxta-
foveal or no exudates were not
Pts patients; VA visual acuity; DR diabetic retinopathy; PDR proliferative diabetic retinopathy; NPDR non-proliferative diabetic retinopathy; CSME clini-
cally significant diabetic macular edema; SLO scanning laser ophthalmoscope; MP-1 Microperimeter MP-1
Fig. 2. Microperimetry map (in decibels) superimposed onto the color fundus image in a
case of severe CSME with large hard exudates. Over hard exudates the retina shows some dense
scotomatous zones. Fixation (tiny light blue spots centred onto the fovea) is stable and central.
influenced by either topographical extension of edema (focal or diffuse) or by the OCT

classification of edema. Moreover, fixation pattern was not significantly influenced by
the presence of subfoveal serous neuroretinal detachment, showing a different fixation
behavior compared to age-related macular degeneration [105, 119]. The only parameter
influencing fixation was the presence of subfoveal hard exudates. In these cases, the
knowledge of fixation location and stability is fundamental in order to avoid complica-
tions due to the photocoagulation of newly developed fixation area (Fig. 2).
The duration of DME, which cannot be exactly quantified in a cross-sectional study,
might have a relevant impact on the survival and/or functional reserve of macular cells
undergoing mechanical and toxic stress induced by edema, and this may explain the
difference in fixation results described above. It seems that in patients with DME, the
damage to photoreceptor occurs as a late phenomenon and probably is not related to
intraretinal cysts formation. In diabetic retinopathy, retinal neurodegeneration may pre-
cede photoreceptor loss, as previously reported [123].
Therefore, microperimetry may be of value in predicting the functional outcome of
DME after interventions that seem equally effective in restoring normal foveal thick-
ness. This hypothesis has been recently confirmed by a randomized and prospective
study conducted by Vujosevic et al. [124]. These authors have demonstrated that sub-
threshold micropulse diode laser is as effective as modified ETDRS photocoagulation
in reducing central retinal thickness. But with subthreshold treatment, retinal macular
sensitivity stabilizes or improves, whereas with standard photocoagulation, it signifi-
cantly deteriorates, manifesting as progressive microscotomata.
CONCLUSION
Diabetes has a relevant impact on visual function, up to permanent visual acuity loss
when retinopathy is clinically evident, but changes in visual function may occur long
before any structural change is detected by experienced fundus examination or even
by fluorescein angiography. Visual function abnormalities in diabetes, mainly detected
and quantified using psychophysical tests, should therefore be viewed as a new way of
detecting and quantifying diabetic retinopathy and evaluating any old or new treatment
approach.
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7
Mechanisms of Blood–Retinal Barrier
Breakdown in Diabetic Retinopathy
Ali Hafezi-Moghadam
CONTENTS
The Protective Barriers of the Retina
The Inner and the Outer BRB
Other Mediators of Leukocyte Recruitment in DR
Structural Compromise of the BRB
Anti-VEGF Properties of Natriuretic Peptides
Acknowledgments
References
Keywords Vascular leakage • Leukocyte adhesion • ICAM-1 • b2-integrin • VAP-1

• Azurocidin (AZ) • Atrial natriuretic peptide (ANP)
The consequences of the currently growing epidemic of type 2 diabetes would soon
debilitate the public health [1], unless new ways are rapidly found for prevention or
therapy of the various complications of the disease.
Vascular leakage is a prominent feature of diabetic retinopathy (DR), an ocular mani-
festation of diabetes. Vascular leakage is routinely quantified in patients as an important
end point of ocular examinations and also studied at the bench in a variety of in vitro and
in vivo assays. However, despite the pertinence of vascular leakage for both research
and clinic, the cellular and molecular mechanisms underlying vascular leakage are not
well understood.
THE PROTECTIVE BARRIERS OF THE RETINA

A barrier function in normal blood vessels of the central nervous system (CNS) was
first proposed by Paul Ehrlich (1854–1915). Reese and Karnovsky [2] later showed at an
ultrastructural level that tight endothelial barriers are responsible for the unique barrier
properties of CNS vessels (Fig. 1). In the eye, the blood retinal barrier (BRB) describes
the selective physiological barrier that protects the neural retina from molecules and

105
106 Hafezi-Moghadam
Fig. 1. Neural retina and the surrounding vasculature. The retina has two separate vascular
systems: retinal and the choroidal vessels. The retinal vessels have tight endothelial barriers as
also seen in the vessels of the brain, constituting the inner blood retinal barrier (BRB). In com-
parison, the outer BRB is comprised of the retinal pigment epithelium (RPE) together with the
Bruch’s membrane, separating the leaky choroidal vessels from the neural retina.
cells in the blood. The BRB acts as an active regulatory interface, where transport of
fluids, proteins, and cells in both directions takes place [3]. The integrity of BRB is
essential for retinal neuronal health, and a compromised BRB is seen in various ocular
diseases. The inner BRB is formed by normal retinal vessels, while the outer BRB is
made by the retinal pigment epithelium (RPE) (Fig. 1). Cumulatively, these barriers
regulate the flow of fluid, proteins, and cells into the extracellular space of the neural
retina. Active transport mechanisms in the RPE result in a net fluid flow out of the neural
retina [4]. Even under pathological conditions, RPE function can compensate for part of
the leakage of vessels into the extracellular environment and reduce fluid accumulation
in the outer retina.
THE INNER AND THE OUTER BRB

The inner BRB of the retinal vessels is similar to that in brain microvessels (Fig. 2).
Various cellular components are needed to form such a barrier [5]. A milestone was the
discovery that astrocyte end feet surround microvessels and that their connection to the
endothelium induces various unique barrier properties in the endothelial cells [5]. These
properties include high-resistance tight junctions between the capillary endothelial cells
that impede the passive diffusion of solutes from the blood into the extracellular space
[5]. Since then, much of the insight gained about vascular barriers comes from cell
Mechanisms of Blood–Retinal Barrier Breakdown 107
Fig. 2. Schematic of the neurovascular barrier. This is a schematic showing the tight appo-
sition of endothelial cells lining blood vessels in the brain. This is characteristic of the selective
blood–brain barrier, which separates the circulation from brain parenchyma. Pericytes sheath the
basement membrane covering the vascular endothelium.
culture models, in which endothelial cells are co-cultured with astrocytes or sometimes
also with pericytes.
Changes of BRB in diabetes has long been of central interest. In DR, BRB breakdown
causes protein and fluid extravasation, possibly leading to acute macular edema or longer-
term neuronal damage. Therefore, elucidating the factors that compromise the BRB might
lead to new therapeutic approaches for DR or diabetic macular edema, which is the main
cause of visual loss in diabetic patients. BRB investigations in vivo are commonly stud-
ied in the streptozotocin (STZ)-induced diabetes in rats [6]. STZ, an antibiotic produced
from Streptomyces achromogenes, enters the cytoplasm via glucose transporter (GLUT)
2, which is the b-cell’s GLUT in the pancreas [7], and reduces insulin secretion through
b-cell toxicity [8]. STZ-injected animals rapidly develop hyperglycemia, resembling the
conditions found in type 1 diabetes, and develop diabetic retinal vasculopathy, making
them a convenient tool in the study of early diabetic changes. These animals develop
some earlier vascular changes, such as increased retinal leukostasis, vascular leakage, or
elevated cytokine expression. However, STZ-injected animals do not exhibit the entire
pathology of the human DR. For instance, they do not show retinal neovascularization.
Furthermore, the following metabolic disarray, including insulin resistance, dyslipidemia,
and adipokine changes, is not truly reflected in STZ-induced diabetes. The recently intro-
duced model of spontaneously occurring type 2 diabetes in the Nile grass rat (NGR)
shows many pertinent characteristics of the human condition [9]. The hyperglycemia in
NGR is accompanied by dyslipidemia and insulin resistance. Hope is great that with the
help of such realistic models of human diabetes, effective mechanistic explorations as
well as therapeutic advances will take place.
108 Hafezi-Moghadam
Due to the growing importance of age-related diseases, a large amount of interest lies
in understanding the physiological changes of vascular barrier function during aging
[10]. Recent work indicates a gradual and continuous decline in vascular barrier func-
tion with physiologic aging and that immune cells contribute to this process [11]. This
indicates that the barrier-privileged vessels of the body, similar to other organs, are sub-
ject to changes resulting from age.
A plausible explanation for how physiologic aging might impact vascular barrier
function comes from the observation that deficiency of a cholesterol transport pro-
tein, the apolipoprotein E (apoE), in mice substantially accelerates the barrier decay
with age [11]. Since apoE−/− mice are prone to chronic vascular inflammation, such as
accelerated atherosclerosis [12] and neurodegeneration [13], this indicates that chronic
inflammation compromises vascular barrier privilege. Analogously, in normal animals,
constitutive inflammatory processes during aging cause cumulative damage to the vas-
culature, which can be a prelude to age-related vascular diseases [11].
To investigate retinal vascular leakage in vivo, for instance in diabetes, many inves-
tigators use protein leakage assays, of which various modifications exist. These assays
commonly quantify the passage of plasma albumin into the parenchyma. To do so, dyes
such as Evans blue (EB) are injected into the circulation [14, 15]. Under controlled
conditions, these techniques allow quantitative assessment of inner BRB leakage. How-
ever, due to the low amount of retinal tissue and the large variability between animals,
albumin/protein-based leakage assays have limitations both in terms of sensitivity and
in the large variability of the outcome. Therefore, there is currently a great need for more
sensitive in vivo assays that can reliably quantify subtle leakage.
The outer BRB is primarily comprised of the RPE, a cellular layer that causes a
tight epithelial barrier. The healthy RPE forms not only the outer BRB but also actively
removes subretinal fluid, thus regulating fluid accumulation in the subretinal space. RPE
function is essential to maintaining a balanced outer retinal environment. Moreover, the
RPE is a principal source of angiogenic and antiangiogenic factors and also expresses
the receptors for these agents.
Both acute and chronic inflammation disrupt the (BRB), as in uveitis or diabetic
retinopathy, respectively [16]. These facts have led to the hypothesis that barrier changes
in physiologic aging or in acute or chronic inflammation are related. Indeed, certain
immune cells in the peripheral blood, neutrophils and macrophages, contain a highly
potent permeability factor, azurocidin (AZ), that these cells release when interacting
with the activated endothelium.
Inflammation and BRB Permeability

Leukocyte accumulation in retinal vessels is a critical early event in the pathogen-
esis of DR. Firm adhesion of neutrophils to the inflamed endothelium causes vascular
leakage [17–19]. However, the molecular details are only beginning to be understood.
Leukocyte accumulation on the inflamed endothelium of retinal vessels follows the
general principles of cascade-like recruitment [20]. Leukocyte rolling, the initial step
in the recruitment cascade, is followed by leukocyte activation, firm adhesion, and
transmigration into the interstitial tissue [20]. The endothelium sequentially expresses
adhesion molecules, such as selectins, integrins, and immunoglobulins, and presents
Fig. 3. Steps of inflammatory leukocyte recruitment. The transition from rolling to firm
adhesion is achieved by endothelial intracellular adhesion molecule (ICAM)-1 that interacts with
its leukocyte ligand, CD18 [23]. The retinal endothelium of diabetic animals expresses ICAM-1,
which binds to leukocyte b2-integrins, LFA-1 (CD18CD11a) and Mac-1 (CD18CD11b), mediat-
ing firm leukocyte adhesion. Leukocytes use their integrins to extravasate through the extracel-
lular matrix (ECM) [103].
chemoattractants to the free-flowing leukocytes to orchestrate each stage of the

recruitment process [20, 21] (Fig. 3).
Selectins mainly mediate the first steps of the leukocyte-endothelial interaction
[20]. Through their lectin domain, the selectins bind to other carbohydrates presented
by mucins [22]. P-selectin is the first adhesion receptor transiently upregulated on the
endothelium during inflammation, which initiates leukocyte rolling [21].
Leukocyte adhesion to the retinal vessels is critical for DR pathology, as inhibition
of leukocyte adhesion through intracellular adhesion molecule (ICAM)-1 or b2-integrin
blockade effectively suppresses vascular endothelial growth factor (VEGF)-induced
and diabetic BRB breakdown, establishing the link between leukocyte adhesion and
increased retinal vascular leakage [23, 24]. However, the molecular pathways involved
in BRB breakdown downstream of leukocyte adhesion are only beginning to be under-
stood.
When neutrophils and monocytes, two leukocyte subtypes, interact via their b2-
integrins with ICAM-1 on activated endothelium, they release the content of their
azurophilic granulae. One of the protein contents of these granulae, AZ, is a potent
permeability factor [25]. Interestingly, b2-integrin expression on peripheral blood neu-
trophils is higher in diabetic animals [24]. Under these conditions, leukocytes are more
prone to release AZ.
110 Hafezi-Moghadam
Leukocyte Mediators of Vascular Leakage

AZ, heparin-binding protein (HBP/CAP37) is an inactive serine protease consisting of 225
amino acid residues and is a highly glycosylated molecule of 37 kDa. AZ is stored in the
azurophilic granules of neutrophils [26]. Upon binding of neutrophils to the activated
endothelium, b2-integrin ligation with endothelial ICAM-1 causes AZ release [25]. It is
a multifunctional protein with diverse roles in host defense and inflammation [27]. AZ
is a chemoattractant for monocytes and T cells and induces monocytes to differentiate
into macrophages [28]. Furthermore, AZ stimulates endothelial cells via an unknown
receptor to detach and aggregate [25].
AZ induces Ca2+-dependent cytoskeletal rearrangement and intercellular gap for-
mation in endothelial cell monolayers in vitro and increases macromolecular per-
meability [25]. Moreover, AZ blockade prevents neutrophil-induced endothelial
hyperpermeability, emphasizing the crucial role of AZ in vascular responses during
inflammation [25].
The serine protease inhibitor, aprotinin, binds AZ and abolishes its ability to disrupt
endothelial junctions [29]. Aprotinin is used clinically to protect patients undergoing
extensive surgery, that is, cardiopulmonary bypass, from leukocyte sequestration in
organs and fluid loss from the vasculature [30]. Recent in vivo results show that aprotinin
is an effective inhibitor of the AZ-induced retinal vascular leakage. Aprotinin treatment
also significantly decreases VEGF-induced leakage and BRB breakdown in experimen-
tally induced diabetes, suggesting a possible role for AZ in these events. Aprotinin, as a
broad inhibitor, also blocks other serine proteases, such as neutrophil-derived elastase,
cathepsin G, proteinase 3, and some proteases in coagulation and fibrinolysis pathways,
including plasmin and kallikrein [29, 31, 32]. Some of these proteases may be involved
in retinal vascular leakage [33], and since aprotinin does not exclusively block AZ, there
is potential involvement of other proteases in the VEGF-induced retinal vascular leak-
age or the BRB breakdown seen in early diabetes. Furthermore, since aprotinin is known
to be anti-inflammatory and an inhibitor of leukocyte recruitment, aprotinin’s protective
function against BRB breakdown could in part be due to its anti-inflammatory proper-
ties. Taken together, aprotinin or similar inhibitors of AZ might be useful in the treat-
ment of retinal vascular leakage in DR.
Aprotinin is in clinical use for patients undergoing extensive cardiothoracic and
orthopedic surgery. These patients often develop neutrophil sequestration in organs and
massive leakage of fluid from the vasculature, and aprotinin can help to reduce blood
loss and blood transfusion requirements postoperatively [30, 32]. Inhibition of AZ was
proposed by Gautam et al. [25] as a possible mechanism of action for aprotinin in these
clinical settings, considering the crucial role of AZ in neutrophil-evoked permeability.
Two recent reports show an increased risk of renal [34] and cardiovascular toxicity,
including myocardial infarction and stroke [35], following aprotinin administration in
major surgeries. These systemic side effects of aprotinin might in part be due to its
limited specificity in vivo. To date, there is no selective inhibitor of AZ. However, upon
availability of such inhibitors, their intravitreal delivery in DR might lower the risk for
systemic side effects.
OTHER MEDIATORS OF LEUKOCYTE RECRUITMENT IN DR

Due to the immune-privileged status of the eye, few immune cells transmigrate into
the retina under physiological conditions. However, in DR, large numbers of immune
cells cross the BRB and migrate into the neuronal retina. The infiltrating leukocytes are
believed to be the cause of considerable harm to the neurons. Recent results indicate a
critical role for a new molecule, the vascular adhesion protein 1 (VAP-1), in the retinas
of diabetic animals [36].
VAP-1 is an endothelial adhesion molecule involved in leukocyte recruitment [37,
38]. It is a homodimeric sialylated glycoprotein expressed on the endothelium of human
tissues such as skin, brain, lung, liver, and heart under both normal and inflamed con-
ditions [39–42]. Increased levels of both soluble and membrane-associated VAP-1 are
reported in diabetes [43].
In addition to being an adhesion molecule, VAP-1 is also an enzyme. Indeed, VAP-1
is the only known adhesion molecule that also has catalytic activity. It has characteristics
of semicarbazide-sensitive amine oxidases (SSAO), enzymes that catalyze the deamina-
tion of primary amines such as methylamine and aminoacetone [44, 45]. SSAO’s active
site generates toxic formaldehyde and methylglyoxal, hydrogen peroxide and ammonia
[45], reactive chemicals, and major reactive oxygen species [43].
VAP-1 is expressed on the retinal endothelium, and it plays a critical role in the
recruitment of leukocytes to the eye during DR [36], acute inflammation [46], and laser-
induced neovascularization [47]. The fact that VAP-1 is expressed in the human eye
[48] suggests that it could become an attractive molecular target in the prevention and
treatment of ocular inflammatory diseases, such as DR.
To detect molecular changes or early endothelial injury at the BRB, we recently intro-
duced a new noninvasive molecular imaging approach [49, 50]. In this technique, fluo-
rescent microspheres (MSs), of slightly less than cellular dimensions, are conjugated
with ligands or antibodies to one or more endothelial surface molecules of interest [50,
51]. After systemic injection, the interactions of these MSs with the endothelium of the
retinal and choroidal vessels of live animals is studied by scanning laser ophthalmos-
copy (SLO) in normal or diabetic animals. These new approaches will likely advance
our understanding of the cellular and molecular events that lead to BRB breakdown, for
instance in early DR.
STRUCTURAL COMPROMISE OF THE BRB

The inner and outer BRB can also be compromised due to structural changes. A com-
mon cause of the structural damage underlying BRB breakdown is neovascularization,
or the growth of new vessels. Neovascularization in the eye is a leading cause of vision
loss. It occurs in the proliferative stage of diabetic retinopathy, where retinal vessels
grow, likely secondary to ischemia. While normal retinal vessels have the BRB function,
the neovascular vessels are leaky for proteins and also prone to bleeding, allowing accu-
mulation of fluid within the extracellular spaces of the neurosensory retina. The ensuing
damage to the cells of the neuronal retina can result in permanent vision loss. Neo-
vascularization occurs in consequence of the intraocular release of the pro-angiogenic
cytokine and vasopermeability agent, VEGF [52].
112 Hafezi-Moghadam
Fig. 4. Vascular endothelial growth factor (VEGF) isoforms and their endothelial receptors.
Vascular Endothelial Growth Factor

A key mediator of permeability as well as neovascularization is VEGF. VEGF
expression is primarily triggered through hypoxia [53], but growth factors [54], inflam-
matory molecules [55], oxidative stress [56], and advanced glycation end products [57]
can also induce VEGF production. A major source of VEGF in the eye is the RPE [58].
Under normal conditions, VEGF secretion from the RPE stimulates choriocapillaris
endothelium development [59]. The role of VEGF in endothelial cell biology has been
extensively studied. VEGF receptors activate multiple signaling pathways including
survival [60], migration [61], mitogenesis [62], and permeability [63]. Recent studies
show expression of VEGF receptors on RPE [64] and that VEGF modulates RPE bar-
rier properties through the VEGFR-2 receptor [65].
The VEGF family consists of five members that bind to and activate three distinct
receptors [66, 67] (Fig. 4). VEGF-A binds to both VEGFR-1 and VEGFR-2, while pla-
cental growth factor (PlGF) and VEGF-B bind only to VEGFR-1. VEGF-C and VEGF-
D are the only known ligands for VEGFR-3 and do not bind to VEGFR-1 [68, 69].
VEGF-A is upregulated in various physiological and pathological conditions, causing
endothelial permeability [70], lymph- [71], and angiogenesis [72]. VEGF-A induces pro-
liferation and migration of the lymphatic endothelium through the VEGFR-2 [73]. Pro-
teolytically processed VEGF-C binds to and activates VEGFR-2, while the unprocessed
precursor form of VEGF-C signals through VEGFR-3 [74]. Both VEGF-C and VEGF-
D primarily affect development of lymphatic vasculature through VEGFR-3 activation,
but they also participate in angiogenesis through VEGFR-2 [75]. For instance, a solu-
ble VEGFR-2 form that is secreted by corneal epithelial cells selectively suppresses the
physiologic growth of lymphatics; however, it does not address the interdependency of
lymph- and angiogenesis [76]. VEGF-C expression is higher in blood vessel endothelium
than in lymphatic endothelium; conversely, VEGFR-3 expression is higher in lymphatic
endothelium [73]. In comparison, VEGFR-2 expression is similar in both endothelial cell
types [77]. However, the differential contribution of VEGF-C/VEGFR-2 interaction to
lymph- and angiogenesis is not well understood.
VEGF is closely tied to the pathogenesis of DR. It plays a key role in the leukocyte-
mediated breakdown of the BRB as well as retinal neovascularization [78]. Recent
evidence ties VEGF with inflammation [79]. VEGF increases endothelial ICAM-1
expression, facilitating leukocyte adhesion [80] and BRB breakdown in diabetic retinal
vessels [23].
Within the first 2 weeks of experimental diabetes in rats, retinal VEGF levels increased
with associated upregulation of ICAM-1 in retinal endothelial cells and its ligands, the
b2-integrins, on the surface of peripheral blood neutrophils [81, 82]. These molecular
events result in increased adhesion of leukocytes, predominantly neutrophils, with a
concomitant increase in retinal vascular permeability. Analogously, intravitreal VEGF
injection induces retinal vascular changes that are quite similar to those seen in experi-
mental diabetes, namely retinal leukostasis and the concomitant BRB breakdown [78],
while blockade of VEGF abolishes retinal leukostasis and vascular leakage in experi-
mentally induced diabetes [81, 83, 84].
Recent evidence shows that in addition to being the principle cytokine in growth and
leakiness of neovascular membranes, VEGF also regulates RPE function [64]. The lead-
ing treatment of neovascular diseases is based on VEGF inhibition, using monoclonal
antibody fragments. These anti-VEGF therapies are efficacious not only for reducing
neovascularization but also for resolving retinal edema. However, recent evidence sug-
gests that VEGF is required for normal retinal physiology, raising concerns about the
long-term use of the VEGF inhibition strategy.
This motivated a search for endogenous antagonists of VEGF. A recent study
revealed natriuretic peptides (NP), cyclic peptide hormones with diuretic, natriuretic,
and vasodilatory properties, which antagonize not only choroidal neovascularization
but also the breakdown of the outer BRB [85]. Understanding the role of endogenous
antagonists of VEGF in the retinal barrier function will help to develop new strategies
in the management of DR.
ANTI-VEGF PROPERTIES OF NATRIURETIC PEPTIDES

Inhibition of VEGF is currently under investigation in clinical trials, where retinal
leakage and edema is a complication [86], such as DR [87], macular edema, [88], and
retinal vein occlusion [89]. The rationale in these therapies is that removal of VEGF
and the edematous fluid from the intraocular environment might be beneficial. How-
ever, VEGF has also protective properties for the retina [90], suggesting that VEGF is
required for normal retinal physiology. This raises concerns about the long-term use of
VEGF inhibition strategy. Furthermore, the simple removal of VEGF also eliminates
the potential antiproliferative effects associated with VEGFR-1 activation [91], which
might explain the lack of success in some cases.
114 Hafezi-Moghadam
Two endogenous anti-VEGF agents have been identified in the eye. Tombran-Tink
et al. [92] reported the expression of pigment epithelium-derived factor (PEDF), pro-
duced and secreted by the RPE. PEDF was initially identified as a neurotrophic factor
secreted by fetal human RPE cells, but later, vascular quiescence and permeability were
also found to depend on the balance between VEGF and PEDF [93]. Molecules that
interfere with the VEGF signaling pathways are attractive candidates for prevention of
BRB breakdown. PEDF blocks the VEGF-induced TEER breakdown via the activation
of juxtamembrane proteases to digest the VEGFR-2 receptor [64]. Thus, VEGF signal-
ing is inhibited by limiting the available VEGFR-2 receptors. PEDF’s anti-VEGF and
antipermeability effects in the RPE could potentially be utilized to treat retinal vascular
leakage or edema.
Another endogenous anti-VEGF factor in the eye is the atrial natriuretic peptide
(ANP) [85]. Natriuretic peptides are cyclic peptide hormones with diuretic, natriuretic,
and vasodilatory properties. The NP family consists of three members: atrial NP (ANP),
brain NP (BNP), and C-type NP (CNP). The action of NPs is mediated through two
types of receptors: guanylate cyclase type A, which reacts with ANP and BNP, and gua-
nylate cyclase type B, which is CNP specific [94, 95]. Binding of NPs to these receptors
results in cGMP production, which activates protein kinase G and subsequent target
genes [96]. Although primarily produced by the cardiac atria, ANPs are used in the treat-
ment of various disorders, including hypertension, renal insufficiency, and congestive
heart failure. Interestingly, ANP is also expressed in the inner plexiform layer and RPE
of the human retina [97].
Recent results indicate that ANP plays an important role in neovascular diseases of
the eye, as it antagonizes not only neovascularization but also the breakdown of the
outer BRB [85]. VEGF-A produces a significant TEER drop in the outer BRB within
2 h posttreatment. This response reaches its peak by 5 h and lasts approximately 48 h
[98]. In the presence of ANP, however, TEER levels remain at baseline values by 2 h
despite VEGF administration, showing the protective function of ANP in the outer BRB.
Furthermore, the ANP response is polar, as only apical but not basolateral administration
of ANP reverses apical VEGF response [85]. Isatin, a universal NP receptor antagonist,
completely reverses the inhibitory effects of ANP with respect to the VEGF-induced
TEER reduction, indicating that ANP receptor-mediated signaling is critical in this
event. These data indicate that ANP acts by inhibiting VEGF signaling pathways in RPE
cells. The recent linking of the expression of natriuretic peptides and the barrier function
of the RPE and the retinal vessels might lead to new therapeutic strategies in reducing
retinal edema. This is because natriuretic peptides are already in use in vascular disor-
ders, and thus, detailed knowledge of their dosage and toxicity exists. However, future
work will need to address the impact of these peptides on immune regulation and other
aspects of DR development.
Proposed Model of BRB Breakdown in DR

A working model for how BRB breakdown might occur in early DR involves interaction
of leukocytes via their b2-integrins to the endothelial ICAM-1. The resulting release of the
serine protease, AZ, from leukocytes causes an increase in BRB permeability (Fig. 5). This
is backed by the fact that recombinant AZ injected intravitreally significantly increases
Fig. 5. Leukocyte-induced BRB permeability in early DR. b2-integrin ligation with endothe-
lial ICAM-1 (1) initiates signaling (2) that leads to release of AZ containing granulae (3). AZ
binds to unidentified endothelial ligands and causes rapid opening of the BRB leading to leakage
of plasma proteins (4).
BRB permeability as quantified by EB technique. AZ appears to be also an attractive target

for controlling BRB permeability, as for instance systemic injection of aprotinin, a broad
protease inhibitor, 1 h before the AZ injection completely blocks the increase in leakage.
More striking is that the AZ-induced leakage is rather rapid, with a peak BRB leakage
approximately 1 h after intravitreal AZ injection, suggesting a key role for AZ in diabetic
BRB breakdown.
Key Role of AZ in VEGF-Induced Leakage

VEGF causes leukocyte accumulation in retinal vessels as well as protein leakage
into the retinal parenchyma. Since VEGF is a key permeability factor in DR, the ques-
tion arises, what portion of the VEGF-induced leakage is a direct effect of VEGF on the
endothelium rather than through downstream mediators. Of course, the editors have the
discretion to correct potential grammatical errors of the newly suggested sentence, how-
ever, the suggested sentence by the editors did not meet the intended scientific meaning.
Whether AZ is a downstream mediator of VEGF’s action is addressed by an experiment
showing suppression of VEGF-induced retinal vascular leakage by AZ blockade. Intra-
vitreal injection of VEGF together with systemic application of aprotinin completely
prevents VEGF’s permeability increase.
Interestingly, VEGF-induced leakage peaks around 6 h after its intravitreal injec-
tion [99]. In comparison, AZ-induced effect is more immediate, and its highest level is
116 Hafezi-Moghadam
Fig. 6. Working model of VEGF-induced BRB leakage.
reached within the first hour after injection [100]. VEGF causes endothelial ICAM-1
upregulation as well as leukocyte activation [101]. The fact that AZ’s effect on perme-
ability is more rapid than that of VEGF and that leukocytes also respond to VEGF [102]
makes it likely that that part of VEGF’s impact on permeability in vivo is AZ mediated
(Fig. 6).
How VEGF induces BRB leakage is not well understood. A novel link between
VEGF and AZ suggests AZ to be a downstream effector of VEGF in causing vascular
leakage:
• VEGF induces ICAM-1 expression on the endothelium of the BRB, resulting in the
recruitment of leukocytes.
• Leukocyte CD18 interaction with ICAM-1 induces release of AZ.
• AZ interacts with unidentified endothelial receptors, causing the tight endothelial
junctions of the BRB to open.
• AZ also acts as a chemotactic factor, recruiting additional leukocytes to the BRB,
which potentiates the process.
Additionally, VEGF activates leukocytes directly, which could cause the release of
AZ and thus result in amplified BRB leakage.
Azurocidin Inhibition Prevents Diabetic Retinal Vascular Leakage

Whether the newly discovered link between AZ and VEGF plays a role in DR was
addressed in experiments with diabetic animals. By 2 weeks after diabetes induction
with STZ, animals showed significant signs of DR, such as leukostasis and vascular
leakage. However, when AZ is blocked in diabetic animals, vascular leakage is remark-
ably reduced and comparable to that of normal animals [100].
The results suggest that AZ plays a role in BRB breakdown induced by VEGF or in
experimental diabetes. AZ release from neutrophils may be the final common pathway
for a variety of upstream factors, which during DR promote neutrophil adhesion and
cause BRB breakdown. These findings indicate that targeting AZ may prove beneficial
in the treatment of retinal vascular leakage in experimental DR. However, the role of
AZ in human DR remains to be investigated. Development of specific inhibitors of AZ
might lead to a treatment option for DR.
Other ocular diseases, such as age-related macular degeneration (AMD), also have a
vascular and inflammatory component, with vascular leakage being a common denomi-
nator. However, the mechanisms underlying the leakage in most cases are not under-
stood. Better understanding of the pathogenesis of DR might not only help to find better
therapies for this common and devastating disease but also for other important age-
related and neurodegenerative diseases.
Vascular leakage is a critical component of DR and its management of paramount
importance. VEGF is a key mediator of vascular leakage in DR, and its inhibition
might become an effective strategy in reducing leakage. However, there are also con-
cerns about long-term use of VEGF inhibitors, due to VEGF’s importance in reti-
nal health. Therefore, it is key to identify downstream mediators of VEGF that might
be more specific in mediating the vascular leakage component of VEGF, while their
inhibition would not affect the beneficial effects of VEGF. AZ is such a downstream
mediator of VEGF-induced vascular leakage in DR. This raises the hope that retinal
vascular leakage in DR could be opposed more specifically than before. However, as
promising as the experimental data are, the contribution of AZ in human patients first
would need to be confirmed. More importantly, more selective inhibitors of AZ need
to be developed and their toxicity in humans tested.
ACKNOWLEDGMENTS
Rebecca C. Garland and Alexander Schering helped with the preparation of the man-
uscript and figures, respectively.
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8
Molecular Regulation of Endothelial Cell Tight
Junctions and the Blood-Retinal Barrier
E. Aaron Runkle, Paul M. Titchenell, and David A. Antonetti
CONTENTS
The Blood-Retinal Barrier
The Junctional Complex
Vascular Permeability in Diabetic Retinopathy
Conclusions
References
Keywords Pericytes • Protein kinase C • Retinal pigment epithelium • Tight junction proteins
• VEGF
THE BLOOD-RETINAL BARRIER

The neural retina requires metabolic support supplied by the vasculature; however,
retinal function demands that these vessels yield minimal impact on light transmission.
This metabolic support is provided by two independent vascular systems: the retinal
and the choroidal [1–3]. The choroidal vessels include a dense, highly permeable capil-
lary network that supports the outer retina, including the rods and cones. The BRB is
maintained by a well-developed junctional complex in the retinal pigment epithelium
(RPE) that controls the flux of fluid and solutes to the retina from the choroidal capil-
lary plexus. Diffusion of metabolites and gasses across the RPE from the choroid sup-
ports the highly active outer retina. Meanwhile, the RPE controls retinal fluid by active
transport of chloride followed by osmotic flow of water through aquaporins, a system
regulated by lactate production in the outer retina [4]. This transcellular transport sys-
tem requires the formation of the tight junction complex between RPE cells to maintain
defined environments in the apical and basolateral compartments.

123
124 Runkle et al.
The Retinal Vascular Barrier

The inner retina, including the ganglion cell layer, is supported by the retinal vascular
system that emanates from the central retinal artery in the optic nerve and radiates to the
four retinal quadrants [1, 3]. These four branches form three capillary plexuses, one in
the nerve fiber layer and ganglion cell layer and two outer capillary plexuses that border
the inner nuclear layer termed the shallow inner nuclear layer and deep inner nuclear
layer capillary beds [5]. The inner capillary bed that resides within the nerve fiber layer
and ganglion cell layer can separate to two additional beds or appear as one capillary
bed. The arterioles and venules are restricted to the ganglion cell layer, and nerve fiber
layer with only capillaries developed from angiogenesis, extending deeper into the ret-
ina. Primates have an avascular region known as the macula that includes the fovea,
which is highly enriched with cones necessary for the high-contrast central vision [6].
The BRB controls the flux of blood-borne solutes and fluid into the retina and main-
tains the proper retinal environment for normal neural conduction. Low number of
vesicles and fenestrae, expression of multidrug-resistance genes, and well-developed
junctional complex in both the retinal vasculature and RPE combine to provide the nec-
essary defined neural environment for proper retinal function.
Multiple cell types in the retina contribute to endothelial junctional complex for-
mation and regulation. Investigators have demonstrated the ability of glial cells to
induce vascular barrier properties in a variety of systems for both brain and retinal
glia. Both astrocytes [7] and Müller cells [8] are capable of inducing barrier proper-
ties in endothelial cells, and injection of astrocytes or Müller cells into the anterior
chamber of the rat eye leads to vascularization and formation of vessels with elevated
barrier properties. Conversely, transplanting the avascular neural tissue of stage 13
quail brains into the coelomic cavity of 3-day chick embryos caused the invading cap-
illaries to take on blood-brain barrier characteristics including reduced permeability to
circulating dye [9].
Recent studies have identified a signal transduction adaptor molecule that promotes
production of probarrier factors from astrocytes. Src-suppressed C kinase substrate
or SSECKS in rodents, also termed gravin in humans, or AKAP12, coordinates sig-
nal transduction pathways by binding and organizing signaling molecules such as pro-
tein kinase C, protein kinase A, calmodulin, cyclins, and b (beta)-adrenergic receptors.
In brain, SSECKS colocalizes with GFAP, indicating a glial expression pattern, and a
recent report demonstrated that expression of SSECKS contributes to astrocytic induc-
tion of the blood-brain barrier [10]. Overexpression of SSECKS reduces expression of
vascular endothelial growth factor (VEGF) apparently through a reduction of c-Jun and
AP1 signaling and promotes angiopoietin 1 production.
In addition to astrocytes, pericytes also contribute to barrier formation by secreting an
angiopoietin 1 complex, which induces occludin expression [11]. Angiopoietin 1 is a lig-
and for the Tie2 receptor and both stabilizes blood vessels and protects them from VEGF-
induced permeability [12, 13]. Together, these studies demonstrate that glia and pericytes
contribute an important role in the induction of the blood-brain and BRB. Indeed, coc-
ulture of astrocytes and pericytes with endothelial cells induces barrier properties to a
greater extent than either cell type alone [14]. An understanding of the molecular mecha-
nisms by which this differentiation proceeds is only beginning to be elucidated.
Molecular Regulation of Endothelial Cell Tight Junctions 125
THE JUNCTIONAL COMPLEX

Formation of a well-developed tight junction creates the barrier across both the reti-
nal vasculature and RPE as shown by electron microscopy studies. Horseradish peroxi-
dase used as a stain in electron microscopy diffuses only to the tight junction in brain
cortical capillaries, while in other tissues without tight junctions, this marker diffuses
out of the vascular lumen [15]. Similar studies in the retina with dyes reveal that tight
junctions mediate the BRB, preventing solute flux into the retinal parenchyma [16, 17];
however, the adherens junctions are essential to development of the barrier, and likely
influence the formation of the tight junction [18–21]. Further, in blood-brain and BRBs,
the tight junctions and adherens junctions are indistinguishable at the ultrastructural
level [22, 23].
Tight junctions are composed of over 40 proteins encompassing transmembrane
proteins, intracellular scaffolding proteins, and signaling proteins, acting in concert to
influence barrier properties [24]. The transmembrane proteins include occludin, claudin
family members, tricellulin, and the junctional adhesion molecules (JAMs). The trans-
membrane proteins are linked to the cytoskeleton via an interaction with the scaffolding
protein family zonula occludens (ZO). Together, these proteins create a barrier to para-
cellular flux and contribute to the BRB.
ZO Proteins
The zonula occludens, or ZO, family members bind to both transmembrane struc-
tural proteins and regulatory proteins and organize the junctional complex. ZO-1 (210–
225 kDa) was the first tight junction protein identified, and subsequent studies using
coimmunoprecipitation identified the other ZO family members, ZO-2 (180 kDa) and
ZO-3 (130 kDa) [25–29]. ZO-1 and ZO-2 also associate with the adherens junctions [30]
potentially as a first step in formation of tight junctions. ZO proteins are members of the
membrane-associated guanylate kinase (MAGUK) family and are characterized by the
presence of three PDZ domains, one SH3 domain, and a GUK domain [31]. ZO family
members are also characterized by the presence of an acidic domain, a basic domain, a
leucine zipper, and a proline-rich C-terminus [25, 27, 32, 33].
The contribution of ZO-1 in junctional protein organization has been demonstrated
in cell culture and gene deletion studies. The calcium switch assay allows rapid disas-
sembly of tight junctions followed by reassembly upon return of calcium to the medium.
The use of siRNA to reduce ZO-1 expression results in reduced tight junction assembly
in the calcium switch assay [34, 35]. ZO-2 also contributes to junction assembly and
permeability as demonstrated by ZO-2 silencing which leads to a reduction in TER val-
ues in the calcium switch assay, without affecting mature TJs and increased permeability
to 70 kDa dextran [36]. Deletion of ZO-1 and ZO-2 in a cell line lacking ZO-3 led to a
complete loss of tight junction formation [37]. In vivo, ZO-1 [38] and ZO-2 [39] gene
deletions have been described and both are lethal very early in mouse embryogenesis.
However, distinct phenotypes suggest nonredundant function for these isoforms. ZO-1
gene deletion caused developmental defects in mouse embryo, yolk sac, and allantoic
membrane vasculature, suggesting a role for ZO-1 in angiogenesis [38]. Interestingly,
ZO-3 deletion does not impart lethality [39].
126 Runkle et al.
Claudins
The claudin family consists of 24 distinct proteins that form the tight junction seal
between neighboring cells particularly regulating ion flux. The claudins are 20–27 kDa
and possess four membrane-spanning domains with two extracellular loops and the
N- and C-terminus in the cytoplasm [40–42]. The C-terminus of claudins is essential to
both their stability and their membrane targeting [43, 44]. Of important note, all claudins
possess a YV sequence as the final two amino acids that is necessary for their interaction
with ZO [45, 46].
Claudin family expression patterns vary from tissue to tissue, and expression of dif-
ferent claudins confers specificity of barrier properties. In Madin Darby canine kidney
(MDCK) cells, claudin-1 overexpression increases TER values by fourfold concurrent
with a decrease in permeability to small and large molecules (4 and 40 kDa FITC-
dextrans) [47]. Claudins not only increase barrier properties but can also form charge-
selective paracellular ion channels. For example, claudin-16 controls magnesium flux
in the loop of Henle in the kidney and genetic defects of this claudin are associated
with loss of magnesium [48]. Mutations of claudin-16 alter the sodium flux reducing
magnesium transport potential [49]. A role for claudins in creating a charge specific
barrier was demonstrated by mutational analysis. Exchanging two acidic residues in the
first extracellular loop, Asp55 and Glu64, to create basic residues (D55R and E64K)
in the extracellular loop of claudin-15 changes charge selectivity for paracellular per-
meability from sodium to chloride [50].Finally, siRNA studies altering expression of
claudins-2, 4, and 7 can differentially alter cation or anion permeability [51]. Together,
these studies demonstrate claudin expression, provide specific ionic barriers, and pro-
vide charge-selective paracellular channels.
A model for claudin barrier formation has recently been proposed based on transfec-
tion studies and is distinct from many of the schematics of tight junctions previously
presented. Overexpression of claudin-5 in human embryonic kidney (HEK) cells, a cell
type that typically does not express tight junctions, leads to formation of strands of
tight junctions in the plasma membrane [52]. The investigators used mutational analysis
to distinguish trans-interactions or interactions between claudins on adjacent cells as
opposed to cis-interactions or interactions between claudins within a cell. By express-
ing fluorescent-tagged claudin-5 and performing a combination of live cell imaging,
fluorescence resonance energy transfer, and scanning electron microscopy (SEM), the
investigators were able to identify specific amino acids in the second extracellular loop
responsible for trans-interactions. The position of these amino acids combined with
SEM images led the investigators to propose a model in which 2 claudins first form a
dimer within a membrane (cis-interaction). This dimer then interacts by loop 2 interac-
tions to another dimer pair across the membrane (trans-interaction). This model of clau-
din interaction literally forms a zipper with the dimer pair of claudins interdigitating to
create the tight junction seal (Fig. 1).
In the RPE, the expression of claudins-1, 2, and 5 have been detected in the develop-
ing chick embryo by embryonic day 14 [53]. Further, claudins-1, 5, and 15 are expressed
in endothelial cells [45], and claudin-5 is expressed in the retinal vasculature [54]. Sev-
eral studies have examined the effect of loss of claudins on barrier properties. Claudin-1
deletion in mice is lethal within 1 day postbirth as a result of excessive water loss through
Fig. 1. Proposed interactions between claudins at the tight junction. The claudin proteins
form a zipper-like structure at the tight junction by alternating cis- and trans-interactions. Clau-
din proteins within the same cell form a cis-interaction forming a dimer pair. This dimer of
claudins interacts with another dimer pair in adjacent cells through loop 2 interactions forming a
trans-interaction between the two pair. Adopted from Piontek et al. [52].
the skin [55]. A claudin-5 knockout mouse was created, which developed normally and
upon birth appeared grossly normal. However, the mice died within 10 h after birth due
to increased permeability of small molecules (<800 Da) across the blood-brain barrier
[56]. Finally, evidence for claudin-11 in the neural tissue is found from gene deletion
studies. Mice deficient for claudin-11 showed severe neurological disorders and male
sterility as a result of loss of tight junctions within the CNS and Sertoli cells [57]. Unfor-
tunately, there is little information regarding specific changes to claudins in diabetic
retinopathy. A study of mRNA content of claudins-1 and 5 reveal claudin-1 mRNA first
increases at 6 weeks then decreases by 12 weeks postinduction of diabetes, while clau-
din 5 mRNA is decreased modestly at both time points [58]. Collectively, these studies
indicate that claudins are essential for tight junction function, creating charge specific
barriers while providing ion selective paracellular channels across the barrier. The regu-
lation of claudin function in diabetic retinopathy remains an area for further research.
Junctional Adhesion Molecules

The junctional adhesion molecules, or JAMs, are glycosylated single-pass transmem-
brane proteins, with the C-terminus located intracellularly, and an extracellular N-terminus
with two immunoglobulin (Ig)-like domains [42]. The JAMs are subdivided into two
groups based on sequence homology [59, 60]. The first subgroup, composed of JAM-A,
JAM-B, and JAM-C, directly interacts with ZO-1 and PAR3, a protein required for cell
polarity, through a C-terminal class II PDZ-binding domain motif [61–63]. The second
subgroup, which is composed of coxsackie and adenovirus receptor (CAR), JAM-4, and
endothelial-cell-selective adhesion molecule (ESAM) contains a class I PDZ-binding
128 Runkle et al.
domain motif [42]. CAR and JAM-4 bind with the Ligand-of-Numb protein X1 by this
PDZ-binding domain [64, 65], while JAM-4 and ESAM interact with the MAGUK
protein [66, 67]. JAMs are also able to form homodimers and heterodimers through
the extracellular domains. Specifically, JAM-A, JAM-B, and JAM-C interact with the
integrins aLb2, a4b1, and aMb2, respectively [59, 60, 68].
JAM-A is necessary for junction resealing in both epithelial and endothelial cells.
Specifically, studies demonstrate that monoclonal antibodies against JAM-A signifi-
cantly inhibit junction recovery in a calcium switch assay as measured by transepithelial
electrical resistance (TER) [69–71]. JAM-A also is involved in proper polarity main-
tenance [72] likely through its direct and specific interaction with PAR-3 [61, 62, 73].
Finally, ESAM is exclusively localized to endothelial cells [74], and its loss augments
VEGF-induced permeability [75].
Occludin and Tricellulin

Occludin was the first transmembrane TJ protein discovered and is a 522-amino-acid
protein of 55.9 kDa, and like the claudins, has four transmembrane domains [76]. How-
ever, the sequence and structure of occludin is sufficiently distinct from claudins, sug-
gesting a unique role of this protein in tight junctions. A second gene product, tricellulin
or MARVEL D2, has recently been identified as a 555-amino acid protein localized spe-
cifically at regions where three cells make contact [76]. Tricellulin and occludin share
homology in the MARVEL domain across the tetra-transmembrane regions. MAL and
related proteins for vesicle trafficking and membrane link or MARVEL domains are
present in vesicle transport proteins such as MAL, which are essential for apical traf-
ficking of membrane and secretory proteins in epithelia and also in the neural vesicle
proteins synaptophysin and synaptogyrin [77]. In epithelial cells, occludin is enriched at
bicellular junctions, while tricellulin is enriched at tricellular junctions; however, upon
knockdown of occludin, tricellulin can be observed at bicellular junctions, which sug-
gests occludin normally restricts tricellulin localization [78]. Little is known about tricel-
lulin in endothelial cells, so this chapter’s primary focus will be on occludin.
Occludin content at the TJ correlates with barrier properties such that occludin is
higher in cells with a tighter barrier, such as arterial endothelial cells and brain and
retinal endothelium, and lower in cells known to have a more permeable barrier, such as
venous endothelial cells and endothelial cells of nonneuronal tissues [79, 80] (Fig. 2).
However, occludin does not provide a structural barrier for the tight junctions as do
the claudins. Occludin knockout mice are viable and appear to form TJs but exhibit a
number of abnormalities, including postnatal growth retardation, abnormalities in the
testis leading to male infertility, and inability of females to suckle their young. Addi-
tionally, salivary gland abnormalities, thinning of compact bone, brain calcium depos-
its, chronic gastritis, and hyperplasia of the gastric epithelium are all a consequence
of occludin gene deletion in mice [81, 82]. While a large number of additional stud-
ies including siRNA and overexpression studies suggest occludin contributes to barrier
properties in a host of cell types (reviewed in ref. 2), the role of occludin in the barrier
has remained difficult to understand. Recent studies suggest that occludin might not
provide a direct structural component to the tight junction complex but rather act as a
regulator of barrier properties.
Fig. 2. Localization of occludin and claudin-5 in the vasculature of rat retina. Whole rat
retinas were dissected and labeled with antibodies directed against occludin and claudin-5 for
observation by confocal microscopy. These images show that occludin is differentially distrib-
uted in the blood vessels of the normal rat retina. (A) Occludin immunoreactivity is intense in
the cell borders of main arterioles, and also can be detected as punctate immunoreactivity within
cells (arrow). (B) The cell borders of smaller arterioles are also immunoreactive for occludin.
(C) Occludin immunoreactivity in the capillaries of the inner retina (arrowheads) is less than that
of the arterioles. (D) Occludin immunoreactivity of the capillaries of the outer plexiform layer is
as intense as that of the arterioles. (E) Occludin immunoreactivity of the postcapillary venules
(arrowheads) of the inner retina is diminished. (F) Immunoreactivity of the main venules (arrow-
heads) is further reduced as they approach the optic disk (right). In contrast, claudin-5 immuno-
reactivity is evenly distributed in the blood vessels of the rat retina as shown by its expression in
the arteriole (G, arrow) and venule (H, arrow). Images taken from Barber and Antonetti [54].
130 Runkle et al.
VASCULAR PERMEABILITY IN DIABETIC RETINOPATHY

The cause of visual loss in diabetic retinopathy remains unclear but likely involves
loss of proper cellular interaction between the neural retina and retinal vasculature [83].
Changes in blood vessel permeability and macular edema consistently rank as the top
clinical correlates associated with loss of vision [84, 85]. Indeed, central macular thick-
ness, as measured by optical coherence tomography, and fluorescein leakage combined
with age account for 33% of the variation in visual acuity [85]. Further, the location,
severity, and duration of macular edema are all linked to visual loss [86]. Alterations to
the BRB are believed to contribute to retinal macular edema with increased fluorescein
permeability related to the progression of macular edema [87, 88]. Collectively, these
clinical studies demonstrate a strong correlation with alterations to the BRB, increased
macular edema, and loss of vision in patients with diabetes. It should also be noted,
however, that other factors clearly contribute to vision loss in diabetes.
Vascular changes in diabetic retinopathy are due, at least in part, to elevated VEGF
expression [89–94]. Indeed, recent clinical studies using anti-VEGF antibody therapy
improved visual acuity in combination with laser compared to laser treatment alone
[95]. In addition to VEGF, other cytokines likely also contribute to vascular changes
in diabetic retinopathy. Increased levels of interleukin-1 beta (IL-1b (beta)) and tumor
necrosis factor-alpha (TNF-a (alpha)) are increased in the vitreous of diabetic patients
with proliferative diabetic retinopathy [96, 97] and in diabetic rat retinas [98–100], while
leukostasis has been observed in response to elevated intracellular adhesion molecule-1
expression in diabetic rodents [101]. Furthermore, proteomic analysis of vitreous from
patients with diabetic retinopathy reveals increased carbonic anhydrase I likely as a
result of retinal hemorrhage and erythrocyte lysis [102]. The pH increase driven by
carbonic anhydrase drives kallikrein activation leading to bradykinin production and
permeability of the retinal vasculature as demonstrated by carbonic anhydrase I intrav-
itreal injection. Therefore, multiple factors contribute to the increased retinal vascular
permeability in diabetic retinopathy. Changes in both growth factors and inflammatory
cytokines may induce alterations in the vascular barrier properties by distinct mecha-
nisms over the course of diabetes. Thus, understanding the mechanisms of vascular
permeability in diabetic retinopathy will allow the development of rationale therapies
targeting specific disease characteristics or potentially identifying common mechanisms
shared by the variety of cytokines altered in diabetic retinopathy.
VEGF-Induced Regulation of Endothelial Permeability

Both VEGF treatment of endothelial cells and induction of diabetes alter occludin
content and localization associated with alterations in barrier properties. Studies on rats
with streptozotocin-induced diabetes with 3-month duration reveal decreased occludin
content and immunostaining at cell borders concomitant with increased BRB perme-
ability. This change in occludin content can be recapitulated in bovine retinal endothelial
cells (BREC) treated with VEGF [103]. Immunohistochemical analysis of occludin in
diabetes or after addition of VEGF demonstrates that occludin localization at the cell
border changes specifically at regions of paracellular permeability [54]. In this study,
fluorescently labeled concanavalin A was perfused through control and diabetic or con-
trol and VEGF-treated retinas that were fixed to prevent active transport and preserve
protein localization. Concanavalin A does not bind endothelial cells directly but deco-
rates regions where pores have formed that allow transport of the lectin to the endothe-
lial basement membrane. Immunohistochemical analysis revealed that concanavalin A
stained the basement membrane specifically at regions of low or absent occludin border
staining, suggesting that redistribution of occludin away from the cell border created
regions of paracellular permeability. Likewise, treatment of RPE cells with hepatocyte
growth factor (HGF) reduced tight junctions, decreased TER, and increased diffusion of
fluorescently labeled marker from the apical to basolateral membrane. After 6 h of HGF
treatment, occludin, claudin-1, and a-catenin were redistributed from the membrane to
the cytoplasm, and ZO-1 immunostaining was reduced [104]. Together, these studies
demonstrate that changes in occludin are associated with altered permeability in the
retina and suggest that occludin contributes to regulation of paracellular permeability in
retinal endothelial cells.
Occludin Phosphorylation and Permeability

While gene deletion and knockdown of occudin expression reveal occludin is not
necessary for formation of tight junctions, the observed changes in occludin content and
localization associated with changes in barrier properties suggest occludin contributes to
regulation of barrier properties. Recent studies suggest phosphorylation of occludin acts
as a molecular switch to regulate endothelial barrier properties. Treatment of endothelial
cells with VEGF [105, 106], cytokines [107], oxidized phospholipids [108], monocyte
chemoattractant protein-1 (MCP-1 or CCL2) [109, 110], or shear stress [111] increased
both serine/threonine phosphorylation of occludin and permeability. Furthermore, dia-
betes increases occludin phosphorylation in the rat retina similar to the VEGF-induced
increase in BREC [106].
Phosphorylation of occludin leads to ubiquitination and subsequent endocytosis regu-
lating endothelial barrier properties. The use of two-dimensional gel electrophoresis
in BREC demonstrates that occludin is basally phosphorylated on two residues, and
growth factor stimulation leads to phosphorylation at three additional sites [106]. Using
mass spectrometry of occludin immunoprecipitated from vascular endothelial cells,
Sundstrom et al. identified five putative occludin phosphosites and demonstrated at least
one of these sites: Ser490 was VEGF responsive as shown by the use of a phospho-
specific antibody [112]. This Ser490 phosphorylation allows subsequent ubiquitination
of occludin by the E3 ligase Itch and endocytosis of the transmembrane protein by
binding epsin, eps15, and Hrs, which possess ubiquitin interacting motifs and chaperon
occludin through endocytosis [113]. Importantly, mutating Ser490 to alanine (S490A)
prevented both occludin ubiquitination and VEGF-induced permeability, while express-
ing an occludin-ubiquitin chimeric protein creates leaky endothelial junctions. Thus,
the carboxy-terminal tail of occludin can be phosphorylated and subsequently ubiq-
uitinated, directing occludin into the endocytosis pathway and regulating endothelial
barrier properties, potentially by controlling the localization of other junctional proteins
such as the claudins.
While occludin phosphorylation and ubiquitination are necessary steps for VEGF-
induced permeability, additional junction alterations are likely involved in the process.
Recently, ubiquitination of claudins has also been observed in epithelial cells with the
132 Runkle et al.
E3 ubiquitin ligase LNX1p80 regulating claudin internalization and lysosomal degra-

dation [114]. Further, in endothelial cells without tight junctions, the phosphorylation
and endocytosis of VE-cadherin is an essential step to regulate barrier properties [115].
Additionally, the ubiquitin ligase Hakai ubiquitinates E-cadherin and induces endocyto-
sis [116]. While the mechanisms controlling barrier properties are complex, posttransla-
tional modifications regulating endocytosis of junctional components provide important
mechanisms of permeability regulation.
Protein Kinase C in Regulation of Barrier Properties

Key mediators of BRB homeostasis and diabetes-induced vascular abnormalities
include the Protein Kinase C (PKC) family [117]. Alterations of PKC isoforms during
diabetes may result from hyperglycemia, de novo synthesis of diacylglycerol (DAG),
advanced glycation end products (AGEs), increased expression of growth factor/inflam-
matory cytokines, and to a generally altered redox state [118]. As a member of the larger
protein kinase AGC super family, PKC isozymes regulate essential signaling pathways
in various tissues controlling proliferation, differentiation, survival, and cell growth
(reviewed in [119–122]). There are three main classes of PKC isoforms based on their
cofactor requirements. The classical PKC isoforms, a (alpha), bI, bII (betaI, betaII), and
g (gamma), require Ca2+ and diacylglycerol (DAG) for activation. Novel PKC isoforms,
d (delta), e (epsilon), h (eta), and q (theta), require DAG; while the atypical PKC iso-
forms, z (zeta), i (iota) and l (lamda), require neither DAG or Ca2+ to become activated
[122].
Evidence for a role of PKC isoforms in vascular permeability and increased flux of
macromolecules began in the late 1980s and early 1990s [123, 124]. Treatment of bovine
pulmonary artery endothelial cells with phorbol 12-myristate 13-acetate (PMA), an acti-
vator of classical and novel PKC isoforms, leads to an approximately twofold increase
in 125I-albumin permeability [123]. Additionally, PMA and diacylglycerol treatment of
bovine aortic endothelial cells alters 14C-sucrose and 3H-inulin flux but not 125I-polyvinyl
pyrrolidone (360 kDa) permeability, indicating PKC isoforms control paracellular per-
meability [124].
Diabetes-induced vascular permeability can be partly attributed to increased classical
PKC activity. PKC activity is altered in the diabetic rat retina, BREC, and in bovine reti-
nal pericytes (BRPs) [117]. Oral administration of LY333531, a specific PKCb (beta)
inhibitor with low nanomolar potency similar to ruboxistaurin, ameliorates the diabe-
tes-induced effect on retinal blood flow [125]. Membrane translocation and activation
of PKCa (alpha), b (beta)II, and d (delta) isoforms in response to VEGF have been
observed in vivo [126], and this translocation was blocked by oral administration of the
PKCb (beta) inhibitor [127]. Mechanistically, increased activity of classical PKC iso-
zymes leads to tight junction deregulation, cytoskeleton rearrangements, and endothelial
permeability [106, 128]. Data from our laboratory demonstrates VEGF-induced occludin
phosphorylation, and ubiquitination requires PKCb (beta) (manuscript in preparation).
Furthermore, PKCa (alpha) mediates hyperglycemia-induced porcine aortic endothe-
lial cell permeability demonstrated by RNAi knockdown [129]. Collectively, these data
implicate classical PKC isoforms mediate vascular endothelial permeability induced by
diabetes.
Although classical PKC isoforms contribute to VEGF-induced endothelial permeability,

other signaling pathways also contribute to control of the BRB. Studies of primary reti-
nal endothelial cell culture assays show an incomplete attenuation of VEGF-induced
endothelial permeability via classical PKC inhibition [106]. In addition, tumor necrosis
factor a (alpha) induces endothelial permeability over 6 h but is unaffected by clas-
sical PKC inhibitors (manuscript under review). Together, these data suggest concur-
rent or alternative signaling pathways may also contribute to the vascular permeability
observed in diabetic retinopathy.
In addition to classical PKC isozymes, novel PKCs are implicated in mediating dia-
betes-induced alterations of BRB homeostasis. PKCd (delta) translocates to the mem-
brane fraction of retinal lysates of diabetic mice indicative of PKCd (delta) activation
[130]. Geraldes et al. identified Src homology 2 domain-containing phosphatase-1
(SHP-1), a protein tyrosine phosphatase, as a downstream target of PKCd that leads to
platelet-derived growth factor beta-receptor (PDGFb (beta) receptor) dephosphoryla-
tion. PDGFb (beta) is a survival signal for retinal pericytes allowing for activation of
Akt, which is essential to pericyte survival [131]. Reduced PDGFb receptor signaling
results in diabetes-induced pericyte apoptosis, which increases vascular permeability in
the diabetic mouse retina [130]. In addition, PKCd mediates AGE-induced permeability
in human retinal endothelial cells (HREC) as shown through the use of PKCd small
molecule inhibitors and siRNA studies which prevent the AGE-induced alterations to
ZO-1 and ZO-2 protein expression [132].
In addition to the well-established contributions of classical and novel PKC iso-
forms to diabetes-induced junctional deregulation and vascular permeability, a role for
the atypical PKC (aPKC) isoforms is emerging. The aPKC isoforms act downstream
of both the phosphatidylinositol 3-kinase (PI3-K) and the small Rho GTPases family
members in response to growth factors, leading to proliferation, differentiation, and
cell polarity/apical-basolateral orientation [73, 133]. Additionally, aPKC isoforms are
critical for the establishment of primordial junction development and the regulation of
junction complexes in both endothelial and epithelial cells [134, 135]. VEGF admin-
istration leads to a twofold increase in PI3-K activity as well as transiently activating
small Rho GTPases such as Cdc42, Rac1, and Rho, contributing to endothelial per-
meability in endothelial cells [126, 136]. Therefore, aPKC isoforms may play a criti-
cal role in the regulation of growth-factor-induced vascular permeability. Data from
our laboratory demonstrates overexpression of PKCz (zeta), an atypical PKC iso-
form, potentiates the effect of VEGF on permeability, whereas kinase dead-mediated
competitive inhibition of PKCz (zeta) blocks VEGF-induced permeability in BREC.
Importantly, aPKC inhibition prevents TNFa-induced endothelial permeability and
prevents loss of tight junction proteins claudin-5 and ZO-1 and cell border disorgani-
zation (manuscript under review). Together, these studies demonstrate aPKC isoforms
contribute to VEGF and TNFa-induced permeability, elucidating a common signaling
mechanism in diabetic retinopathy. Collectively, these data show a contribution of
classical, novel, and atypical PKC isoforms in the control of retinal vascular perme-
ability (Fig. 3).
134 Runkle et al.
Fig. 3. PKC isozymes in the blood-retinal barrier. In endothelial cells, both classical and
atypical PKC isozymes contribute to VEGF signaling. VEGF activates classical PKCs, such as
PKCb (beta) leading to phosphorylation of the tight junction protein occludin and promoting
internalization and subsequent endothelial permeability. Ruboxistaurin inhibition of PKCb (beta)
prevents VEGF-induced permeability by blocking this pathway. Concurrently, atypical PKC iso-
forms, such as PKCz (zeta), lead to increased endothelial permeability via unknown mecha-
nisms. However, inhibition of atypical PKC activity effectively blocks both growth factor and
inflammatory-cytokine- induced endothelial permeability. In pericytes, hyperglycemia-induced
increase of novel PKCs, specifically PKCd (delta), inhibits PDGFb (beta) survival signaling to
Akt, leading to pericyte apoptosis. Loss of pericytes, coupled with VEGF-induced endothelial
permeability likely contributes to the macular edema observed in diabetic retinopathy.
CONCLUSIONS
Vascular permeability in diabetic retinopathy may be attributed to a host of changes
in the retina, including increases in growth factors such as VEGF, cytokines like
TNFa (alpha), or protease activation such as kallikrein/bradykinin system. Posttrans-
lational modification of the junction proteins and regulated endocytosis is an impor-
tant mechanism controlling retinal vascular permeability. Indeed, VEGF activation of
PKCb (beta) controls occludin phosphorylation and subsequent ubiquitination neces-
sary for VEGF-induced permeability. As information regarding changes to the junction
complex becomes better understood, more targeted therapies may become available,
increasing our ability to maintain retinal vascular integrity and visual function in the
face of diabetes.
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9
Capillary Degeneration in Diabetic Retinopathy
Timothy S. Kern
CONTENTS
Vascular Nonperfusion in Diabetes: Mechanisms
Molecular Causes of Capillary Degeneration
Unexplained Aspects of Diabetes-Induced Degeneration
of Retinal Capillaries
What Is the Relation Between the Retinal Vasculature
and Neuronal Retina Structure and Function in Diabetes?
Conclusion
Acknowledgment
References
Keywords Diabetic retinopathy • Vasoocclusion • Nonperfusion • Pathogenesis
Capillary degeneration is a required step during normal development [1–5]. Capillary

degeneration also has serious and undesirable consequences in several ischemic dis-
eases, including retinopathy of prematurity, sickle-cell retinopathy [6–9], and diabetic
retinopathy. This review will focus on causes of vascular nonperfusion and capillary
degeneration in the retina, and their relation to diabetic retinopathy.
Vascular pathology in the early stages of diabetic retinopathy is characterized histologi-
cally by the presence of saccular capillary microaneurysms, pericyte-deficient capillaries,
and nonperfused and degenerate capillaries in patients (Fig. 1). Capillary nonperfusion
and/or degeneration are particularly important lesions of the early retinopathy [10, 11].
The area of nonperfusion in the retina is significantly correlated with the mean severity
grade of the retinopathy [12], and it is generally accepted that capillary nonperfusion and
degeneration play major and causal roles in the progression to preretinal neovasculariza-
tion that develops in some diabetic patients [13]. The extent of capillary nonperfusion
in diabetic retinopathy has been found to correlate with the amount and localization of
neovascularization [13]. As more and more capillaries become nonperfused or occluded,
local areas of the retina likely become deprived of oxygen and nutrients, thus stimulating
production of one or more ischemia-driven growth factors, such as vascular endothelial

143
144 Kern
Fig. 1. (A) Low-power view of retinal histopathology in a patient having nonproliferative

diabetic retinopathy. There is a large area of capillary degeneration in the photo, indicated by the
absence of dark nuclear stain in most vessels. Numerous microaneurysms are along the top and
bottom of the micrograph. (B) Close-up of vascular histopathology in a diabetic patient. Degen-
erate capillaries are indicated by arrows, and saccular capillary microaneurysm is indicated by
asterisk (*).
growth factor (VEGF). VEGF is known to be a key molecule leading to retinal permeability
and neovascularization in diabetes and other retinal diseases [14–16].
VASCULAR NONPERFUSION IN DIABETES: MECHANISMS

Capillary nonperfusion can be due either to temporary or permanent occlusion/degen-
eration. Degenerate capillaries that are detected via histologic preparations of the isolated
vasculature (trypsin digest or elastase methods) apparently once were functional capil-
laries that degenerated until only a basement membrane tube remains. These degenerate
capillaries are no longer perfused, and have been used as histologic markers of nonper-
fused capillaries [10]. Although devoid of nuclei, these degenerate vessels sometimes
are not truly acellular, and may be filled with cytoplasmic processes of glial cells [17].
Nonperfusion of capillaries also might be temporary. Temporary occlusions do not always
cause damage to the capillary or nearby tissue, but repeated ischemic insults in a chronic
disease like diabetes likely could cause progressive injury. Moreover, the neural retina of
diabetic animals has been shown to be more sensitive to ischemia [18]. Small nonperfused
areas observed in some retinas of diabetic patients later were found to be reperfused, and
even the entire fundus became reperfused in a small number of other diabetic patients [19].
It is not clear if the reperfusion occurred in vessels that originally were occluded, or if other
patent vessels took their place to supply blood to the ischemic region.
Mechanisms believed to contribute to the nonperfusion and degeneration of retinal
capillaries in diabetes include occlusion of the vascular lumen by white blood cells,
platelets, or other cells (notably glial cell processes), or altered hemodynamics. These
mechanisms are not mutually exclusive.
1. Vasoocclusion by white blood cells. Using either ex vivo or in vivo techniques, diabetes
increases adhesion of leukocytes to the vascular wall in diabetic animals [20–34]. More-
over, instances have been reported where the circulation of fluorescent dye injected into
Capillary Degeneration in Diabetic Retinopathy 145
the blood or using in situ (whole mount) perfusion methods is blocked by an immobile
leukocyte, suggesting that the leukostasis is contributing to the capillary nonperfusion
in diabetic retinopathy [27, 35]. Although individual instances of temporary capillary
occlusion by a blood cell might be short-lived, cumulative effects of such repeated
ischemia/reperfusion injuries over a prolonged interval are not known. Leukocyte stiff-
ness has been reported to be increased in diabetes, thus making the cells less filterable
and more likely to occlude retinal vessels [21, 36]. Abnormal leukocyte adherence to
retinal vessels in diabetes occurs via expression of ICAM-1 and other adhesion mol-
ecules on the endothelial surface. Diabetes increases expression of ICAM-1 and other
adhesion molecules in retinas of animals and humans [24, 28, 37–39], and interaction
of this adhesion molecule with the CD18 adhesion molecule on leukocytes contributes
to the diabetes-induced increase in adherence of white blood cells to the vascular wall
in retinal vessels [24]. Diabetic mice lacking ICAM-1 and CD18 do not develop either
the diabetes-induced increase in leukostasis, vascular permeability, or degeneration of
retinal capillaries [33], providing strong evidence that white blood cells likely contrib-
ute to the eventual capillary damage and degeneration that is characteristic of diabetic
retinopathy. Leukocytes have been found to be associated with capillary closure in reti-
nas of spontaneously diabetic monkeys [40].
Although evidence suggesting a role for white blood cells in the development of
the retinopathy is accumulating [33, 41, 42], whether or not leukostasis [23, 24, 26,
27, 33, 39, 43, 44] per se is a good parameter of the process of leading to capillary de-
generation or diabetic retinopathy is less clear. A disconnect between leukostasis per
se and the degeneration of retinal capillaries in diabetes was suggested by evidence
that 12-lipoxygenase−/− diabetic mice did not develop the diabetes-induced increase
in leukostasis, but nevertheless developed the capillary degeneration of diabetic retin-
opathy [45].
2. Vasoocclusion by platelets. Platelet microthrombi have been detected in the retinas of
diabetic rats and humans, and have been spatially associated with apoptotic endothe-
lial cells [46, 47]. Nevertheless, the selective antiplatelet drug (clopidogrel) did not
prevent neuronal apoptosis, glial reactivity, capillary cell apoptosis, or degeneration
of retinal capillaries in diabetic rats [48], thus providing no support for a postulated
role of platelet aggregation in the development of capillary occlusion in diabetes.
Moreover, aspirin (delivered at low doses that should have inhibited platelet aggrega-
tion) did not [49] or only modestly [50] inhibited the progression of diabetic retinopa-
thy in clinical trials.
3. Hemodynamics. Many studies of diabetes indicate that there are alterations in blood
flow to the retina [51–54]. Reduction in flow might be due to diabetes-induced in-
crease in vascular resistance or viscosity, or to a reduction in metabolic activity in the
retina which thus reduces the metabolic demand for flow. Whatever the cause, sub-
sequent impairments to flow, even if slight, have been speculated to allow temporary
stasis until backpressure increases.
4. Invasion of the vascular lumen by other cell types. Cellular processes from retinal glial
cells have been found inside of occasional degenerate capillaries (identified from the
basement membrane tube that surrounds vessels) [17, 55, 56]. It is not clear whether
this glial invasion precedes and causes the capillary to degenerate or is a result of the
capillary cells dying (thus opening spaces for the glial cell to expand into).
146 Kern
5. Growth factor withdrawal. Intravitreal administration of VEGF antagonists has been

reported to cause apparent nonperfusion or regression of neovascular tufts in diabetic
retinopathy [57, 58]. The later reappearance of the neovascular tufts in the same area
of retina in some patients [57], however, suggests that the treatment had reduced per-
fusion of the vessels, but apparently had not caused regression.
MOLECULAR CAUSES OF CAPILLARY DEGENERATION

The molecular mechanisms by which capillary degeneration occurs in diabetes have
not been studied in humans, human studies instead focusing on the retinopathy as a
whole. Thus, the primary focus of the present discussion on molecular causes of dia-
betes-induced degeneration of retinal capillaries will focus largely on animal studies.
Factors or pathways involved in the capillary degeneration in early stages of diabetic
retinopathy have been identified primarily using pharmacologic inhibitors or genetically
modified animals.
Metabolic control. Intensive insulin therapy, blood pressure medications, and lipid-low-
ering therapy all have been shown to inhibit the development of diabetic retinopathy
in patients [59–63]. Consistent with this, animal studies have demonstrated that these
therapies likewise inhibited degeneration of the retinal vasculature in diabetes [64–67],
and they demonstrate that the therapies did inhibit degeneration of the retinal vascula-
ture. Likewise, lipid levels have been shown to influence the development or progression
of the retinopathy in diabetic animals [68, 69].
Pathways secondary to poor metabolic control of diabetes. Metabolic sequelae of hyper-
glycemia have been extensively studied to identify potential causes responsible for the
development of diabetic retinopathy and its associated vascular abnormalities. A variety
of therapies have reduced the number of TUNEL-positive capillary cells or degenerate
capillaries compared to control [27, 33, 39, 44, 48, 67, 70–77], suggesting that related
metabolic abnormalities also contribute to the capillary cell death. Tables 1 and 2 sum-
marize a number of therapies or genetic modifications that have been reported to inhibit
degeneration of retinal capillaries in diabetic animals. TUNEL-positive retinal capillary
cells are a much less reproducible finding in diabetic mice than in diabetic rats (Kern,
unpublished).
UNEXPLAINED ASPECTS OF DIABETES-INDUCED DEGENERATION

OF RETINAL CAPILLARIES
Nonuniform degeneration of capillaries within the same retina. Despite the evidence
indicating that hyperglycemia is a (or the) major determinant of capillary degeneration in
diabetic retinopathy, capillary degeneration (like other lesions of the retinopathy) does not
develop uniformly across even the same retina of diabetic dogs or patients [78, 79]. The
superior temporal portion of retina develops significantly more pathology than, for exam-
ple, inferior nasal retina. Likewise, midperipheral retina is more prone to undergo capil-
lary nonperfusion in diabetic retinopathy than is the posterior or anterior retina [13].
Why does it take so long for capillary degeneration to become apparent in diabetic
retinopathy? As mentioned earlier, vascular remodeling is a normal process, and so all
Table 1. Pharmacologic inhibition of capillary degeneration in retinas from diabetic animals
Presumed target Drug Presumed pathway References Other possible mechanisms References
Angiotensin converting Captopril Blood pressure [67] Inhibition of glucose uptake [93]
enzyme into retina
Caspase-1 Minocycline Inflammation [94] Inhibition of microglia [95]
Cyclooxygenase Nepafenac Inflammation [76]
Poly(ADP-ribose) PARP inhibitor Inflammation [39]
polymerase
p38 p38 inhibitor Inflammation [96]
Inflammation Salicylates Inflammation [48, 77, 97]
TNFa (alpha)a Pegsunercept Inflammation [98]
FOXO1 siRNA against FOXO1 Cell signaling [99]
RAGE sRAGE Inflammation [69]
Aldose reductaseb Aldose reductase Metabolic abnormality [74, 100] Inflammation (independent [101–104]
inhibitor of hyperglycemia)
Transketolase Benfotiamine Metabolic abnormality [105]
Glycation, Pyridoxamine Metabolic abnormality [73] CD36 [106]
Capillary Degeneration in Diabetic Retinopathy
lipoxidation
iNOS Aminoguanidine Metabolic abnormality [71] Inhibit formation advanced [107, 108]
glycation endproducts
AGE formation Tenilsetam AGE formation [109]
Oxidative stress Antioxidants Oxidative stress [72, 75, 110]
Oxidative stress AREDS diet Oxidative stress [111]
TrkA Nerve growth factor Indirect action via [112], Kern, Neuroprotection [113]
nonvascular cell unpublished
Although not studied in diabetic animals, inhibition of TNFaa or aldose reductaseb inhibited capillary degeneration in galactose-fed animals
[114–116]
147
148 Kern
Table 2. Genetic modifications found to inhibit diabetes-induced capillary degeneration in

animals
Gene modification Target Presumed action References
Cu/Zn superoxide Superoxide dismutase Oxidative stress [117]
dismutase−/−
Mn superoxide Superoxide dismutase Oxidative stress [118]
dismutase−/−
CD-18−/− Leukocyte adherence Inflammation [33]
ICAM-1−/− Leukocyte adherence Inflammation [33]
IL-1b receptor−/− IL-1b signaling Inflammation [94]
iNOS−/− Nitric oxide production Inflammation [44]
5-Lipoxygenase−/− Eicosenoid production Inflammation [45]
retinas have at least some degenerate, nonperfused remnants of vessels, and occasional
vessels likely become occluded or nonfunctional also throughout life. Diabetes greatly
accelerates this process, but prolonged exposure to the abnormal milieu of diabetes
(approximately 6 months in rodents, 3 or more years in dogs and other larger mammals,
and many years in patients) still is required before the diabetes-induced vasoobliteration
becomes clearly greater than normal. Why this prolonged interval is required before the
degenerative process become apparent remains a mystery, but understanding it likely will
provide valuable information into understanding the pathogenesis of the retinopathy.
Metabolic memory. Capillary degeneration has been observed to continue on for at
least some interval after restoration of euglycemia in diabetic dogs [65] and rats [80].
Although not specifically focusing on capillary degeneration, retinopathy likewise was
found to progress for about a year in diabetic patients after reinstitution of glycemic
control [59]. Various molecular changes also have been found to show this “memory”
after prior exposure to elevated glucose concentration [81–84], but their relevance to the
vascular degeneration of diabetic retinopathy has not been clearly established.
WHAT IS THE RELATION BETWEEN THE RETINAL

VASCULATURE AND NEURONAL RETINA STRUCTURE
AND FUNCTION IN DIABETES?
Like other neural tissues, metabolic demand by the neural retina influences the retinal
vasculature to regulate blood flow to that tissue [85–87]. Conversely, delivery of oxygen
and nutrients and removal of waste by the vasculature influence function of the neural
retina. Thus, there is neurovascular coupling which can become altered in diabetes [88].
In a very interesting study, the disruption of that coupling led to protection of the retinal
vasculature in diabetes. As expected, the density of the retinal vasculature in wild-type
control animals diabetic for many months became subnormal, but this capillary degen-
eration did not develop in diabetic mice having photoreceptor degeneration (rhodopsin
knockout mice) [89]. Thus, the outer retina seemed to somehow influence the retinal
vasculature (possibly via effects on metabolism by the inner retina), and loss of the
outer retina protected the vasculature despite continued exposure to hyperglycemia. In
contrast to this report, however, degeneration of retinal neurons in a different model of
retinal degeneration (transgenic rat overexpressing a mutant cilia gene polycystin-2)
resulted in increased degeneration of retinal capillaries [90]. The neuronal and vascular
components of the retina clearly are interactive, but the extent of that interaction under
pathologic circumstances requires additional investigation.
Although diabetes-induced defects in metabolism of retinal neurons might impair
vision in diabetes independent of vascular disease, occlusion of retinal vessels is closely
associated with detrimental effects of diabetes on visual function. The extent of retinal
capillary nonperfusion detected by fluorescein angiography has been associated with
a reduction in retinal sensitivity as assessed by microperimetry [91]. In addition, dia-
betic patients with extensive retinal arteriolar and capillary obstruction developed an
ischemic maculopathy that resulted in severe loss of visual acuity in some eyes [92].
Whether this is due solely to the vascular nonperfusion or associated neuronal dysfunc-
tion is not clear.
CONCLUSION
Vascular abnormalities are major contributors to the morbidity resulting from long-
standing diabetes in patients, and capillary nonperfusion and degeneration are especially
important in the progression the advanced, proliferative stages of the retinopathy. Clini-
cal attention has focused especially on inhibiting the abnormalities (such as neovascu-
larization and retinal edema) that can have immediate effects on visual impairment, but
appreciable retinal vascular damage already will have occurred by focusing on these late
stages of the disease. Success is now being made also in the earlier stages of the retin-
opathy to inhibit capillary degeneration, with hopes that inhibiting the early damage will
inhibit development of the more advanced stages of the retinopathy.
ACKNOWLEDGMENT
This work was funded by PHS grant EY00300 and a grant from the Medical Research
Service of the Department of Veteran Affairs.
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10
Proteases in Diabetic Retinopathy
Sampathkumar Rangasamy, Paul McGuire, and Arup Das
CONTENTS
Proteases in Retinal Vasculature
Proteases in Retinal Neovascularization
Tissue Inhibitor of Matrix Metalloproteinases in Retinal
Neovascularization
Proteases in Diabetic Macular Edema
Conclusion
Acknowledgment
References
Keywords Urokinase Plasminogen activator (uPA) • Matrix Metalloproteinases (MMPs)

• Tissue inhibitors of metalloproteinases (TIMPs) • Plasminogen activator inhibitors (PAI)
PROTEASES IN RETINAL VASCULATURE

The human retinal structure along with the neuronal component develops from a single
layer of undifferentiated neuroepithelial cells during embryonic ontogenesis. During this
process, retinal vasculature develops to form an elaborate vascular tree that matches the
metabolic need of tissues. Retinal vascular development involves a complex process of
vasculogenesis and angiogenesis. Vasculogenesis describes the de novo formation of ves-
sels from vascular endothelial precursor cells (angioblasts), which migrate to or differen-
tiate at the location of future vessels, coalesce into cords, and differentiate into endothelial
cells leading to the formation of ultimate vessels [1]. Angiogenesis is a multistep proc-
ess that requires degradation of the basement membrane, endothelial cell migration and
proliferation, and the capillary tube formation, which results in sprouting of new capil-
laries from the existing blood vessels. Also, new evidence indicates that the bone mar-
row–derived endothelial progenitor cells contribute to the postnatal neovascularization.

157
158 Rangasamy et al.
Angiogenesis plays a central part not only in the development of retina but also in the
visual impairment attributable to retinopathy in diabetes, retinal vascular occlusion, retin-
opathy of prematurity, sickle cell disease, and in age-related macular degeneration. The
process of angiogenesis in the retina and other tissues is characterized by distinct phases
or activities including an initial response to locally produced angiogenic factors and sig-
nals. This event is followed by a rapid upregulation of matrix-degrading enzymes or
extracellular proteases (extracellular proteolytic mediators) that facilitate the breakdown
of the capillary basal lamina and migration and subsequent invasion of activated endothe-
lial cells into the surrounding extracellular tissues [2, 3]. Extracellular proteases help not
only in the degradation of interstitial extracellular matrices (ECMs) and basement mem-
branes but also in the recruitment of progenitor cells into the ECM during tissue remod-
eling. Proteases are expressed by normal cells in tissue remodeling events and also during
pathological events such as tumor angiogenesis and metastasis. This chapter will review
these extracellular proteases and discuss their potential roles in diabetic retinopathy and
the development of therapeutic strategies targeting these molecules in preventing retinal
neovascularization and diabetic macular edema.
Extracellular Proteases
The ECM is a complex assembly of proteins and polysaccharides which provides
the physical support and organization to tissues. Cell-surface receptors on the plasma
membrane bind to ECM and regulate intracellular signaling pathways that control cell
migration and proliferation. Cell migration often involves the coordination of ECM pro-
teolysis, adhesion, and signaling. The important enzymes that are primarily involved in
the process of ECM proteolysis are the serine proteases that include (1) urokinase plas-
minogen activator (uPA) and (2) members of the family of zinc-dependent endopepti-
dases called matrix metalloproteinases (MMPs).
Urokinase Plasminogen Activator System (uPA/uPAR System)

The proteolytically active urokinase (uPA) on the endothelial cell surface is critical
for cell migration. The uPA is produced as an inactive single-chain protein known as
pro-uPA, which binds to uPAR (uPA receptor) and is activated by plasmin [4]. Receptor-
bound pro-uPA is more rapidly cleaved by plasmin than the unbound form. The uPA is
present in cells in two molecular forms, a 54 kDa high-molecular-weight form and a
32 kDa low-molecular-weight form which lacks the amino-terminal fragment (ATF) of
the protein [5–7]. The ATF contains the growth factor and kringle domains of the pro-
tein that mediate binding to uPAR and play an important role in cell proliferation [8].
The main function of the uPA is to convert the inactive zymogen form of the enzyme
plasminogen to plasmin, a broad spectrum of proteinase, which can cleave a variety of
ECM components including collagen IV, fibronectin, and elastin including uPA (Fig. 1).
The invasive and migratory potential of endothelial cells is largely determined upon
the pool of active urokinase available on the cell surface. The uPA has also shown to
directly activate the prohepatocyte growth factor/scatter factor (HGF/SF), and it also
cleaves fibronectin and its own inhibitor, plasminogen activator inhibitor-1 (PAI-1), in
Proteases in Diabetic Retinopathy 159
Fig. 1. uPA/uPAR in the degradation of ECM. Binding of inactive urokinase (pro-uPA)

to urokinase receptor (uPAR) activates uPA. Active uPA proteolytically converts the inactive
zymogen plasminogen to active plasmin, which then breaks down ECM components or activates
latent growth factors such as transforming growth factor 1 (TGF-1). Plasmin can also degrade the
ECM indirectly through activation of promatrix metalloproteinases (pro-MMPs).
a plasminogen-independent manner. The uPA/uPAR interaction represents a sensitive

and flexible system to regulate proteolytic potential in endothelial cells. The uPAR is
a cell-surface molecule that interacts with many potential ligands including uPA and
vitronectin. The uPAR has also shown to be associated with several members of the
integrin family which plays an important role in cell adhesion and migration [9]. This
process is mediated through the low-density-lipoprotein-receptor-related protein (LRP),
a multiligand receptor that can interact with both PAI-1 and uPAR. The uPA system also
plays an important role in the activation of several MMPs and in the release and activation
of growth factors stored in the ECM [10]. The contribution of the uPA/uPAR system to
angiogenesis has been studied in several animal models of tumor angiogenesis, choroidal
angiogenesis, and retinal angiogenesis. Many studies show that in addition to regulating
proteolysis, uPAR is a signaling receptor that promotes cell motility, invasion, prolifera-
tion, and survival. Signaling through uPAR has been shown to activate many pathways
involving kinases such as Ras–mitogen-activated protein kinase (MAPK) pathway [11].
These signaling events have been shown to involve the binding of its ligand such as uPA
(independent of uPA proteolytic activity) and vitronectin.
The uPAR is a member of the lymphocyte antigen 6 (Ly-6) superfamily of proteins
that are characterized by the Ly-6 and uPAR (LU) domain, also called the three-finger
fold [12]. The LU domain folds into a globular structure with 5–6 antiparallel b-strands
linked by 4–5 disulfide bonds [12, 13]. The uPAR contains three LU domains, desig-
nated D1–D3, connected by short linker regions, and these three domains pack together
into a concave structure [14–16] in which the ligands such as uPA and vitronectin bind.
Recent studies have indicated the importance of uPAR in human diseases, including
many cancers. Hence, therapeutic targeting of uPAR is considered as an important con-
cept to interrupt proteolytic cascades and block intracellular signaling in disease patho-
genesis [17].
Matrix Metalloproteinases
The MMPs are a family of zinc-containing endopeptidases that are capable of degrad-
ing various components of ECM. These proteases are produced as latent proenzymes
that are activated proteolytically. At least 21 different types of MMPs have been iden-
tified to date. Based on their structure/substrate specificity and cellular localization,
MMPs are grouped into the collagenases (MMP-1, MMP-8, and MMP-13), the gelati-
nases (MMP-2 and MMP-9), stromelysins (MMP-3, MMP-10, and MMP-11), and the
nontraditional MMPs (matrilysin or MMP-7 and metalloelastase or MMP-12) and the
membrane-type MMPs (MT-MMPs) [3, 18]. There are at least five distinct types of
MT-MMPs (MMP-12, -15, -16, -17 and -21), and these MMPs are bound to cell surface
through C-terminal transmembrane domain or glycosylphosphatidylinositol anchor. The
MT-MMPs can degrade gelatin, fibronectin, and other ECM substrates [19, 20].
The basic structure of the MMPs contains the following domains that include (a)
pre- or signal-peptide domain that directs MMPs to the secretory or plasma membrane
insertion pathway; (b) prodomain that confers latency to the enzymes by occupying the
active-site zinc, making the catalytic enzyme inaccessible to substrates; (c) zinc-con-
taining catalytic domain; and (d) hemopexin domain or the C-terminal domain which
mediates interactions with substrates and confers specificity of the enzymes, and also,
it is connected to the catalytic domain by a flexible hinge region or linker region [21]
(Fig. 2).
Various members of the MMPs have been implicated in a wide range of physiologi-
cal and pathological processes, including wound healing, angiogenesis, inflammation,
and tumor metastases [22–24]. During the physiological and pathological processes, the
MMP functions included the proteolytic cleavage of ECM structures and destruction of
cell-surface proteins and proteinase inhibitors. In addition to their capacity to degrade
a large variety of ECM molecules, MMPs are known to process a number of bioactive
molecules, and in many cases, MMP action leads to the proteolytic activation or release
of latent signaling molecules and proteases including cytokines [25]. MMPs regulate a
variety of cell behaviors such as cell proliferation, migration, differentiation, apoptosis,
and host defense (Fig. 3).
Studies have shown that MMPs are one of the important molecules in the cascade of
angiogenesis process and can be considered as proangiogenic agents. Specific MMPs
have been shown to induce angiogenesis by detaching the pericytes from vessel wall
and thereby releasing ECM-bound angiogenic growth factors. Also, this process has
been implicated in the exposure of cryptic proangiogenic integrins binding sites in
the ECM through the cleavage of endothelial cell–cell adhesion [26, 27]. Degrada-
tion of ECM releases ECM/basement membrane–sequestered angiogenic factors such
as VEGF, bFGF, and TGF-b [28]. MMPs have been shown to have multiple effects
on endothelial cells themselves. As mentioned earlier, MMPs facilitate endothelial cell
migration and tube formation [29, 30]. Exogenous MMP-9 has been shown to enhance
endothelial cell growth in vitro [31]. The cleavage of the ectodomain of VE-cadherin
by MMPs is considered as an important event in the breaking of cell–cell adhesions
[32]. MMPs involved in angiogenesis have been shown to originate from the infiltrat-
ing inflammatory cells or from endothelial cells. MMPs are synthesized in response
Fig. 2. Basic domain structure of MMPs. The domain structure of MMPs includes
(a) pre- or signal-peptide domain that directs MMPs to the secretory or plasma membrane inser-
tion pathway, (b) prodomain, (c) zinc-containing catalytic domain, and (d) hemopexin domain or
the C-terminal domain. The catalytic domain is connected to the C-terminal domain by a flexible
hinge region. The C-terminal domain has structural similarity to the serum protein hemopexin
and is also called as hemopexin domain.
Fig. 3. Matrix metalloproteinases cellular function. Activation of MMPs leads to the proteo-
lytic degradation of various cellular substrates. Also, MMPs induce the release of ECM-bound
growth factors and the degradation of angiogenesis inhibitors. Through the coordinate action
including activation of many molecules, MMPs promote cell growth, migration, and prolifera-
tion resulting in angiogenesis.
Table 1. Different types of MMPs expressed in the retina

Matrix metalloproteinases (MMPs) Retinal expression
MMP-1 (collagenase 1) Inner and outer nuclear plexiform layers [51],
perivascular microglia of optical nerve head [52],
and Bruch membrane [53]
MMP-2 (gelatinase A) Retinal pigment epithelial (RPE), Muller and retinal
capillaries, perivascular microglia of nerve
head [52], and Bruch membrane [53]
MMP-3 (stromelysin-1) Perivascular microglia of nerve head [52] and Bruch
membrane [53]
MMP-9 (gelatinase A) Retinal pigment epithelial (RPE), Muller cells, retinal
capillaries [54, 55], and Bruch membrane [53]
MMP-14 (membrane- Perivascular microglia of nerve head [53]
type MMP)
ADAM15 (disintegrin and Retinal capillaries [56]
metalloproteinase domain–
containing protein 15)
to diverse stimuli including cytokines, growth factors, hormones, and oxidative stress
[33, 34]. Basic fibroblast growth factor (bFGF) induces endothelial MMP-9 expression
via AP-1 [35]. Stimulation of endothelial cells by bFGF also upregulates the expression
of uPA and integrin avb3 which then leads to the activation MMPs [36]. VEGF has also
been indicated in the expression of MMP-1 [37], and also, the inflammatory cytokine
TNF-a has been shown to upregulate the MMP-2 and -9 expressions [38]. Factor such
as thrombin has been shown to activate the pro-MMP-2 directly in the endothelial cells
[29]. Release of NO by inflammatory cells has been shown to transcriptionally upregu-
late MMP-13 and its activation by endothelial cells [34]. A connective tissue growth
factor (CTGF) forms an inactive complex with VEGF165, and cleavage of CTGF by
MMPs has been shown to release active VEGF165 [39]. MMP-2 has been indicated in
the release of latent TGF-1, while MMP-2 and MMP-9 cleave the latency-associated
peptide to activate TGF-b1 [40, 41].
The presence of MMPs in the eye has been demonstrated as early as 1968 in the
cornea through its proteolytic activity on collagen substrate [42]. MMPs have been indi-
cated in many eye disorders such as age-related macular degeneration [43], proliferative
diabetic retinopathy (PDR) [44, 45], glaucomatous optic nerve head damage [46], vitreal
liquification [47], and vitreoretinopathy [48, 49]. The cellular origin of the MMPs in
these studies is still not clear, but it is likely that the expression would come from the
resident cells, invading vasculature, and the inflammatory cells [50]. The importance of
MMPs in the retinal pathology is currently well known, and many recent studies have
demonstrated the presence of various MMPs such as MMP-1, MMP-2, MMP-3, MMP-9,
MMP-13, and MMP-14 that are expressed at different retinal tissues (Table 1). Regard-
less of the sources in the retina, MMPs are considered as an attractive therapeutic target
to treat proliferative diabetic retinopathy (PDR) and diabetic macular edema (DME).
Endogenous Inhibitors of Proteases
Tissue Inhibitors of Metalloproteinases (TIMPs)

Tissue inhibitors of metalloproteinases (TIMPs) are specific endogenous inhibitors
that bind MMPs in 1:1 stoichiometry. Four types of TIMPs have been identified, which
have overlapping activities with respect to their inhibition of most soluble MMPs [3, 57].
TIMP molecules block the activity of MMPs by binding to the active-site cleft, in a
manner similar to their substrates. TIMP-2 and TIMP-3 are good inhibitors of MT1-
MMP, MMP-19, and ADAM-17, while TIMP-1 is poor in this respect. TIMPs also have
biological effects unrelated to metalloproteinase inhibition. TIMP-4 has been shown to
be localized mostly in the vascular tissues. TIMP-3, but neither TIMP-1 nor TIMP-2,
is involved in binding to the VEGF receptor-2 (KDR) and competes for debinding of
VEGF to this receptor. Overexpression of TIMP-3 can induce apoptosis. TIMP-1 and
TIMP-2 display antiapoptotic properties and indirectly induce cell signaling. A point
mutation of the TIMP-3 gene has been implicated in Sorsby’s fundus dystrophy, an auto-
somal dominant macular disease similar to wet macular degeneration, but with earlier
onset of symptoms [58, 59]. Studies have also characterized protein molecules such as
RECK, a2-macroglobulin (a2M), and tissue factor pathway inhibitor-2 to inhibit the
MMP activity [60–62].
Plasminogen Activator Inhibitors (PAI)

Plasminogen activator inhibitors (PAIs), which are members of the serine proteinase
inhibitor (SERPIN) family, regulate the proteolytic activity of uPA through the inhibi-
tion of uPA and plasmin formation. PAI-1 and PAI-2 have been found to interact with
urokinase in 1:1 ratio to inhibit enzyme activity and cause enzyme/inhibitor internaliza-
tion and turnover [63]. These serine protease inhibitors (SERPINS) bind covalently to
their targets, inhibiting proteolytic activity [64]. PAI-1 has been shown to be a strong
prognostic marker for several cancer types [65].
PROTEASES IN RETINAL NEOVASCULARIZATION

Significant upregulation of uPA (both the 54- and 32-kDa isoforms) along with
increases in secretion and activation of MMP-2 and -9 was observed in the retinas of
animals with neovascularization [45]. These results suggest that proteolytic activity
and its regulatory mechanisms might play an important role in the angiogenic process.
Various studies have shown that the plasma levels and the fibrovascular epiretinal mem-
branes MMP-2 and -9 levels were significantly elevated in patients with PDR [66–71].
Examination of proteases in epiretinal neovascular membranes removed surgically from
humans with PDR showed a similar increase in the levels of uPA and proform and active
form of MMP-2 and -9 as compared to normal retinas [72]. It has been also shown that
the pro-MMP-2 is efficiently activated in the fibrovascular tissues of PDR through inter-
action with MT1-MMP and TIMP-2 [73], indicating its increased role in PDR. Further,
MMP-2 deficiency in mice has been shown to reduce the retinal angiogenesis [74].
Type 1 diabetes subjects with retinopathy have displayed elevated systemic levels of
MMP-9 and MMP-9/TIMP-1 ratio. This increased level of MMP-9 has been suggested
to be surrogate biomarkers of retinopathy in type 1 diabetic patients free of other vascu-
lar complications [75].
Further characterization of roles of MMPs in diabetic retinopathy revealed various
molecular aspects of its activity and regulation. Hyperglycemic condition induces the
increased activation of retinal capillary MMP-2 and MT1-MMP and decreases in TIMP-2.
This activation was inhibited by superoxide scavengers, and their accelerated apoptosis
was prevented by the inhibitors of MMP-2 [76]. The hyperglycemia-induced activation
of MMP-9 accelerates apoptosis of retinal capillary cells, a phenomenon that predicts
the development of diabetic retinopathy, and the activation of MMP-9 is downstream of
H-Ras. Also, inhibition of high glucose–activated MMP-9 by pharmacologic inhibitor
or siRNA ameliorated accelerated apoptosis in the retinal endothelial cells [77]. Interest-
ingly, the human retinal pericytes treated with high glucose levels have been shown to
have increased MMP-2 activity leading to increased ECM turnover while there was no
MMP-9 activity observed in those cells. Thiamine and benfotiamine correct the increase
in MMP-2 activity due to high glucose in HRP, while increasing TIMP-1 levels in the
pericytes [78]. MMP inhibitor such as a2M has been shown to play a key role in the con-
trol and regulation of the retinal neovascularization involved in the pathogenesis of PDR
[79]. The transcription factor such as AP-1 and JUN has been shown to regulate retinal
MMP synthesis during neovascularization. The importance of transcriptional factor as a
therapeutic target that regulates the expression of MMPs such as MMP-2 in microvascu-
lar endothelial growth and retinal neovascularization is also considered [80, 81].
Angiogenesis and matrix degradation are an important step in endothelial cell migra-
tion and proliferation. Evidence has indicated the role of serine proteases, such as tis-
sue plasminogen activator (TPA), urokinase-type plasminogen activator (UPA), and
PAI, in the retinal neovascularization. In PDR, the vitreous levels of these proteases are
increased [82]. At cellular level, hyperglycemic condition has been shown to alter the
levels of t-PA and PAI in the retinal microvascular endothelial cells [83]. In an animal
model of hypoxia-induced retinal neovascularization, it was found that the expression of
the urokinase receptor (uPAR) was required to mediate an angiogenic response. uPAR−/−
mice demonstrated normal retinal vascularity but showed a significant reduction (by
73%) in the extent of pathological neovascularization as compared to wild-type controls
(Fig. 4). The expression of uPAR mRNA was upregulated in experimental animals dur-
ing the active phase of angiogenesis, and uPAR protein was localized to endothelial cells
in the superficial layers of the retina [84–86].
TISSUE INHIBITOR OF MATRIX METALLOPROTEINASES

IN RETINAL NEOVASCULARIZATION
In the retinas of normal mice, TIMP-2 mRNA and protein levels have been found to
increase steadily between postnatal days 13 and 17. This was in contrast to retinas of
mice with hypoxia-induced retinal angiogenesis, in which TIMP-2 mRNA and protein
remained low and significantly less than in retinas of “room air” controls [84]. Thus, a
temporal correlation between proteases (MMP-2 and -9 and MT1-MMP) and TIMP-2
was seen in retinas with neovascularization as compared to controls [85].
Fig. 4. Absence of the urokinase receptor uPAR reduced the extent of retinal neovascularization
in the mouse. (A) Representative section of the retina from an experimental oxygen-treated P17
C57BL6 mouse demonstrating numerous neovascular tufts on the surface of the retina (arrows).
(B) A similar section from an experimental oxygen-treated P17 uPAR−/− mouse with many fewer
vascular tufts (arrows). (C) Quantitation of neovascularization in C57BL6 and uPAR−/− mice.
The uPAR−/− mice demonstrated 73% less neovascularization compared with the normal C57BL6
mice. Values are the mean ± SEM for n = 4 mice in each group (eight eyes, 15–20 sections/eye).
*Significantly less than in C57BL6 mice, P < 0.01 (reproduced with permission from McGuire
et al. [84]).
Inhibition of Retinal Angiogenesis by MMP Inhibitors

Inhibition of MMP activity is considered an important therapeutic option in the pre-
vention of diabetic retinopathy. Preclinical studies have shown the importance of these
inhibitors in the prevention of retinal neovascularization. Systemic injection of a broad-
spectrum MMP inhibitor, BB-94 (1 mg/kg), in the murine model has been shown to
suppress retinal neovascularization by 72% [45] (Fig. 5). The retinas of BB-94-treated
animals demonstrated a significant decrease in the levels of active forms of MMP-2 and
MMP-9 compared to controls. In a mouse model of OIR, the extent of preretinal neo-
vascularization was drastically reduced in MMP-2−/− (75%) and MMP-9−/− mice (44%)
at postnatal day 19, compared to wild-type control mice [45]. The functional association
of MMP-2 and avb3 on the cell surface of angiogenic blood vessels points to the ability
of MMPs to regulate cell adhesion and integrin-mediated behavior.
Fig. 5. Use of a matrix metalloproteinase inhibitor suppresses the development of retinal

neovascularization. (A) Hematoxylin–eosin-stained cross section from the retina of a mouse
exposed to 75% oxygen for 5 days followed by room air for an additional 5 days. Capillary tufts
are present on the vitreal side of the inner limiting membrane, characteristic of the angiogenic
response in this tissue (arrow). (B) Representative hematoxylin-and-eosin-stained section from
the retina of an experimental mouse treated with BB-94 1 mg/kg, on postnatal days 12, 14, and
16. (C) Similar section from an experimental animal stained with diamidinophenylindole show-
ing individual endothelial cell nuclei that belong to new vessels (arrow). (D) Similar section from
the retina of a BB-94-treated mouse stained with diamidinophenylindole showing a significant
reduction in the number of neovascular nuclei. Only a single endothelial cell nucleus is present
on the vitreal side of the inner limiting membrane. Scale bars: (A, B) 166 mm; (C, D) 113 mm
(reproduced with permission from Das et al. [45]).
Inhibition of Retinal Angiogenesis by Inhibitors of the uPA/uPAR System

A peptide inhibitor of the urokinase system, A6 (an octapeptide that inhibits the inter-
action of uPA with uPAR), was able to reduce the extent of retinal neovascularization and
uPAR expression in the experimental animals. Intravitreal injection of an adenoviral vec-
tor carrying the murine ATF has been shown to inhibit retinal neovascularization by 78%
in the oxygen-induced retinopathy level [84]. These results suggest that inhibition of the
urokinase receptor might be a promising target for antiangiogenic therapy in the retina.
PROTEASES IN DIABETIC MACULAR EDEMA

The vitreous level of MMP-9 has been shown to be higher in diabetic subjects with
DR than with the diabetic subjects without DR. This study indicates a potential role of
MMPs in the pathogenesis of DR [87]. Furthermore, in an animal model of diabetes,
both MMP-2 and MMP-9 were elevated in the retinas [88]. The MT1-MMP was also
increased along with MMP-2 in the diabetic animals, and concomitant to this, there
was an increased apoptosis of pericytes in the diabetic retina when compared to the
normal retina. This may further accelerate the BRB alteration in the diabetic state. We
have shown that retinal vascular permeability was significantly increased in rats fol-
lowing 2 weeks of diabetes coincident with a decrease of VE-cadherin expression. This
increased vascular permeability could be inhibited with an MMP inhibitor [89]. Treat-
ment of endothelial cells with AGE-BSA led to a reduction of VE-cadherin staining on
the cell surface and increased permeability, which was MMP-mediated. This suggests
that MMPs have a direct role in the alteration of endothelial permeability [89]. Treat-
ment of cells with specific MMPs or AGEs resulted in cleavage of VE-cadherin from the
cell surface. These observations suggest a possible mechanism by which diabetes con-
tributes to BRB breakdown through proteolytic degradation of VE-cadherin. The ability
of a broad-spectrum MMP inhibitor in the breakdown of BRB suggests a potential alter-
native therapeutic strategy to the treatment of diabetic macular edema. High glucose can
activate many soluble mediators such as AGE, ROS, and inflammatory cytokines, which
can increase MMP expression and activity in the diabetic state.
The role of MMP-9 is implicated in the alteration of barrier function which is shown
to be mediated by TGF-b [90]. Studies have hinted that diabetes causes retinal inflam-
mation which unleashes a sequelae of events resulting in the vascular leakage. Retinal
inflammation attracts increased leukocytes to the retina which then bind to the vascular
endothelium. The binding of leukocyte to the endothelial cells can also activate cellular
proteases that may clip off VE-cadherin and its associated protein from the cell surface
resulting in endothelial monolayer alteration.
Inhibition of Proteases in the Prevention of Blood–Retinal

Barrier in Diabetes
MMPs have emerged as regulators of endothelial barrier function in several tissues.
Studies have demonstrated an increased expression of MMPs in the retinas of diabetic
animals. The proteolytic degradation of vascular endothelial (VE)-cadherin from the
surface of cultured endothelial cells by MMP-9 has been shown to increase the vascu-
lar monolayer permeability. An inhibitor of MMP-9 (Batimastat (BB-94)) was able to
block diabetes-induced vascular permeability and prevented the loss of VE-cadherin in
the retinal vasculature. These study result indicates a role for extracellular proteases in
the alteration of the BRB seen in diabetic retinopathy and can be a potential therapeutic
target for treating DME [89].
We have shown that the increased retinal vascular permeability in diabetic rats was
associated with a decrease in vascular endothelial (VE)-cadherin expression in retinal
vessels. Treatment with the uPA/uPAR-inhibiting peptide (A6) was shown to reduce
diabetes-induced permeability and the loss of VE-cadherin [91]. The increased perme-
ability of cultured cells in response to advanced glycation end products (AGEs) was also
significantly inhibited with A6. Treatment of endothelial cells with specific MMPs or
AGEs resulted in loss of VE-cadherin from the cell surface, which could be inhibited
by A6. uPA/uPAR physically interacts with AGEs/receptor for advanced glycation end
products on the cell surface and regulates its activity. uPA and its receptor uPAR play
important roles in the alteration of the blood–retinal barrier through proteolytic degrada-
tion of VE-cadherin. The ability of A6 to block retinal vascular permeability in diabetes
suggests a potential therapeutic approach for the treatment of diabetic macular edema.
CONCLUSION
Emerging evidence indicates that extracellular proteases play a role in both retinal
angiogenesis and diabetic macular edema. Also, studies have shown the beneficial effect
of protease inhibitors in the prevention of retinal-barrier breakdown and in retinal ang-
iogenesis. Thus, proteases may serve as an attractive therapeutic target in diabetic retin-
opathy. Currently, the majority of the clinical trials in retinal diseases have targeted the
VEGF molecule. Clinical trials have shown that at least for diabetic macular edema,
anti-VEGF agents may not be sufficient to prevent the leakage, and repeated injections
are needed. Probably, factors other than VEGF, like proteases may play a role in diabetic
macular edema. The urokinase inhibitor, A6 (Angstrom Pharmaceuticals, San Diego,
CA), which is currently in a Phase II clinical trial in ovarian carcinoma patients, has
been shown to be a promising agent in both retinal angiogenesis and macular edema
in the preclinical studies. Several MMP inhibitors are currently in clinical trials for dif-
ferent types of cancer, and many of these agents have been shown to be effective in
retinal angiogenesis as well. Factors other than VEGF are critical in the development of
diabetic retinopathy, and targeting these “other” molecules will probably result in better
clinical outcome. A combination therapy with proteinase inhibitors with the currently
used anti-VEGF agents may be an effective alternative strategy which needs to be fur-
ther explored. Such an option may reduce the number of intravitreal injections that is
often needed to control the extent of neovascularization and edema.
ACKNOWLEDGMENT
Supported by NIH Grant RO1 EY 12604 and Juvenile Diabetes Research Foundation
(JDRF).
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11
Proteomics in the Vitreous
of Diabetic Retinopathy Patients
Edward P. Feener
CONTENTS
Introduction
Vitreous Anatomy
A Candidate Approach
Proteomic Approaches
The Vitreous Proteome
Summary and Conclusions
Acknowledgments
References
Keywords Diabetic retinopathy • Mass spectrometry • Proteomics • Retina • Vitreous
INTRODUCTION
Vision loss cause by diabetic retinopathy is primarily associated with advanced stages
of this disease, including proliferative diabetic retinopathy (PDR) and diabetic macular
edema (DME). While abnormalities in microvascular functions and structure appear
central to the progression of diabetic retinopathy [1], the specific factors that modulate
the transition to the advanced sight-threatening stages of this disease are not fully under-
stood. Moreover, since animal models do not reproduce many of the specific pathologies
associated with PDR and DME, further characterization of ocular biochemical changes
from patients with diabetic retinopathy is needed to identify factors that could be associ-
ated with the advance stages of this disease and vision loss. Analyses of vitreous fluid
obtained during pars plana vitrectomy have provided opportunities to identify factors
that may contribute to, or protect against, advanced stages of diabetic retinopathy. This
chapter examines the methodologies for vitreous proteomics and the findings that are
beginning to emerge from studies using this approach.
Characterization of vitreous from patients with diabetic retinopathy compared with
vitreous from nondiabetic subjects has revealed a variety of differences in intraocular

173
174 Feener
protein abundance, modification, and activities. Over the past several decades, a variety
of biochemical and immunological techniques have been used to characterize specific
candidate proteins and protein functions from vitreous samples. While this approach
continues to provide important new information, especially for low-abundance pro-
teins, emerging opportunities utilizing omic technologies are rapidly expanding our
understanding of the complexity of vitreous fluid. Proteomic approaches have identified
specific proteins in vitreous that are associated with diabetic retinopathy, and a limited
number of these proteins have been shown to induce functional and structural changes
in the retina in animal models that are consistent with diabetic retinopathy. Moreover,
recent advances in proteomics and bioinformatics are creating opportunities to char-
acterize biological processes that may contribute to diabetic retinopathy and identify
biomarkers that further characterize differences in disease progression and responses
to therapeutic interventions among patients with seemingly similar disease characteris-
tics. While vitreous proteomics holds exciting potential for expanding understanding of
the molecular mechanisms and complexities of diabetic retinopathies, these studies will
require methods to integrate the rapidly expanding volume of proteomic data with basic
science and clinical aspects of vitreous biology and diabetic retinopathy.
VITREOUS ANATOMY
The vitreous is an optically transparent gel-like fluid that provides both structural
and biochemical functions in ocular physiology. The gel-like composition of the vit-
reous is derived mainly from a hydrated network of fibular macromolecules, includ-
ing glycosaminoglycans (GAG), proteoglycans, and collagen fibrils. Within this fluid
and lattice of macromolecules there is a metabolically active and dynamic biochemical
milieu. Soluble proteins can diffuse between the vitreous and retinal interstitial fluid
across of the inner limiting membrane (ILM), suggesting that the vitreous may contain
information derived from retinal disorders, and proteins in the vitreous can feedback to
influence retinal functions and pathologies.
The normal adult vitreous is largely acellular and organized with collagen fibrils ori-
ented along an anterior to posterior axis [2]. The interface between the vitreous and retina
involves the posterior vitreous cortex and ILM, which mediate regions of vitreoretinal
adhesion. The concentrations of collagen isoforms, including types II, V, IX, and XI, are
higher in the vitreous cortex compared to central vitreous [3]. Intravitreal localization
of other major component molecules, such as hyaluronan, also varies according to their
anatomical distribution within the vitreous. These extracellular matrix (ECM) molecules
provide a scaffold that binds ions, water, and soluble proteins, which can influence dif-
fusion within the vitreous compartment. The organization of ECM molecules within
the vitreous suggests the possibility that soluble proteins that bind to ECM may also be
spatially organized or heterogeneously distributed within this compartment.
The vitreous often undergoes a liquefaction process during aging, which alters the
biochemical and anatomical heterogeneity of this structure and can alter oxygen con-
sumption and gradients [4]. Liquefaction of vitreous together with the age-related
weakening of adhesion between the vitreous cortex and ILM contributes to vitreoretinal
disorders, including rhegmatogenous retinal detachment (RRD) [2, 5]. Changes in vit-
reous ECM, liquefaction of vitreous during aging, and effects of vitreoretinal traction
Proteomics in the Vitreous of Diabetic Retinopathy Patients 175
could influence the diffusion, retention, and localization of proteins in the vitreous. Thus,
the composition of vitreous samples collected from control subjects and subject patients
with diabetic retinopathies is likely influenced by coexisting vitreous disorders.
A CANDIDATE APPROACH
Studies of vitreous during the 1970s and 1980s revealed a number of proteins and
biochemical activities within this fluid. These early studies of vitreous identified iron-
binding proteins, including transferrin [6], which were suggested to provide a protective
role for the retina against the detrimental effects of iron, resultant of vitreous hemor-
rhage [7, 8]. The vitreous was also shown to contain fibrinolytic activity and comple-
ment components, which were implicated as clearance mechanisms for hemorrhage and
infection [9, 10]. Further early investigations of vitreous activities identified growth
factors, potential regulators of growth factor action, and proteins involved in remodeling
[11–15]. These findings, and others, revealed that proteins within the vitreous provide a
plethora of biochemical functions in ocular physiology. Moreover, this early work sug-
gested that vitreous may not only contain protein involved in the maintenance of normal
ocular physiology but may also contain factors that contribute to retinal diseases, includ-
ing diabetic retinopathy [16, 17].
A series of reports in 1994 revealed increased abundance of vascular endothelial
growth factor (VEGF) in vitreous during ocular neovascularization, experimentally
induced retinal ischemia, and PDR [18–20]. Subsequent reports demonstrated that intra-
vitreal injection of VEGF induces retinal vascular permeability (RVP) [21], intravitreal
VEGF levels are elevated in DME [22], and inhibition of the VEGF pathway amelio-
rates DME [23, 24]. These findings have revealed that the vitreous, at least in a subgroup
of patients with diabetic retinopathy, contains a key mediator of PDR and DME, namely
VEGF.
Over the past 2–3 decades, multiple studies have utilized similar candidate molecule
approaches to further characterize changes in proteins, including a variety of chem-
okines, hormones, growth factors, inflammatory molecules, as well as angiogenic and
anti-angiogenic factors, in vitreous from patients with diabetic retinopathy. Funatsu
et al. reported that in DME VEGF levels in vitreous correlate with elevated levels of
intercellular adhesion molecule-1 (ICAM-1), interleukin (IL)-6, and monocyte chem-
otactic protein-1 (MCP-1) [25], suggesting a link between VEGF and inflammation.
Moreover, elevated levels of these factors correlated with increased RVP and retinal
thickness [22, 25]. Yoshimura et al. has shown that IL-6, IL-8, and MCP-1 are elevated
in vitreous from PDR and DME compared with nondiabetic (NDM) controls [26], and
increases in levels of these inflammatory factors correlated with elevated VEGF levels
in vitreous. Platelet-derived growth factor (PDGF)-AA, PDGF-AB, PDGF-BB isoform
levels were shown to be elevated in vitreous from subjects with PDR, and increasing
concentration of these PDGF isoforms was also shown to correlate with VEGF levels
[27]. Moreover, changes in intravitreal levels of insulin-like growth factor-I (IGF-I) and
IGF-binding proteins in people with diabetic retinopathy have also been reported [28].
This growing body of work has provided insights into the complexity and heterogeneity
of potential hormonal, growth factor, and cytokine influences of the vitreous on diabetic
retinopathy. While these finding suggest a variety of protein and pathways that may
176 Feener
contribute to diabetic retinopathy, limitations of this candidate protein approach are that
it is often directed by preexisting theories and the relatively small number of molecules
that have been examined.
PROTEOMIC APPROACHES
Proteomics is the large-scale analysis of proteins, which often includes a combination
of characterization of amino acid sequence, quantification, modifications, and interac-
tions. Advances in proteomics over that past decade have created opportunities to use
rapid de novo protein discovery methods to further characterize the composition of vit-
reous and identify protein changes associated with diabetes and diabetic retinopathy.
Most of this work has utilized mass spectrometry as the centerpiece for protein iden-
tification; however, markedly different proteomic methods have been utilized, which
limit the comparison of studies and findings across studies. As such, the present status
of vitreous proteomic data in diabetes is a collection of somewhat unique studies. The
following describes the proteomic approaches that have been used for the analysis of
vitreous and discusses findings that are beginning to emerge from this work.
Proteomics is a multistep process with variety of options available at each step.
Although the utilization of diverse methods yields important information and differ-
ences in perspectives, the lack of uniformity limits the assimilation of data among dif-
ferent studies. Further understanding of the differences among experimental design and
data output is critical for interpreting the current body of vitreous proteomic informa-
tion. The workflow of vitreous proteomics can be separated into a series of steps, includ-
ing (1) vitreous acquisition, (2) sample fractionation, (3) mass spectrometry, (4) spectral
analysis, and (5) data analysis (Fig. 1). The following section describes options and
parameters that have been applied to vitreous proteomics within each of these steps.
Vitreous Acquisition
Study design has an overarching influence on the information generated from vitreous
proteomics. Vitreous fluid is usually obtained during pars plana vitrectomy for treatment
of specific retinal and vitreoretinal disorders, including, but not limited to, epiretinal
membrane (ERM), macular hole (MH), vitreoretinal traction, and non-clearing vitreous
hemorrhage. The potential influences of these surgical indications, apart from the influ-
ences of diabetes and diabetic retinopathy, on the vitreous proteome are unknown.
Additional factors that could influence the vitreous proteome at a given stage of dia-
betic retinopathy include patient demographics, rate of disease progression, disease
duration, and treatment history, including, for example, laser photocoagulation and
pharmacotherapy. A growing number of studies have shown that levels of specific proteins
can differ markedly within a selected group of patients, for example, VEGF levels can
differ markedly among individual PDR vitreous samples [20, 26]. Since obtaining multiple
vitreous samples for longitudinal studies is generally not feasible, large numbers of samples
from well-characterized patients will be needed to examine protein correlations with
retinopathy stage.
Increases in total protein concentration in the vitreous in diabetic retinopathy are well
documented (Table 1). Most studies have reported that vitreous protein levels are about
Fig. 1. Vitreous proteomics. An example of a work flow for 1-DE-based proteomics is

shown. The major steps include vitreous acquisition, which involves both study design and clini-
cal characteristics. Sample pre-fractionation in performed by separation by 1-D SDS-PAGE fol-
lowed by fractionation into gel slices. Mass spectrometry involves analysis of m/z of peptides
and fragmentation ions. Spectral analysis involves matching spectra with amino acid sequences
using search algorithms such as Sequest, Mascot, and X!Tandem, and quantitative analysis based
on spectral parameters. Data analysis enables proteome comparisons, analysis of pathways and
functions, and posttranslational modifications (PTMs) and proteolysis.
Table 1. Total protein concentration in control and PDR vitreous

NDM vitreous (mg/mL) PDR vitreous (mg/mL) References
0.4668, MH (n = 26) 4.129 (n = 33) [29]
1.96 ± 0.5, MH (n = 10) 4.45 ± 1.4 (n = 8) [30]
0.77 ± 0.47, MH, ERM (n = 13) 4.21 ± 2.2 (n = 16) [31]
0.67, MH, ERM (n = 30) 3.97 (n = 28) [32]
fourfold higher in PDR compared with vitreous obtained from NDM subjects with MH.
A primary cause for increased total protein in diabetic retinopathy is due to elevated
RVP, which occurs early in diabetic retinopathy and increases further during disease
progression [33, 34]. These additional increases in protein content in advanced diabetic
178 Feener
Fig. 2. Biological processes that contribute to the vitreous proteome. A variety of biologi-
cal processes contribute to the release of proteins into the vitreous, including secretion, plasma
extravagation due to pathological retinal vascular permeability (RVP) and edema, hemorrhages,
release of microparticles (MP) and cell lysis, and release due to retinal ischemia and clearance
of blood cells. Vitreous proteins can be retained in the vitreous by binding to extracellular matrix
(ECM) or removed by active or passive transport mechanisms. Vitreous proteins also undergo
proteolysis, which may modify their activities and facilitate clearance.
retinopathy are likely the results of a combination of factors including increased RVP,
vitreous and intraretinal hemorrhage, tissue damage associated with retinal ischemia,
and neovascularization (Fig. 2).
Sample Pre-Fractionation
Sample fractionation provides opportunities to further characterize the vitreous
proteins based on physiochemical properties and improves detection sensitivity. One
of the goals of most pre-fractionation methods is to separate high-abundance proteins,
such as serum albumin, from lower-abundance proteins to improve their detection.
Most proteomic analyses of vitreous have utilized protein fractionation based on either
1-dimensional (1-D) or 2-D gel electrophoresis. 1-D SDS-PAGE provides a prepara-
tive method of fractionation that enables downstream mass spectrometry of the entire
sample separated according to molecular weight (mw, mobility in SDS-PAGE). In 1-DE
gel protein staining is typically performed using Coomassie Brilliant Blue stain, and
quantitative comparison of proteins among samples utilizes mass spectrometry data. In
2-DE, samples are fractionated by isoelectric focusing (IEF) followed by SDS-PAGE
and protein staining. This results in a 2-D display of vitreous proteins, and relative
protein staining can be used as a semiquantitative measure of abundance. 2-DE provides

both isoelectric point and mw information, and selected proteins and protein isoforms,
resolved by IEF, can be isolated for analysis. Quantifying proteins from 2-DE gel staining
is complicated by protein isoform separation into multiple spots along an IEF gradient
and the possibility that a single spots can contain multiple proteins. Albumin and IgG
affinity chromatography has been used in a limited number of studies, prior to separa-
tion by gel electrophoresis, to increase detection sensitivity for low-abundance proteins
[30, 35]. In solution digestion of protein methods for vitreous proteomics could provide
opportunities for increasing throughput; however, this approach does not provide protein
mw data, and high levels of glycated macromolecules could potentially interfere with
digestion and downstream separation methods.
Mass Spectrometry
A variety of mass spectrometry platforms have been used for vitreous proteomics,
which can be separated into two groups based on ionization source, including electro-
spray ionization (ESI) liquid chromatography–tandem mass spectrometry (LC MS/MS)
[35–40] and matrix-assisted laser desorption ionization mass spectrometry (MALDI MS)
[29–31, 35, 38, 41]. In addition, the parameters for a given mass spectrometry platform
can have a major impact on instrument sensitivity and performance with complex sam-
ples. Kim et al. performed side-by-side analyses of vitreous proteins using LC-MALDI-
MS/MS and LC-ESI-MS/MS systems [35]. This study reports that MALDI and ESI
systems identified 83 and 518 proteins, respectively, which resulted in 531 proteins in
the merged datasets. While these findings demonstrate that different mass spectrometry
platforms can provide complementary protein datasets, these results also show the limi-
tations in comparing results from different systems. Since there are a number of inherent
differences among mass spectrometry platform [42], in addition to user defined param-
eters, the assimilation of data across studies requires downstream solutions directed at
spectral and data analysis.
Spectral Analysis
Spectra generated by mass spectrometry is matched to amino acid sequences using a
variety of algorithms, including Sequest, Mascot, and X!Tandem. Gao et al. compared
Sequest and X!Tandem analyses of LC-MS/MS data from a set of human vitreous sam-
ples [37]. This study generated 231 and 213 proteins using X!Tandem and Sequest,
respectively, with 192 proteins identified by both algorithms and a total of 252 proteins
in the merged dataset. As described above, these data show that different platforms pro-
vide complimentary data that increase the number of proteins identified. However, some
low-abundance protein matches were limited to single search algorithms. The criteria
used to identify a match are user-defined and instrument-dependent. Parameters and
thresholds used to identify proteins are a balance between optimizing detection sensi-
tivity and minimizing the false positive rate (FDR), which is determined by searches
against a reversed or randomized protein database [43]. The criteria used to identify
a protein vary among vitreous proteomic studies. For example, in two studies using a
similar LC-ESI-MS/MS platform, Gao et al. used two unique peptides identified from
the same or adjacent gel slice in at least two independent vitreous samples to generate
180 Feener
252 proteins [37], and Kim et al. used a single peptide match as a minimum criteria to
identify 518 protein matches [35]. In the latter study, a single unique peptide spectral
was detected for about 100 proteins, which has a higher FDR compared with proteins
detected based on at least two unique spectral-peptide matches. Moreover, the Gao et al.
study use individual samples whereas the Kim et al. study used pooled samples and both
nondepleted and immunoaffinity-depleted preparations. Thus, comparisons of protein
lists from different studies should take into account both protein identification criteria
and sample preparation.
Spectral data provides multiple options for both relative and absolute quantification of
protein levels. The most widely used method for vitreous proteomics has been based on
label-free measurements of spectral-peptide matches, using either the number of unique
[36] or total spectral matches [37] for a given protein. Addition label-free options the
use of multiple reaction monitoring [44] and analyses of ion intensity and spectral peak
area [45]. The use of high mass accuracy and resolution mass spectrometers not only
improves the sensitivity of these label-free methods but also creates more robust quan-
titative options that involve isotope-labeling techniques [46]. Quantitative proteomic
methods are of central importance to characterizing the changing in proteins in diabetes
and diabetic retinopathy, and the topic of quantitative proteomics has been extensively
reviewed elsewhere [47, 48].
Data Analysis
Vitreous proteomics from multiple laboratories has generated lists of proteins detected
in vitreous fluid along with quantitative data used for comparisons of protein levels
among patients with or without diabetic retinopathy. As describe above, the parameters
used to collect these data differ at multiple levels. Thus, while these studies provide
different perspectives of the vitreous proteome, the assimilation of data from different
reports is complex and often relies on manual techniques. The in-depth comprehension
and comparison of proteomic dataset from different groups will likely require integra-
tion of these data with emerging bioinformatics tools and strategies [49].
In contrast, there are multiple options available for data analysis within a given pro-
teomic database. Vitreous proteomic databases have been used for quantitative compari-
sons of protein abundance among groups of subjects, analysis of amino acid modifications
and protein fragments, and grouping of proteins according to gene ontology and func-
tional networks [37]. One important limitation of this bioinformatics approach in further
understanding the vitreous proteome is that many of the proteins that have been identi-
fied in this fluid are not well characterized. Moreover, the functions of these proteins, as
well as other more full-characterized proteins, in the vitreous compartment are largely
unknown. Thus, in addition to the organization of vitreous proteome using computer
algorithms and databases, it is likely that functional studies will be needed to assess the
actions of individual proteins within the vitreous milieu.
THE VITREOUS PROTEOME

Two main proteomic approaches, based on 2-D and 1-D gel pre-fractionation, have
been used to characterize protein composition of the human vitreous and identify changes
associated with diabetic retinopathy. Although differences in experimental methods
(as described above) complicate the comparison of these studies and data, a number of
findings from vitreous proteomics have emerged.
2-DE-Based Proteomics
The earliest comparative proteomic studies were performed using vitreous samples
separated by two-dimensional electrophoresis (2-DE). Nakanishi et al. [38] compared
silver-stained proteins separated by 2-D electrophoresis of vitreous obtained from sub-
jects with MH and diabetic retinopathy. This study analyzed proteins from 412 spots
separated by 2-DE of diabetic retinopathy vitreous and identified proteins in 113 of
these spots, which represented 50 different proteins. Comparison of vitreous was nor-
malized to 100 mg of dialyzed protein, and the authors reported that Ig, a1-antitrypsin,
a2-HS glycoprotein, and complement factor 4, and pigmented epithelial-derived factor
(PEDF) were elevated in vitreous from diabetic retinopathy. While this study, and others
that visualized vitreous proteins by 2-DE, detected several hundred spots of protein
staining, these include a large fraction of spots corresponding to protein isoforms sepa-
rated along the IEF gradient.
A report by Yamane et al. [29] using 2-DE detected more than 400 silver-stains spots
and identified 78 proteins in vitreous from patients with MH and 600 spots and identi-
fied 141 in vitreous from patients with PDR. This study showed that vitreous (both MH
and PDR) and plasma displayed similar patterns of proteins, and most proteins that
were identified to be increased in PDR compared with MH were also found in serum.
Comparisons of vitreous were normalized to 40 mL of undiluted vitreous volume. The
authors concluded that the increases in proteins in the PDR vitreous were the result
of increased RVP and hemorrhage. Four proteins, including PEDF, prostaglandin-D2-
synthase, plasma glutathione peroxidase, and IRBP were identified in MH vitreous but
not in serum, suggesting that these proteins are locally produced in the eye [29]. An
analysis of relative protein-staining intensity among gel spots indicates that the most
highly abundant proteins in the vitreous include serum albumin, PEDF, a1-antitrypsin,
prostaglandin-D2-synthase, apolipoprotein A1, and transthyretin. Ouchi et al. detected
over 200 spots using SYPRO Ruby staining of vitreous and identified proteins in 72
spots from vitreous from non-proliferative diabetic retinopathy (NPDR) with DME
and 64 spots from vitreous from subjects with NPDR without DME [40]. Comparisons
were normalized to 15 mg of total protein. ApoH was detected in non-DME vitreous
but not in DME vitreous. PEDF, plasma retinol-binding protein (PRBP), apo A4, apo
A1, Trip-11, and vitamin D–binding protein were reported to be elevated in DME
vitreous [40].
Garcia-Ramirez et al. [30] compared vitreous proteomes from PDR and MH subjects
using fluorescence-based labeling differences in 2-DE. Vitreous samples were subjected
to affinity depletion to removed albumin and IgG, and comparisons were normalized to
2-mg/mL protein eluate. This study reported that levels of eight proteins were increased
in PDR vitreous, including zinc a2-glycoprotein, apo A1 and apoH, fibrinogen A, com-
plement proteins C3, C4b, C9, and factor B. In addition, three proteins were identified
to be decreased in PDR vitreous, including PEDF, IRBP, and inter-a-trypsin inhibitor
heavy chain. Subsequent studies from this group further characterized the decrease in
IRBP [50] and increased in apo A1 and apoH [51] in diabetic retinopathy.
182 Feener
Kim et al. [42] compare vitreous from subjects with MH and PDR. In this study,
compared with MH, prostaglandin-H2 d-isomerase and PEDF were elevated, and a1-
antitrypsin and beta V spectrin were reduced in PDR. Shitama et al. [31] compared
the relative abundance of 105 proteins among approximately 400 spots visualized by
2-DE of vitreous samples collected from control subjects or patients with NPDR, PDR,
RRD, or proliferative vitreoretinopathy. This study identified about ten proteins that
were elevated in NPDR and PDR compared with control vitreous, including apo A4,
complement C3, a1-B-glycoprotein, a1-antitrypsin, zinc a2-glycoprotein 1, vitamin
D–binding protein, and fibrinogen g.
1-DE-Based Proteomics
Preparative 1-DE was also used in early studies to characterize the vitreous composi-
tion however comparative analyses of groups of samples required the development of
databases and spectral-based quantitative methods. Koyama et al. [39] characterized
the vitreous protein, separated by 1-DE, from a single subject with diabetic retinopathy.
This report cataloged 84 different proteins in this vitreous sample.
Gao et al. [36] compared vitreous from three groups of subjects, including NDM,
diabetes with no diabetic retinopathy (DM noDR), and PDR. This study identified 117
proteins, including 27 proteins that were elevated in vitreous from PDR compared with
vitreous from NDM. This report revealed that PDR vitreous contains increased levels of
a number of intracellular and plasma proteins, suggesting that retinal hemorrhage and
increased RVP have a major impact on the composition of vitreous in diabetic retinopa-
thy. A key observation generated from this work was that the effects of these newly dis-
covered vitreous proteins on ocular functions were not readily apparent from previous
descriptions of protein activities and subcellular locations. This report demonstrated that
intravitreal injection of carbonic anhydrase I (CA-I) into rat vitreous increased RVP and
retinal thickness via activation of the plasma kallikrein system [36]. The findings sug-
gested a new pathway contributing to diabetic retinopathy which involved intraocular
hemorrhage, lysis of erythrocytes to release intracellular CA-I, followed by activation of
the kallikrein kinin system (Fig. 3). Moreover, beyond this specific pathway, this report
demonstrated that the functions of proteins in the vitreous may not be readily inferred
by previous descriptions of protein annotations, and that direct functional analyses of
protein actions within the vitreous milieu may be needed to elucidate protein actions
from the information generated by vitreous proteomics. Kim et al. [35] used both 2-DE
and 1-DE fractionation methods to characterize both non-depleted and albumin/IgG-
depleted vitreous from PDR and MH. Pooled samples were used, and comparisons of
PDR and MH were normalized to 500 mg per lane for 1-DE. This study generated used
multiple pre-fractionation methods and mass spectrometry platforms to generate the
largest number of proteins identified from vitreous from diabetic retinopathy; however,
the study was not designed to enable statistical comparisons among conditions.
Gao et al. [37] expanded the analyses of NDM, DM noDR, and PDR vitreous that
was initiated previously [36]. This report identified 252 proteins in vitreous and used
spectral-peptide counts to characterize the vitreous proteome. This analysis showed that
albumin represents about 40% of the total soluble protein content (Fig. 4), and that
the total spectral peptide content for albumin in PDR vitreous is increased by about
Fig. 3. Origins of vitreous proteins that been implicated in diabetic retinopathy progression.
Diabetic retinopathy induces the release of active proteins into the vitreous by secretion (for
example, VEGF), RVP (for example, plasma kallikrein), and retinal hemorrhages and cell lysis
(for example, carbonic anhydrase I).
two- and fourfold compared with noDR and NDM vitreous, respectively. In addition to
transport proteins, this analysis revealed that the protease inhibitor a1-antitrypsin, the
anti-angiogenic factor PEDF, and complement C3 are highly abundant in PDR vitreous.
This report also identified 56 proteins which differed in abundance in noDR and PDR
compared with NDM. The majority of these changes were increases by two- to fourfold,
which were comparable with increases in serum albumin (Fig. 5). For example, angi-
otensinogen (AGT) was show to be increased by two- to threefold in DM noDR and
PDR vitreous. In addition, small subsets of proteins were increased by over tenfold or
were decreased in noDR and PDR compared with NDM vitreous. As previously reported
with CA-I, the functions of most of the vitreous proteins may require further study to
evaluate their effects in the vitreous. This proteomic study also revealed that groups of
proteins from the complement cascade, coagulation system, and kallikrein kinin system
are present in the vitreous, suggesting that the vitreous proteome contains biochemical
systems [37]. Further analyses revealed that a number of individual proteins existed
as protein fragments, suggesting that the vitreous is proteolytically active, and certain
protein functions may be associated with these fragments, as previously described for
the anti-angiogenic factor endostatin, which is generated from the limited proteolysis of
collagen XVIII [52].
184 Feener
Fig. 4. Fractional distribution of the most abundant proteins in human vitreous. (A) Chart
showing a summary of the relative amounts of highly abundant proteins in PDR vitreous. (B) Table
showing the mean percent of number of total peptides for the 15 most abundant proteins identi-
fied in NDM, noDR, and PDR samples relative to the number of total peptides detected from
respective samples. Reprinted with permission from Gao et al. [37]. Copyright 2008 American
Chemical Society.
SUMMARY AND CONCLUSIONS

Mass spectrometry–based proteomics has identified at least several hundred pro-
teins from human vitreous. Diabetic retinopathy is associated with about a fourfold
increase in total vitreous protein content and increased protein diversity compared
Fig. 5. Comparison of proteins abundance in noDR and PDR vitreous relative to NDM
vitreous. Ratio of the mean total peptides detected in noDR or PDR groups relative to the
NDM group. The absence of protein detection in a group is indicated by >20-fold. Reprinted
with permission from Gao et al. [37]. Copyright 2008 American Chemical Society.
with NDM control vitreous. Most of these increases in protein in diabetic retinopathy
appear to be due to the infiltration of plasma proteins and contributions from intraocu-
lar hemorrhage and cell lysis. Once in the vitreous, a limited number of these plasma
and intracellular proteins have been shown to exert potent effects on retinal functions.
These findings suggest that the loss of blood retinal barrier function in diabetes may
promote further increases in RVP as diabetic retinopathy progresses. While the number
of proteins identified by vitreous proteomics is increasing rapidly, the relative signifi-
cance and biological functions of most of these proteins within the vitreous milieu are
unknown. Direct functional analyses of protein action in the vitreous are needed to
elucidate their potential effects in diabetic retinopathy. In addition, further charac-
terization of the vitreous proteome may reveal biomarkers that correlate with clinical
characteristics and could provide new insights into disease progression and responses
to therapies.
ACKNOWLEDGMENTS
This work was supported in part by the US National Institutes of Health (grants
EY019029, DK 36836) and the Juvenile Diabetes Research Foundation.
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12
Neurodegeneration in Diabetic Retinopathy
Alistair J. Barber, William F. Robinson, and Gregory R. Jackson
CONTENTS
Introduction
Histological Evidence
Biochemical Evidence of Neurodegeneration and Cell Death
Functional Evidence of Neurodegenerative Changes
Potential Mechanisms of Retinal Neurodegeneration in Diabetes
Summary and Conclusions
References
Keywords Neurodegeneration • Retinal ganglion cell • Nerve fiber layer • Caspases • Scotopic
threshold response
INTRODUCTION
Neurodegeneration can be defined as a chronic, progressive loss of neuronal function
and structural integrity, which usually includes the death and removal of neurons at an
accelerated rate. In neurodegenerative diseases, the loss of neurons occurs gradually over
a protracted period of time, such as the kind of neural loss that occurs in Parkinson’s
or Alzheimer’s disease. The term neurodegeneration is used frequently in discussions
of many disease pathologies that primarily affect neurons; however, neurodegenerative
diseases have been more accurately defined as, “…neurological disorders with hetero-
geneous clinical and pathological expressions affecting specific subsets of neurons in
specific functional anatomic systems; they arise for unknown reasons and progress in
a relentless fashion” [1]. By this strict definition, neuronal loss in Alzheimer’s disease
is classed as neurodegeneration; while acute loss of neurons in a stroke is not, although
neurodegeneration is often modeled using experimentally induce ischemia to accelerate
neuronal cell death.
Neurodegenerative diseases are commonly thought of as affecting the brain or periph-
eral nervous system, but this chapter will consider diabetic retinopathy as a candidate
neurodegenerative disease of the retina. There are a series of features that are gener-

189
190 Barber et al.
ally associated with neurodegenerative diseases, which can be broadly categorized into
histological, biochemical, and functional pathologies. This chapter will present evidence
for retinal neurodegeneration in diabetes, segregated according to these three categories,
and will finish by including a brief summary of the theorized mechanisms.
HISTOLOGICAL EVIDENCE
Early Pathology Studies
Early efforts to characterize the histology of diabetic retinopathy were the first to
identify potential neuropathy accompanying the vascular changes. An early study of
histological sections from postmortem specimens noted atrophy of retinal ganglion cells
(RGCs) as one of the pathological changes that accompanied vascular lesions, and sug-
gested that diabetes may induce a gradual loss of neurons as the disease progresses [2].
A similar study on a larger number of specimens also identified degeneration of the inner
plexiform and ganglion cell layers as common features in humans with diabetic retin-
opathy [3]. Later, a paper by Bresnick suggested that neurodegeneration could possibly
be viewed as a neurosensory disorder that involved degeneration of the neural retina,
possibly preceding the vascular lesions [4]. One common feature of diabetic retinopathy
that can be recognized by clinical observation is the appearance of “cotton wool spots”
which are thought to be the axoplasmic debris from atrophied neurons in the nerve fiber
layer (NFL) [5], and can appear as an early pathological feature in some patients [6].
Histological Evidence of Apoptosis

Studies of tissue from human and animals with diabetes identified apoptotic cells in
the retina. In some cases, these included RGCs reviewed recently by Kern and Barber [7].
Many histological studies of apoptosis have used the classic technique of DNA terminal
dUTP nick end labeling (TUNEL), which most commonly uses terminal transferase to
label nuclei-containing DNA nicks in fixed tissue sections [8–10]. An early study using
TUNEL identified apoptotic cells in cross sections of retinas from streptozotocin (STZ)-
diabetic rats, although quantification of the numbers of neurons was not possible in this
study [11]. Another study, using the trypsin-digest approach to specifically examine the
vasculature of rat retinas, indicated a modest increase in TUNEL-labeled nuclei in rats
after 6–8 months of STZ diabetes, suggesting that vascular cells also underwent apopto-
sis [12]; a finding that has been confirmed by others [13–15].
While trypsin digest makes it possible to specifically examine the vasculature of the
retina, TUNEL labeling in intact flat-mounted retinas from STZ-diabetic rats made it
possible to quantify the numbers of cells undergoing apoptosis in the entire retina. Using
this approach, it was found that diabetic rats had significantly more TUNEL positive
cells with a similar rate of cell death in groups of rats after 1, 3, 6, and 12 months of
hyperglycemia (Fig. 1). The absolute number of positive cells was greater than in the
trypsin-digest studies, suggesting that neurons and glial cells were also involved [16].
Others showed that TUNEL labeling was also increased in mouse models of both type
I and type II diabetes [17, 18], and quantification of TUNEL labeling in whole retinas
from Ins2Akita mice, a spontaneously diabetic genetic model, found a frequency of apop-
tosis similar to the STZ-diabetic rats [19].
Neurodegeneration in Diabetic Retinopathy 191
Fig. 1. Diabetes increased apoptosis in whole rat retinas. Apoptotic cells were identified
by TUNEL in whole retinas of STZ (streptozotocin)-diabetic rats after 1, 3, 6, and 12 months of
hyperglycemia. The total number of positive nuclei in each retina was counted by microscopy.
There were significantly more apoptotic cells in the retinas from diabetic rats (black circles)
compared to controls (white circles), *p < 0.01, **p < 0.001, 1-way ANOVA with Newman-Keuls
test. Taken from Barber et al. [16].
A variety of other histological studies have confirmed the increase in TUNEL labe-
ling in diabetic animals, although the types of cells and the degree of apoptosis vary
widely. An early phase of TUNEL labeling in photoreceptors was indicated in one study,
accompanied by several indications of degeneration in amacrine, horizontal, and gan-
glion cells [20], although one study reported no significant increase in apoptosis of
nonvascular cells in STZ-mouse retinas [21]. The rate of retinal apoptosis in diabetic
rats was further increased by experimentally induced intraocular hypertension, similar
to that in glaucoma [22].
As an alternative or additional approach to using TUNEL to detect cells undergoing
apoptosis, some investigators have used antibodies to the activated form of caspase
enzymes in histological sections of retina. Caspases-3 and -7 are often referred to as
“executioner enzymes” because they cleave target proteins at specific aspartate recogni-
tion sequences. Antibodies raised to identify only the active form of caspase-3 can be
used for immunohistochemical detection of cells undergoing apoptosis at the time of tis-
sue fixation [23]. Using this approach, the number of cells positive for active caspase-3
was found to be elevated in the ganglion cell layer of retinas from mice after 2, 6, and 12
weeks of STZ diabetes [17]. A similar approach labeling for active caspase-3 in whole-
mount retinas from Ins2Akita mice found that, after 4 weeks of hyperglycemia, there were
significantly more positive cells compared to nondiabetic age–matched litter mates [24].
There is also evidence that caspase-3 is activated in ganglion cells of postmortem retinas
from subjects with diabetes [25]. Similarly, caspase-3 and -9 immunohistochemistry in
human postmortem retinas colocalized with Fluoro-Jade B, an indicator of degenerat-
ing neurons, and was most abundant in cell bodies in the RGC layer [26]. Caspase-3
immunoreactivity was also found to colocalize with several other neuronal markers in
flat-mount retinas of Ins2Akita diabetic mice, suggesting that the cells undergoing apop-
192 Barber et al.
Fig. 2. Immunoreactivity for active caspase-3 did not localize to the vasculature. Whole
retinas from STZ-diabetic rats were labeled by immunofluorescence for agrin, a vascular
basement membrane glycoprotein (green) and active caspase-3 (red). The majority of caspase-3
positive cells were located away from blood vessels, suggesting that they were neural in origin,
scale bar = 50 mm. Taken from Gastinger et al. [38].
tosis included RGCs, amacrine cells, and photoreceptors. Quantification of caspase-3

positive cells in these mice yielded a similar estimate of the total number of apoptotic
cells compared to data obtained by TUNEL, and the majority of caspase-3 positive
cells did not colocalize with agrin immunoreactivity in vascular basement membrane,
indicating that the dying cells were mostly not vascular in origin [19] (Fig. 2).
Gross Morphological Changes in the Retina

Many studies investigating loss of neurons in the retina use measures of the thick-
ness of retinal layers as a measure of cell loss [27]. STZ-diabetic rats had significantly
reduced thickness of the inner plexiform and inner nuclear layers, 7.5 months after the
onset of hyperglycemia [16] (Fig. 3), suggesting that the increased apoptosis identified
in this study leads to an accumulated loss of cells making up the inner retina. A dif-
ferent study suggested that reduction in the thickness of the inner plexiform layer was
accompanied by loss of the outer nuclear layers and increased TUNEL labeling prima-
rily among photoreceptors in STZ rats after 6 months of diabetes [20]. Decreased thick-
ness of the outer retina was also noted after 12 and 24 weeks of diabetes in STZ-diabetic
rats [28].
Similar reductions in retinal layer thickness were measured in diabetic mice. The
inner retina was reduced in Ins2Akita diabetic mice after 5 months of hyperglycemia,
although the reduction was limited to the peripheral retina, suggesting that the cell loss
may occur more slowly in the central region of the retina in this mouse model [24]. The
reduction in inner retina thickness was comparable to previous observations in STZ-
diabetic mice that were diabetic for 10 weeks [17].
Fig. 3. Diabetes reduced the thickness of the inner retina in rat. The thickness of the inner
plexiform layer (IPL), inner nuclear layer (INL), combined outer plexiform and outer nuclear
layers (OPL + ONL), and entire retina (RET) were measured as a ratio with the choroid in H&E
sections of eyes from rats after 7.5 months of diabetes (shaded bars) and compared to eyes from
control rats (white bars). The IPL and INL were significantly thinner in diabetic rats (*p < 0.001)
compared to controls. Taken from Vanguilder et al. [56].
Several studies have reported cell loss by measuring cell layer thicknesses in rodent
models of diabetes; however, there are disparities in the rate of cell loss and whether the
degeneration is predominantly inner or outer retina. The differences between these studies
are difficult to explain but may be due to variations in the degree of induced diabetes,
genetic background of the animals, and variations in animal husbandry, including the fat
content of the diet [29], differences in handling, or exposure to environmental pathogens.
Reductions in Numbers of Surviving Amacrine Cells

Results of several morphological studies indicate that diabetes may deplete the
number of amacrine cells in the retina. Tyrosine hydroxylase immunoreactivity, a marker
of dopaminergic neurons, was reduced in amacrine cells of the obese sand rat, which
becomes moderately hyperglycemic [30]. Necrosis of amacrine cells was also reported
in STZ rats, along with photoreceptors, ganglion cells, and other neurons [20]. Tyrosine
hydroxylase protein levels were also depleted by approximately 50%, accompanied by
significant reduction in the density of dopaminergic amacrine cells [31]. Labeling of
neuronal nitric oxide synthase (nNOS)-positive amacrine cells was also reduced in dia-
betic rats, suggesting a down regulation in the enzyme expression, or a loss of amacrine
cells [32]. While the morphology of surviving amacrine cells appeared to be normal in
whole-mount retinas from diabetic Ins2Akita mice after 6 months of hyperglycemia, they
were reduced in number by 16–20% [19].
Reductions in neurotransmitters and associated enzyme activity also imply a loss
of amacrine cells. The concentration of dopamine was significantly reduced in STZ-
diabetic rats after 3 weeks of hyperglycemia, while there was no change in tyrosine
194 Barber et al.
hydroxylase activity or the uptake in tyrosine, suggesting a potential increase in the

dopaminergic efflux due to diabetes [33]. In a more recent study, butyrylcholinesterase
activity was reduced 30% in retinas of STZ-diabetic rats, implying a potential loss of
subtypes of amacrine cells [34]. A similar study confirmed the depletion of the butyryl-
cholinesterase enzyme activity in STZ rats [35]. Similarly, NADPH diaphorase immu-
noreactivity was reduced in the processes of amacrine cells [36].
Retinal Ganglion Cell Loss

Evidence for the loss of RGCs in animal models of diabetes was recently reviewed [7].
Apoptosis had been noted in RGCs using TUNEL in retinal cross sections [11]. An
approximation of ganglion cell loss was also made by counting large nuclei in H&E
sections of STZ-diabetic rat retinas. There was a 10% reduction in these cells after
7 months of diabetes [16]. A similar approach identified a 20–25% loss of ganglion cells
from retinas of STZ-diabetic mice after 14 weeks of hyperglycemia [17]. The number
of ganglion cells in the retinas of Brown-Norway STZ-diabetic rats was also found to be
reduced by about 16% within 4–5 weeks, using a fluorescent retrograde labeling tech-
nique [37]. Another study on STZ-diabetic mice, however, reported no change in H&E
sections [21]. Ganglion cell bodies can be easily confused with astrocytes and amacrine
cells in this type of preparation, which may account for the variation in results using
this method. To overcome this potential confounding variable, RGCs were quantified in
whole retinas of mice-expressing endogenous ganglion cell markers. Ins2Akita mice were
crossed with Thy1-CFP transgenic mice, which express an endogenous fluorescent pro-
tein in the cell body of the majority of RGCs. There was a 16% reduction in RGCs in the
peripheral retina within 3 months of the onset of diabetes in these mice [38].
Abnormalities in Ganglion Cell Morphology

Accelerated loss of RGCs due to diabetes has been suggested in a number of studies,
but it is likely that the apoptosis is accompanied by other pathological features in these
important neurons. A study of flat-mounted retinas from Ins2Akita diabetic mice with
endogenously fluorescent markers under the Thy1 promoter revealed several abnormal
features in subsets of RGCs [38]. Cell bodies were enlarged, and there were numerous
axonal swellings, often associated with a constriction between the cell body and the
swelling. The morphology of dendrites was also altered, most dramatically in the large
On-ganglion cells. The dendritic fields of these neurons tended to be more complex,
possessing more branches and terminals. It was suggested that the reason for this appar-
ent increase in plasticity among certain ganglion cells was in compensation for loss of
input from bipolar or amacrine cells or an attempt to compensate for the loss of neigh-
boring ganglion cells (Fig. 4).
A morphological study of RGCs in rats used DiI (1,1¢-dioctadecyl-3,3,3¢,3¢-
tetramethylindocarbocyanine perchlorate) applied to whole retinas of STZ-diabetic rats
with a gene gun [39]. The largest subtype of cell defined in this study appeared to have
enlarged dendritic field areas in the diabetic animals compared to controls. A similar
study in a small sample of human postmortem samples with advanced stages of dia-
betic retinopathy also suggested abnormal morphology of some parasol and midget
ganglion cells, including axon swelling and beading, while the dendritic field areas of
A
P
-I
µm
0
P 05
I-1
C OD C P
control
D Ins2
Akita
diabetic
ganglion cell density (cells/mm2)

1400
C
1200
1000
800
750
µm
P 600
750 400
µm 200
0
central peripheral
Fig. 4. Diabetes reduced the number of Thy1-CFP-positive ganglion cells in the retinas of
Ins2Akita mice Ins2Akita mice were crossed with transgenic mice-expressing CFP under the Thy1 pro-
moter, which is specific to RGCs. (A) Retinas were flat mounted, and the number of CFP-positive
cells was counted in four inner and four outer regions as illustrated (scale bar = 1 mm). (B, C) The
CFP-positive cell bodies were identified in confocal maximum projections from confocal z-scans
(scale bar = 100 mm). (D) In mice that were hyperglycemic for 3 months, the average ganglion
cell density was significantly lower in the peripheral regions of retinas compared to age-matched
littermates (n = 5 controls, n = 7 diabetic, *p < 0.05). Taken from Santiago et al. [130].
these cells appeared reduced [40]. In all three studies, the morphology of some classes
of RGCs was found to be changed by diabetes, but the size of the dendritic field and
the density of dendrites were dissimilar. It is unclear why there is disagreement in the
results between mice, rats and human retinas, but the degree of retinal pathology and
methods of identifying and classifying the RGCs may be responsible for at least some
of the discrepancies.
This small number of studies on RGC morphology suggests common features in
which abnormal swellings occurs on ganglion cell axons; although it appears that the
human study suggested a general decline in the size and complexity of the dendritic
field, while the rodent studies suggested that the fields of surviving cells become more
complex. These changes may also represent precursors to apoptosis, or alternatively
could be plastic responses to the loss of neighboring ganglion cells, or to the loss of
input from bipolar and amacrine cells.
Centrifugal Axon Abnormalities

An area of potential neural damage that is not often considered is the centrifugal
axon. This mysterious group of projections was described in early histological studies
of humans, primates, and rodents and was proposed to play a role in regulating blood
flow [41]. These axons can be identified by immunohistochemistry of histamine [42].
196 Barber et al.
A histological study of STZ-diabetic rat retinas indicated that histaminergic centrifugal

axons had several pathological abnormalities including swellings [43], which may
indicate potential retrograde transport problems leading to distal accumulation of
materials.
Nerve Fiber Layer Thickness

The evidence of histological changes in RGCs in humans is difficult to interpret
because of the difficulties in collecting postmortem specimens, and there is currently no
way to image ganglion cell structure in vivo. Several studies have, however, used clini-
cal imaging techniques to measure the thickness of the NFL, which is presumably rela-
tive to the abundance of ganglion cells. A defect in the thickness of the NFL was found
in a population of humans with type II diabetes using red-free fundus photography. It
was present in 20% of patients with only mild retinopathy (no microaneurysms) and in
57–78% of patients with more severe vascular abnormalities [44]. Scanning laser polar-
imetry has also been used in several studies to assess changes in the NFL due to diabetes.
In age-matched patients grouped according to their glycosylated hemoglobin levels, the
NFL was significantly thinner in patients with diabetes and poor blood glucose control
(HbA1c > 8%) and in patients with nonproliferative retinopathy [45]. The NFL thickness
in patients in this study who maintained HbA1c < 8%, however, was not different from
normal. A similar study identified an asymmetric NFL loss in the superior segment of
patients with type I diabetes [46]. A further study on type II patients also indicated that
NFL thickness decreased with increasing severity of diabetic retinopathy [47]. Together,
these clinical studies suggest a strong link between NFL thinning, glycemic control of
diabetes, increasing duration, and degree of retinopathy. Recently, a further study on
NFL thickness measured by optical coherence tomography showed that panretinal pho-
tocoagulation can exaggerate the thinning of the NFL in diabetes, suggesting that laser
surgery may induce further atrophy of RGC axons [48].
Thickness of the NFL in rodents has not been measured; however, one study on cross
sections of optic nerve from STZ-diabetic rats indicated a reduction in the density of
axons, accompanied by increases in the number of glial cells, suggesting denervation or
loss of ganglion cells [49].
BIOCHEMICAL EVIDENCE OF NEURODEGENERATION

AND CELL DEATH
The predominant evidence for diabetes-induced neurodegeneration in the retina
comes from histological studies; however, other studies present biochemical evidence of
apoptosis and neuronal dysfunction. Immunohistochemical studies suggest reductions
in Bcl-2, which could be linked to increases in apoptosis [25, 50]. Further evidence
includes increased activity of several caspase enzymes. A comprehensive assessment
of activity of caspases in rat retinas showed that caspases-1, -2, -6, -8, and -9 become
active within 2 months of the onset of diabetes in STZ rats. Similar activities were
found in postmortem tissue donated from humans with diabetes. In this study, the execu-
tioner caspases-3 and -6 became active later in the course of diabetes corresponding to
a period when capillary cells are expected to be lost [51]. Similarly, caspase-3 enzyme
activity was increased in the retinas of alloxan-diabetic rats after 14 months, but not
2 months, of hyperglycemia [52]. In rats after 3 months of STZ diabetes, the increased
caspase-3 activity was reversed by the anti-inflammatory drug, minocycline, suggesting
the possibility that caspase-3 dependent apoptosis is due to an inflammatory signal [53].
Minocycline also reduced caspase-1 activity in STZ-diabetic mouse retinas [54]. Further
evidence of a link between inflammatory signaling and caspase enzyme activation is
provided by a study with nepafenac, a COX-1/-2 inhibitor, given topically to the eye. In
this study, the anti-inflammatory treatment inhibited the increase in caspases-3 and -6
after 9 months of diabetes [55].
While the evidence for increases in apoptosis-associated enzymes is compelling,
the cell types in which these changes take place are not easily determined. It is argu-
able that these changes occur in vascular cells as well as, or to the exclusion of, neu-
rons. Other biochemical evidence for changes in neurons comes from measurements of
synapse-specific proteins such as postsynaptic density 95 (PSD95), and synaptic vesicle-
associated proteins such as synaptophysin. The retinal content of several synaptic pro-
teins was found to be decreased after the first month of hyperglycemia in STZ-diabetic
rats [56] (Fig. 5). These changes were accompanied by a further depletion in the content
of phosphorylated synapsin 1, suggesting a reduction in the mobilization of neurotrans-
mitter vesicles. Interestingly, the content reduction in synaptophysin was reversed by
angiotensin II receptor blockers [57].
Other biochemical changes that could be associated with neurodegeneration include
increases in nNOS, which increased in both protein content and activity in retinas
from STZ rats [58]. It was proposed that nNOS provided a regulatory link between
neurons and vascular blood flow and that the number of nNOS-positive neurons was
depleted by diabetes [59]. A similar study confirmed the increase in nNOS expression
and identified multiple subtypes of nNOS-containing neurons, including amacrine,
bipolar, and horizontal cells, that were damaged by diabetes [28, 32]. Elevated levels
of nNOS are accompanied by increases in the production of nitric oxide, especially
in the plexiform layers, measured by a novel in situ immunohistochemical imag-
ing technique [60]. Elevated levels of nitric oxide could have a dramatic influence
on neuronal function, including altered glutamate receptor signaling [61], increased
peroxynitrite production associated with excitotoxicity [62], and altering RGC axon
morphology [63].
FUNCTIONAL EVIDENCE OF NEURODEGENERATIVE CHANGES

There is an abundant variety of electrophysiological studies indicating that diabetes
induces functional changes in the retina. Many of these studies will be reviewed else-
where in this volume; however, some electrophysiological studies specifically indicate a
neurodegenerative mechanism.
Electrophysiological Evidence for Neurodegeneration

The electroretinogram (ERG) is frequently used to measure the electrical responses
originating from the retina due to light stimulus. The response, recorded by an electrode
placed on the cornea, produces a waveform with several components, provided by
198 Barber et al.
Fig. 5. Diabetes decreased the content of synaptic proteins in rat retinas. Synaptic proteins
were quantified by western blot in the retinal homogenates from STZ-diabetic and control rats
after 1 and 3 months of hyperglycemia. (A) Protein bands were apparent at the predicted molecu-
lar weight for each synaptic protein, and band densities were standardized to b-actin in the same
sample. (B) Relative protein content was obtained as % control. There was a significant reduction
in each of the proteins measured in the retinas from STZ-diabetic rats (n = 8 per group, *p < 0.05,
**p < 0.01, *p < 0.001). Taken from Vanguilder et al. [56].
different cell types from the neural retina. Immediately following light stimulus, the
a-wave is a negative deflection produced by the photoreceptors. The postreceptor b-wave
response is a large positive deflection originating primarily from the ON-center bipo-
lar cells [64, 65] modified by input from OFF-center bipolar and horizontal cells [66].
The oscillatory potentials (OPs) are small, higher frequency wavelets on the ascending
portion of the b-wave, are thought to represent the modulation of interactions between
bipolar, amacrine, and ganglion cells [67, 68], and are often analyzed in clinical and
research studies of diabetic retinopathy.
Clinical studies of patients with diabetes were concerned with OP changes associ-
ated with diabetic retinopathy. In 1962, Yonemura et al. reported deterioration of oscil-
latory potentials not only in patients with diabetes, most of whom had been diagnosed
with retinopathy, but also in a smaller number of patients without ophthalmoscopic

evidence of retinopathy [69]. Additional clinical studies followed, establishing that
humans with diabetic retinopathy have specific alterations in ERG response, includ-
ing reduced OP amplitude [70–72] and increased OP latency [71]. Juen and Kiesel-
bach noted that patients of 18–33 years old had significant loss of OP amplitude after
being diagnosed with diabetes for an average of only 7 years, prior to the advent of any
notable vascular changes associated with diabetic retinopathy [72]. Alterations in OPs
have been correlated with loss of visual acuity, hue discrimination [71, 73], and contrast
sensitivity [70]. Other studies showing that the ERG was altered within a few years of
the onset of juvenile diabetes suggested that this could be used as an early diagnostic
approach [74, 75].
Much of the research into the effects of diabetes on the a-wave has been performed
in the STZ-diabetic rat model. Several studies reported a reduction of the a-wave ampli-
tude by 12 weeks after the onset of diabetes, suggesting loss of photoreceptor function
[76–78]. Hancock and Kraft also found a delay in the a-wave implicit time [79], a result
which had also been reported in humans with diabetes [71, 80]. Animal studies consist-
ently demonstrate a decrease in b-wave amplitude by 12 weeks after the onset of diabetes
[79, 81, 82]. Phipps et al. recorded decreased b-wave amplitudes as early as 2 days after
STZ injection [77]. The same study also determined that there was no change in b-wave
latency in the diabetic rat model, a finding that was replicated in another animal study
[83]. The b-wave latency is increased in patients with diabetic retinopathy [84, 85].
Taken together, the results of many ERG studies provide evidence of loss of function in
photoreceptors, amacrine cells, bipolar and horizontal cells. The mechanism for these
electrophysiological changes is unclear. The small amounts of cell death are unlikely to
give rise to these large changes in the electrophysiological output of the retina. A more
likely possibility is that changes in the amount of neurotransmitter release, or transmem-
brane ionic currents could account for the electrophysiological deficits.
The scotopic threshold response (STR) is another component of the ERG, consid-
ered to be an indicator of RGC function [68, 86, 87]. While this response is often not
measured, because it can only be determined in response to very low intensity flashes
of light, there is good evidence that it is reduced in both humans and rats with diabetes
[83, 88, 89]. Furthermore, electrophysiological ganglion cell function was found to be
compromised even in children with diabetes [90]. These data provide functional evi-
dence of diabetes-induced RGC degeneration.
Optic Nerve Retrograde Transport

Several studies have determined that diabetes causes functional reductions in retro-
grade transport along the optic nerve. Retrograde axonal transport of fluorogold into
medium and large RGCs was reduced in STZ-diabetic rats (but not a type II animal
model) [91, 92]. The effect was reduced by treating rats with an aldose reductase inhibi-
tor, suggesting that the loss of function in diabetes may be due to activation of the polyol
pathway [93]. Loss of the visually evoked potential, accompanied by optic nerve pathol-
ogy, in spontaneously diabetic BB/W rats is a further indication that optic nerve function
is compromised by diabetes [94].
200 Barber et al.
Other Changes in Visual Function

There have been a variety of studies applying psychophysical testing on humans
with diabetes, recording a number of deficits that could be explained by altered neural
function or neurodegeneration. A study of visual evoked potential, a measure of the
visual cortex response to a flash of light, found that the evoked response was reduced
and delayed in juvenile patients with diabetes [95]. Furthermore, the evoked response
to stimuli with low contrast sensitivity was reduced more than stimuli with greater
contrast sensitivity in patients with type 1 diabetes but no evidence of vascular retin-
opathy [96].
Reduced night vision is often associated with the early stages on diabetic retinopa-
thy [97]. Loss of night vision may be associated with reduced contrast sensitivity and
prolonged dark adaptation, and patients with maculopathy are often aware of peripheral
field defects and color vision abnormalities [98].
Contrast sensitivity has also been studied extensively in diabetic patients. In a larger
study, a group of non-insulin-dependent diabetic subjects with minimal visible fundus
signs of diabetic retinopathy had abnormal contrast sensitivity at one or more spatial
frequencies [99]. In another study of type 1 diabetic subjects with no retinopathy, there
was a reduction in contrast sensitivity at multiple spatial frequencies between 1.0 and
9.6 cycles/degree [100]. A similar study indicated that presence of microalbuminuria
predicted a reduction in contrast sensitivity in type 1 patients [101]. Subjects with insu-
lin resistance and dyslipidemia also have significant reductions in mesopic and low pho-
topic contrast sensitivity, suggesting that this loss of function is not limited to those with
severe insulin-dependent diabetes [102].
Color vision defects can also occur in humans with diabetes [103]. A histological
study on postmortem retinas found a selective reduction in the number of S-cones in
samples from donors with diabetes, possibly by apoptosis [104], which could explain the
tritan color confusion and loss of sensitivity to blue light that is known to occur in dia-
betic retinopathy [105–107].
The studies on visual function in humans with diabetes indicate that there are specific
deficits that are measurable early on in the course of the disease, often in the absence of
gross vascular defects evident by fundus examination. These data suggest that changes in
neural function begin early in diabetes. It is important that we examine the cellular sub-
strate for various elements of vision, such as contrast sensitivity, dark adaptation, and color
contrast, in order to develop better ways to protect vision in diabetes. In order to develop
better treatments for neurodegenerative changes in the retina, a number of theories for the
causative mechanisms have evolved, which we will attempt to summarize next.
POTENTIAL MECHANISMS OF RETINAL

NEURODEGENERATION IN DIABETES
The relationship between vascular permeability and retinal neurodegeneration in dia-
betes is still unclear. It is reasonable to assume, however, that a breach in the blood-retinal
barrier will give rise to local changes in neural function that could result in necrosis or
apoptosis of neurons. There is a clinical link between macular edema and loss of visual
acuity, although correlations with more sensitive measures of visual function have not
been attempted [108]. Equally, reductions in contrast sensitivity have been correlated
with reductions in capillary density, as an index of ischemia in the retina [109].
Related to the concept that the neural retina is compromised by ischemia is the pro-
posal that the retina becomes hypoxic in diabetes. One proposed mechanism for hypoxia
is that poor blood flow to the inner retina, in concert with the heavy metabolic demand
from photoreceptors under dark-adapted conditions, leads to tissue oxygen depletion.
This is based on observations that diabetic retinopathy is limited in situations where the
photoreceptors are lost, like retinitis pigmentosa or in animal models such as the rho-
dopsin knockout mouse (Rho−/−) [110, 111].
Glutamate excitotoxicity is a commonly considered mechanism for many diseases
involving neurodegeneration and has been suggested to occur in diabetes [112]. GABA
and glutamate levels were increased in vitreous of 22 patients with proliferative diabetic
retinopathy, compared to a similar set of nondiabetic patients who had pars plana
vitrectomy [113]. Similar increases have been measured in rats [114, 115]. Elevated con-
centrations of glutamate and GABA increased immunoreactivity for glutamate receptors
NMDA and GluR2/3, accompanied by increased expression of calcium-binding proteins
calbindin and parvalbumin in ganglion, amacrine, and bipolar cells [116]. Furthermore,
glutamate oxidation was 62% less than controls in retina explants from STZ-diabetic
rats, related to the reduction in the activity and content of glutamine synthetase, suggest-
ing a reduced ability to process glutamate in the retina [117]. Reductions in the uptake
rate of glutamate into Müller cells have also been measured [118, 119], along with
alterations in the expression of some glutamate receptor subunits [120, 121]. The weak
NMDA receptor antagonist has been reported to correct electroretinographic changes,
prevent loss of RGCs, and reduce the amount of retinal vascular permeability in diabetic
Brown-Norway rats, suggesting that this class of drugs may represent a useful therapeu-
tic to prevent loss of function in diabetic retinopathy [37]. There is an intimate relation-
ship between oxidative stress, nitric oxide toxicity, and glutamate excitotoxicity, and
diabetes may induce all these biochemical processes in the retina [115].
The role of advanced glycation end-products (AGEs) in diabetic complications and
retinopathy in particular has been discussed widely, especially since the AGE recep-
tor was discovered [122]. The specific effect of AGEs on neurons in the retina has not
been as well defined. Many studies have shown that treatment with aminoguanidine, an
inhibitor of AGE formation, can rescue the vascular changes in diabetes [13, 123, 124].
This drug also reduced the loss of nNOS-containing neurons in STZ rats [59]; however,
it failed to improve the abnormal ERG response in diabetic rats [76]. It may be that the
effect of AGEs in neurons is indirect, acting by inducing an inflammatory response in
glial cells and the vasculature [29].
Another mechanism that may be responsible for pathological changes to neurons
in diabetes is loss of growth factor signaling, either through reduction in abundance of
the growth factors or through loss of receptor sensitivity and second messenger signal-
ing. BDNF was depleted from both brain and retina of diabetic rats [31, 125]. Loss of
tyrosine hydroxylase-positive amacrine cells was prevented by injection of exogenous
BDNF in rats [31]. There are also reductions in the kinase activity of components of
202 Barber et al.
Fig. 6. Glucose elevated the intracellular calcium response to membrane depolarization in

cell culture model of retinal neurons. Immortalized retinal neurons (R28 cells) were grown in
5 mM glucose, 20 mM glucose, or 15 mM mannitol with 5 mM glucose, for 2 days. Intracellular
calcium was detected by fluo-4, a compound that becomes more fluorescent in the presence of
the PI3kinase-Akt pathway in STZ-diabetic rat retinas, accompanied by reduced insulin

receptor kinase activity [126]. Systemic administration of IGF-1 was found to reduce the
amount of apoptosis measured by TUNEL and caspase-3 activity in STZ rats, suggesting
that increased growth factor signaling may protect the retina [127].
A less widely considered explanation of neuronal cell death and dysfunction is a
change in the way intracellular calcium concentration is regulated. Calcium is an espe-
cially potent signal in neurons, responsible for initiating many metabolic events, includ-
ing plastic changes at the synapse [128, 129]. Some in vitro studies indicate that elevated
levels of glucose augmented the intracellular calcium response to membrane depolariza-
tion [130] (Fig. 6).
SUMMARY AND CONCLUSIONS

Diabetic retinopathy is considered to be a vascular disease of the retina, because clini-
cally identifiable signs of the disease include vascular lesions such as microaneurysms
and loss of the blood-retinal barrier leading to macular edema (nonproliferative stage).
Later in the disease, there can be vascular proliferation and ischemia (proliferative stage)
resulting in profound vision loss, although progression to this stage is less common
[131, 132]. Clinical detection of diabetic retinopathy is almost exclusively through rec-
ognition of the vascular indications of the disease. These symptoms are accompanied by
loss of visual acuity [133], and the patient usually recognizes the effects of the disease
as a reduction in quality of life due to gradual deterioration of functional vision [134].
There is little doubt that diabetes reduces the ability of the retina to function correctly,
but retinal function is difficult to measure in the clinic, so the fundus examination is
regarded as the standard method to diagnose and map the progress of diabetic retinopa-
thy. The gradual loss of retinal structure and function can, however, be interpreted as
the most basic indication that neurodegeneration of the retina, leading to compromised
visual function, is a prevalent component of diabetic retinopathy. Future advances in
diagnosis and treatment of diabetic retinopathy will likely include consideration of this
important aspect of the disease.
Fig. 6. (continued) calcium. The live cells were imaged by confocal microscopy during mem-
brane depolarization by addition of 20 mM KCl. (A) Five seconds of baseline images of cells
were recorded, followed by depolarization with 20 mM KCl. (B) In control cells with 5 mM glu-
cose, the intracellular fluorescence increased transiently and returned almost to baseline within
65 s. (C) Cells grown with 20 mM glucose had baseline fluorescence similar to control cells.
(D) Cells grown with 20 mM glucose displayed a more dramatic increase in fluorescence in
response to KCl, and this did not return to baseline within 65 s. (E) Relative quantification
of whole cell fluorescence (cytoplasmic and nuclear), by digital image analysis, indicated that
there was a significant increase in calcium-induced fluorescence in the cells grown with 20 mM
glucose compared to those grown with 5 mM glucose. Addition of mannitol did not alter the
calcium response compared to the control cells, indicating that the effect was not due to osmotic
changes in the media (*p < 0.05). Similar results were obtained from primary cultures of retinal
cells. Taken from Santiago et al. [130].
204 Barber et al.
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13
Glucose-Induced Cellular Signaling
in Diabetic Retinopathy
Zia A. Khan and Subrata Chakrabarti
CONTENTS
Introduction
Cellular Targets in DR
Signaling Mechanisms in DR
Concluding Remarks
Acknowledgments
References
Keywords Diabetes • Retinopathy • Complications • Endothelial cells • Pericytes • Angiogen-

esis • Extracellular matrix • Cellular signaling
INTRODUCTION
Diabetic retinopathy (DR) is a microvascular complication of diabetes. It is the most
common cause of blindness in the working population. Nearly all people with diabetes,
both type 1 and type 2, will eventually develop some form of retinopathy [1]. Clinical
trials have consistently shown that good glycemic control can reduce the development
of retinopathy in both type 1 and type 2 diabetic patients [2, 3]. Other factors such as
hyperlipidemia and hyperinsulinemia may also be involved. However, the major con-
tributor does seem to be excess blood glucose levels. Sustained hyperglycemia leads to
a sequence of adverse events in the retina (summarized in Fig. 1). Early events include
altered expression of vasoactive factors and basement membrane (BM) proteins [4–6].
This manifests as loss of vasoregulation, thickening of the BM, and increased perme-
ability. Increased permeability may also cause macular edema and significant vision
loss. With continued hyperglycemic insult, the vascular cells exhibit exhaustion and
degeneration leading to the formation of acellular capillaries [7–9]. All these functional
and structural changes then converge to create an ischemic retina. Elaboration of growth
factors to induce new blood vessel formation then proceeds. This sequence of events,
continued insult, and continued adaptation, ultimately causes unregulated angiogenesis

211
212 Khan and Chakrabarti
Fig. 1. Key events in the development and progression of DR. High plasma glucose levels
lead to biochemical dysfunction in the retinal vascular cells. These changes result in structural
and functional alterations at the vascular unit level. Reduced blood flow to the retina produces an
ischemic environment which dictates elaboration of various angiogenic factors. These continued
insults to the retinal tissue ultimately lead to EC hyperplasia and unregulated angiogenesis.
and blindness in diabetic patients. It is well accepted that understanding the molecular
basis of endothelial cell (EC) dysfunction and loss will provide better therapeutic targets
for DR. In this chapter, we review the cellular and molecular (signaling) mechanisms
that ultimately lead to the development of DR.
CELLULAR TARGETS IN DR
In order to gain insight into the pathogenetic mechanisms underlying any disease, the
first step is to develop in vitro and in vivo models that provide a phenocopy or at least
exhibit the key structural and functional features of the disease. A prerequisite, therefore,
is to identify the target cellular population. In the case of DR, retinal fluorescein angi-
ography has provided important information about the primary cellular target [10, 11].
These studies show numerous areas of nonperfusion in the retina. The underlying cause
of nonperfusion seems to be loss of vascular cells [12, 13]. These vascular cells include
both ECs and pericytes that eventually succumb to glucotoxicity.
Endothelial Cell (EC) Dysfunction

Retinal angiography and digest studies show that normal retinal vascular perfusion
is dependent on intact endothelium [14, 15]. The working hypothesis is that high levels
Signalling Mechanisms in Diabetic Retinopathy 213
Fig. 2. Molecular and phenotypic changes in ECs exposed to high levels of glucose. Studies
from our labs and others have shown that acute exposure to high glucose causes reduced viabil-
ity and increased apoptosis in the ECs. However, with continued exposure, the ECs proliferate
which is associated with increased matrix protein and VEGF production. ET endothelin; FN
fibronectin; MAPK mitogen-activated protein kinase; NOS nitric oxide synthase; PKB protein
kinase B; PKC protein kinase C; VEGF vascular endothelial growth factor.
of glucose lead to EC dysfunction and loss. An important assumption, therefore, is that

high levels of extracellular glucose equate to high levels of intracellular glucose. In other
words, there is no adaptive transport mechanism in the ECs. This certainly seems to be
the case. ECs incorporate glucose via facilitative diffusion without significant alterations
of glucose transporter-1 (Glut1) levels [16]. Therefore, continued exposure of ECs to high
glucose leads to continued intracellular glucose accumulation. When assayed in culture,
exposure of ECs to high glucose causes activation and dysfunction which is reflected by
increased extracellular matrix (ECM) protein production and altered cellular activities
[17–22]. Data from our laboratories and others show that this simple in vitro model illus-
trates most of the molecular changes that we see in clinical DR (Fig. 2). Early changes
in the ECs following glucose exposure include reduced viability and increased apopto-
sis [23]. Interestingly, these changes are followed by increased proliferation [24]. This
biphasic effect is reminiscent of EC changes in the early and advanced DR. Although the
mechanism of this biphasic effect is not clear, we hypothesize that the mechanism of the
late proliferative response is a change in the microenvironment—this is expected to occur
in vivo as well. ECs rest on a scaffold of ECM proteins called the BM. This matrix serves
as a reservoir of growth factors and other signaling proteins. With continued exposure to
high glucose levels, the ECs may accumulate growth factors and other mitogens in the
matrix. In fact, ECs exposed to glucose for more than 72 h have been shown to increase
protein levels of an EC-specific mitogen, vascular endothelial growth factor (VEGF)
[25]. We have also shown that the mRNA of VEGF is upregulated as early as 24 h fol-
lowing exposure to high levels of glucose [26]. In addition, the matrix itself is expected
to change in terms of the protein amount and the protein composition (see below). This
potentially creates a permissive environment that mediates the late changes of glucose in
culture and in advanced clinical DR.
Endothelial-Pericyte Interactions
Pericytes are the contractile cells present in microvessels (similar to smooth muscle
cells in larger vessels). These cells are in close contact with the ECs and form a discon-
tinuous layer. The physiological function of the pericytes is to stabilize vessels, regulate
vessel contraction, and keep the endothelium in a quiescent state. This intimate rela-
tionship between the vascular cells suggests that aberration in one cell type will lead to
alterations in the phenotype of the other cellular component. However, when pericytes
are cultured in high levels of glucose, we see an interesting contrast to ECs. Both peri-
cytes and smooth muscle cells exhibit an autoregulatory glucose transport mechanism
[16], that is, exposure to glucose leads to downregulation of Glut1. The overall transport
of glucose seems to be higher in pericytes possibly due to greater biosynthetic abil-
ity. Therefore, these perivascular cells also undergo glucose-induced dysfunction and
loss. In fact, loss of pericytes is considered one of the structural hallmarks of DR [7–9].
Pericyte loss is implicated in contributing to acellular capillary formation and may also
be important in late stages of DR. Evidence for this comes from studies in platelet-
derived growth factor-B knockout mice that lack pericytes in the brain capillaries [27].
These animals develop microaneurysms, acellular capillaries, and EC hyperplasia. These
results are exacerbated when PDGF-deficient animals are made diabetic [12] suggesting
an important role of pericyte-EC interaction in advanced DR.
The biochemical mechanisms underlying pericyte loss seem to be similar to ECs with
the same players emerging (metabolic distress, vasoactive factors, protein kinase activa-
tion). In addition, it has been shown that an abrupt drop in glucose levels causes pericyte
apoptosis [28]. Another mechanism may involve the angiopoietin system. Hyperglyc-
emia has been shown to increase the expression of angiopoietin-2 in the retina that leads
to pericyte dropout [29]. Furthermore, angiopoietin deficiency in the diabetic animals
prevented pericyte loss and subsequent acellular capillary formation.
Endothelial-Matrix Interactions
Neovascularization, formation of a complete vascular unit either through angiogen-
esis or vasculogenesis, is a multistep process. Both endothelial and perivascular cells
undergo a number of structural and functional changes to form a blood vessel. These
cellular activities include endothelial proliferation and migration, formation of cell-cell
contacts and tubules, recruitment of pericytes, and contribution to the ECM. In addi-
tion to providing a scaffold for the organization of the vascular cells, the ECM has been
implicated in providing critical cues for proper blood vessel formation [30, 31]. The
BM (sheet of ECM proteins) of normal microvessels predominantly contains laminin,
collagen, and nidogen (entactin) [32]. A consistent feature of DR is (a) an increase in

the ECM proteins; (b) a switch in the type of ECM proteins, that is, composition; and
(c) posttranslational modifications of ECM proteins such as glycation.
In cultured retinal ECs, high levels of glucose can increase mRNA expression of
both collagen and fibronectin (FN) [19, 33, 34]. The retinal BM of diabetic animals also
shows increased expression of collagen, laminin, and FN [35]. These are early molecu-
lar changes and are evident in approximately 8 weeks following diabetes induction [35].
We have previously shown that FN is upregulated in the retinal tissues of diabetic rats
in 1 month [36]. This increased expression continues for up to several months. The
upregulated matrix protein expression then manifests as thickening of the BM in animal
models [37]. In addition to collagen and FN, tenascin has been found in retinal vessels
of diabetic patients and animals [38, 39]. It is important to note that this does not repre-
sent a general phenomenon of BM duplication/expansion but is a selective upregulation
of key ECM proteins. For example, no difference in the amount of proteoglycans in
diabetic patients has been reported [40]. This suggests that the composition of the BM
may be important in providing critical cues to the vascular cells [30–32, 41, 42]. In sup-
port, we have recently shown that FN undergoes alterative splicing in DR to produce an
embryonic isoform, ED-B + FN (also known as oncofetal FN) [26, 43]. Increased levels
of this isoform are evident in vitreous of patients with advanced DR [43, 44] and retinal
tissues of diabetic rats [43]. In cultured vascular ECs, we have shown that ED-B + FN
is increased following exposure to high levels of glucose and that this FN isoform is
involved in VEGF expression and EC proliferation.
Functionally, FN in the matrix may play a critical role in DR. FN is highly expressed
in developing vessels as compared to stable quiescent vessels [45, 46]. During vascular
remodeling (e.g., during wound healing or tumorigenesis), FN is upregulated [47, 48].
Further support of a functional role of FN in the retina comes from studies that show
expression of FN in the active zones of vascularization [49]. FN also provides critical
survival and proliferative signals to brain capillary ECs [50]. ECs express a number of
ECM protein receptors, and function-blocking antibodies against FN integrins lead to
reduced EC proliferation [50].
SIGNALING MECHANISMS IN DR
Altered Vasoactive Factors
DR is a culmination of numerous biochemical alterations that take place in the vas-
cular tissue of the retina. An important physiological function of the endothelium is
the regulation of regional blood flow. This is achieved by creating a balance between
vasoconstricting factors and vasodilating factors. Diabetes leads to a disruption of this
balance, and these altered vasoactive molecules play a role in both the early and the late
stages of DR. Increased vasoconstriction and impaired endothelium-dependent vasodila-
tion has been reported in diabetes [37, 51–55]. This vasoregulatory impairment has been
shown to precede the structural changes in the vasculature [52, 54, 56–59]. The mecha-
nistic basis of impaired endothelium-dependent vasodilatory responses has been exten-
sively researched in diabetic patients, animal models, and cultured cells. This mechanism
involves increased expression of endothelin-1 (ET-1), the most potent vasoconstrictor
[60]. ETs are short peptides that are secreted by ECs and mediate vasoconstriction by
binding to ET receptors on the perivascular cells. Increased ET has been shown to cause
vasoconstriction and reduced blood flow in diabetes [60]. Interestingly, improvement
of the vasodilator responses have also been noted in diabetic patients that were admin-
istered an ET receptor antagonist [61]. In streptozotocin-induced diabetic rats, we have
reported that diabetes-induced retinal capillary vasoconstriction is normalized with an
ET receptor antagonist (Bosentan) [37]. We have also shown that high levels of glucose
increase ET-1 and mediate increased EC permeability and ECM protein expression in
cultured cells [26, 62, 63]. ET may also function as a mitogen for both perivascular cells
[64, 65] and ECs [66, 67] which may be important in the late stages of DR.
It is expected that increased ET-1 levels may accompany decreased vasodilator levels
(such as nitric oxide; NO). NO is produced by a family of enzymes called NO synthases
(NOS). Studies have shown increased levels of both endothelial (e-) and inducible (i-)
NOS enzymes in response to high levels of glucose [68–71]. This is also seen in animal
models and human diabetes [69]. A number of signaling pathways that are activated in
diabetes may lead to increased expression of NOS. These pathways may include VEGF
[72] and protein kinase pathways [72–74]. The reason for this apparent discrepancy has
been recently hypothesized to be an increased scavenging and reduced bioavailability
of NO. In diabetes, NO levels may be reduced through sequestration by reactive oxygen
species (ROS). It is also important to note that increased NOS expression may not lead
to increased NO production. Acute exposure of ECs to glucose decreases NO generation
by agonists including bradykinin [75]. These effects were shown to be the direct result
of high glucose levels. Purified eNOS, when assayed in the presence of glucose, shows
significantly lower NO production [75]. This suggests that increasing NO production/
availability may undo some of the glucose-induced changes. When diabetic animals are
treated with an NO donor, molsidomine, the diabetes-induced vasoconstriction in the
retina is normalized [76].
Alteration of Metabolic Pathways

Polyol Pathway
Physiologic metabolism of glucose is accomplished mainly by the glycolytic path-
way. However, in diabetes, increased flux and shunting of glucose through alternative
pathways take place (Fig. 3). One such pathway is the polyol pathway [77, 78]. In this
pathway, glucose is metabolized to sorbitol by aldose reductase (AR) [78]. Sorbitol
itself may cause cellular damage [78, 79] which may be prevented by myo-inositol
supplementation [80]. However, the major contribution of the polyol pathway to the
adverse effects of high glucose levels seems to be the alteration in enzyme cofactor
levels. The first enzymatic reaction that converts glucose to sorbitol requires NADPH.
An increase in glucose flux is expected to decrease NADPH levels. NADPH is also a
cofactor for antioxidant enzyme system (reduced glutathione) and, therefore, contrib-
utes to impairment of cellular antioxidant system. The second reaction that converts
sorbitol to fructose requires NAD+ and generates NADH. It is believed that increased
NADH production leads to augmented levels of glyceraldehyde 3-phosphate. Increased
glyceraldehyde 3-phosphate may then increase advanced glycation end product forma-
tion through methylglyoxal [81].
Fig. 3. Early metabolic/biochemical changes in ECs exposed to high levels of glucose.

Increased flux of cytosolic glucose through the polyol, hexosamine, protein kinase C, and meth-
ylglyoxal pathways represents early alteration in the ECs. Activation of these pathways paves the
path for EC dysfunction and loss through elaboration of reactive oxygen species (ROS), loss of
vasoregulatory function (endothelin/nitric oxide imbalance), and modification of proteins. Key
enzymes involved in these pathways are also indicated. AGE advanced glycation end products;
ET endothelin; PKC protein kinase C; NAD+ nicotinamide adenine dinucleotide; NADH nicoti-
namide adenine dinucleotide, reduced; NADPH nicotinamide adenine dinucleotide phosphate,
reduced.
Clinical studies show that polymorphisms in AR gene may be linked to increased sus-
ceptibility of microvascular complications [82–84]. Although inhibition of AR has not
provided any conclusive results, one recent trial with the AR inhibitor sorbinil showed
slower rate of microaneurysms in the retina [85]. A new class of AR inhibitors was
recently tested in streptozotocin-induced diabetic rats [86], but whether this selective
AR inhibitor (ARI-809) produces favorable results in clinical trials remains to be deter-
mined.
Hexosamine Pathway
Metabolites of the glycolytic pathway may also be shunted through the hexosamine
pathway in diabetes [87]. This pathway produces uridine diphosphate N-acetylglu-
cosamine (UDP-GlcNAc), substrate for O-linked glycosylation of serine/threonine-con-
taining proteins and proteoglycan synthesis. Studies have shown that inhibition of the
key enzyme in this pathway, glutamine:fructose 6-phosphate amidotransferase (GFAT),
reduces hyperglycemia-induced fibrogenic protein expression in aortic ECs [88]. In
addition, a large number of proteins that are implicated in the development of diabetic
complications are modified by O-linked glycosylation. These include protein kinases,
growth factors, and transcription factors [89].
Protein Kinase C Pathway

A number of protein kinase pathways are activated when ECs are exposed to high
levels of glucose [62, 90–92]. Several studies have shown activation of protein kinase
C (PKC) in diabetes [62, 90, 93–95]. There are a number of PKC isoforms that are acti-
vated in animal models of diabetes including PKCa, bI, bII, g, and d [96, 97]. PKCbI
and II show the most prominent level of induction in the retina [97]. We and others have
previously shown that PKC may mediate glucose-induced EC permeability [62, 98] and
ECM protein production [90]. PKC activation in ECs also causes increased expression
of endothelin-converting enzyme-1 and ET-1 [99, 100]. In addition, PKC may also be
involved in pericyte loss and expression of various growth factors and vasoactive factors
[94, 95, 98, 101, 102]. Several experimental and clinical studies have been carried out
with selective PKCb inhibitor, ruboxistaurin mesylate (LY333531) [103–107]. In phase
III clinical trials, ruboxistaurin showed a delay in the occurrence of moderate visual loss
in patients with early DR (nonproliferative phase) at 24 months [108].
Activation of Other Protein Kinases

Mitogen-Activated Protein Kinase (MAPK)
Recently, studies have reported an important role of mitogen-activated protein kinase
(MAPK) pathway in the diabetic complications [109, 110]. The MAPK family con-
sists of extracellular signal-regulated kinase (ERK) and stress-activated components,
namely c-jun N-terminal kinase (JNK) and p38 [110, 111]. We have shown that glu-
cose-induced ECM protein synthesis in cultured ECs is mediated by the activation of
the MAPK pathway [90]. We have further demonstrated that MAPK activity leads to
activation of transcription factors, nuclear factor-kB (NF-kB), and activating protein-1
(AP-1) [90]. Inhibition of either MAPK or PKC is able to normalize the effects of
high levels of glucose. Furthermore, inhibiting PKC in cells exposed to high glucose
reduces MAPK activation suggesting an important cross-regulation between PKC and
MAPK pathways. It is possible that MAPK activation may also occur in vascular ECs
via a PKC-independent pathway [112]. Oxidative stress may cause MAPK activation by
ERK5 (big MAPK1/BMK1) [113]. Knocking out BMK1 results in angiogenic defect
and embryonic lethality [114]. BMK1, however, differs from other MAPK as it contains
a transcriptional activation domain, mediating protein–protein interaction with several
other factors [114, 115]. Whether such pathways are also activated in DR remains to be
determined.
Protein Kinase B and Serum- and Glucocorticoid-Regulated Kinase (SGK-1)

Cultured ECs challenged with high levels of glucose also show an important role of
protein kinase B (PKB) [92] and serum- and glucocorticoid-regulated kinase-1 (SGK-1)
[91]. Several growth factors stimulate the activation of PKB. There are three major
PKB isoforms a, b, g. These isoforms belong to a subfamily of protein kinases named
AGC protein kinases and include PKC and PKA. PKB can regulate the function of cyto-
plasmic as well as nuclear proteins [116, 117]. We have shown rapid glucose-induced
activation of PKB [92] and SGK-1 [91]. Inhibiting PKB and SGK-1 either by dominant
negative transfections and/or small interfering RNA causes complete normalization of
Fig. 4. Mechanisms causing hyperglycemia-induced oxidative stress. High glucose levels

directly increase ROS production by autoxidation. Increased flux through the polyol, hexosamine,
PKC, and methylglyoxal pathways may also lead to increased oxidative stress. In addition,
hyperglycemia may increase ROS indirectly by increasing the activity of various enzymes that
lead to oxidative stress. AGE advanced glycation end products; ET endothelin; HO heme oxy-
genase; PKC protein kinase C; LOX lectin-like oxidized LDL receptor; NO nitric oxide; PARP
poly(ADP-ribose) polymerase; SOD superoxide dismutase.
high glucose-induced FN expression in the vascular ECs. Interestingly, this role of PKB
in ECM protein expression is also regulated by both MAPK and PKC [92]. We have
further shown that PKB phosphorylation can lead to the activation of NF-kB and AP-1
[92]. These studies suggest that multiple pathways converge on NF-kB and AP-1 to
mediate increased ECM protein synthesis.
Increased Oxidative Stress

Increased glucose-induced oxidative stress is another early event in the ECs. There
are multiple pathways that increase oxidative stress (Fig. 4). Acute exposure of vascu-
lar cells to high ambient glucose causes glucose autoxidation [87] and mitochondrial
superoxide production [118–120]. Inhibiting mitochondrial superoxide production
has been shown to be beneficial for DR by blocking major pathogenetic pathways
[118]. Oxidative stress in diabetes may also be induced by indirect means, which
include the NADPH oxidase enzyme [121, 122]. NADPH oxidase may increase
superoxide production and through induction of xanthine oxidase. This pathway may
also inhibit superoxide dismutase. Impairment of antioxidant enzymes could also be

carried out by increased AR activity through the imbalance between NADP+ and
NADPH. A number of other enzymes have also emerged as being important media-
tors of increased oxidative stress. Lipoxygenase enzyme (LOX) may contribute to
diabetes-induced oxidative stress [123]. LOX increases the oxidation of low density
lipoproteins (ox-LDLs) [124, 125]. We have shown that glucose increases CD36 (an
ox-LDL receptor) and leads to increased uptake of ox-LDL and oxidative DNA dam-
age in vascular ECs [124]. Exposure of pericytes to ox-LDL has also been reported to
cause cellular apoptosis [126]. Whether the mechanism involves CD36 in pericytes
remains to be determined.
Recently, several investigators have shown a role of poly(ADP-ribose) polymerase
(PARP) in cultured ECs and retina of diabetic animals [127–129]. Increased PARP
activity, possibly in response to oxidative DNA damage, may cause vascular EC dys-
function by depleting NAD+ and ATP. PARP may also cause NF-kB activation [130]. In
a nondiabetic system, PARP activation has been linked to histone deacetylases (HDACs)
and transcription coactivator p300 [131, 132]. Whether a similar pathway may also be
involved in DR requires further investigation.
Protein Glycation
Accelerated glycation of proteins is also an important mechanism leading to cellu-
lar dysfunction in diabetes. High levels of glucose may cause nonenzymatic glycation
of both intracellular and extracellular proteins [133, 134]. These modified proteins are
recognized by AGE receptors (RAGEs) and possibly other scavenger receptors. Studies
have shown that retinal vascular tissue and cultured ECs express both RAGEs and CD36
(a scavenger receptor) [135–139]. Although the mechanisms of AGE-mediated cellular
dysfunction are currently being elucidated [140–142], aberrant modification of proteins
is expected to alter the function of the proteins. In the case of extracellular proteins, gly-
cation may also lead to aberrant outside-in signaling. Evidence for this comes from stud-
ies that show that injecting exogenous AGEs in diabetic animals causes retinal pericyte
loss [143]. Interestingly, when retinal ECs are exposed to glycated BM proteins [144],
the cells proliferate. A specific inhibitor of nonenzymatic glycation, aminoguanidine,
has been shown to prevent retinal microaneurysms, acellular capillaries, and pericyte
loss in the diabetic dogs [145]. In clinical trials, however, modest beneficial effects were
noted [146].
Aberrant Expression of Growth Factors

A number of growth factors have been implicated in the pathogenesis of DR. Growth
factor alterations are believed to mediate BM thickening, EC hyperplasia, and unregu-
lated angiogenesis [147]. The list of growth factors that exhibit altered expression in
vitreous of diabetic patients or retinal tissues of diabetic rats is a long one [147]. Impor-
tant growth factors include insulin-like growth factor-1 [148], platelet-derived growth
factor [149], basic fibroblast growth factor [150], transforming growth factor-b [151],
and VEGF [152]. These growth factors have been shown to induce EC proliferation,
ECM synthesis (especially in the case of TGF-b), and cause retinopathy-like lesions in
animals [147].
Fig. 5. Mechanisms of glucose-induced growth factor and ECM protein expression in ECs.
High levels of glucose lead to activation of a number of intracellular signaling proteins. These
signaling proteins mediate the effects of glucose by activating transcription factors and alter-
ing other transcriptional regulators (coactivators/corepressors). Transcription factor activity then
leads to increased expression of key ECM proteins and growth factors. AP-1 activating protein-1;
BM basement membrane; ET endothelin; FGF fibroblast growth factor; MAPK mitogen-activated
protein kinase; NF-kB nuclear factor-kB; PKB protein kinase B; PKC protein kinase C; PDGF
platelet-derived growth factor; SGK serum- and glucocorticoid-regulated kinase; VEGF vascular
endothelial growth factor.
Transcription Factors
All glucose-induced signals converge on transcription factors to regulate expression
of key genes involved in vascular function (Fig. 5). Two main transcription factors with
wide range of activities are NF-kB and AP-1. NF-kB is a redox-sensitive transcription
factor. In quiescent cells, NF-kB exists as an inactive dimer bound to an inhibitory
protein, IkB. Upon stimulation, IkB is degraded and NF-kB translocates to the nucleus
[153]. In diabetes, NF-kB is believed to be activated by a number of factors including
ROS and ET-1 [63, 154]. Interestingly, ET-1 expression may also be regulated by NF-
kB activity [155]. Studies have reported nuclear NF-kB immunoreactivity (activated
state) in the pericytes but not ECs of human diabetic eyes [156]. In experimental dia-
betes, however, NF-kB activity is evident in retinal vessel ECs [130, 157–159]. Fur-
thermore, cultured ECs show increased NF-kB activity and downstream effects when
exposed to high levels of glucose [63, 128, 130, 137, 139, 160]. We have also shown that
ECM protein expression in ECs and retinas of diabetic animals is dependent on NF-kB
activity [63, 154].
AP-1 transcription factors [161, 162] are also implicated in ECM protein expression
in diabetes. We have shown that high glucose activates MAPK, increases ECM protein
expression, and that this pathway is dependent on both NF-kB and AP-1 activation [90].
Triamcinolone acetonide, an inhibitor of both NF-kB and AP-1, has been reported in
clinical trials to reduce vascular permeability, hemorrhages, and neovascularization in
DR [114, 163, 164]. Several other transcription factors may play regulatory role in these
pathways. Most recent studies show that forkhead transcription factors of the O family
(FoxO) may also be involved in diabetic vascular dysfunction [165]. FoxOs are ubiqui-
tously expressed including in the brain [166] and have been implicated in cellular prolif-
eration and growth [167]. Exposure of ECs to high glucose increases FoxO1 activation
and mediates cellular apoptosis [165]. Diabetic animals, both streptozotocin-induced
diabetic rats and Zucker rats, show activation of FoxO1 in the retina which precedes
the formation of acellular capillaries. Inhibiting FoxO1 in cultured cells or in diabetic
animals reverses cellular dysfunction and apoptosis. Similar to NF-kB, the mechanism
of FoxO1 activation involves oxidative stress [165, 168]. Interestingly, FoxO1 may also
facilitate eNOS dysfunction and oxidation of LDL [168].
Transcription Regulators
One of the emerging fields in diabetes research is the epigenetic regulation of gene
expression. Chromatin structure and access to transcription factors is regulated by a
number of modifications including acetylation, methylation, and phosphorylation [169].
One of the extensively studied processes is the acetylation and deacetylation of histone
residues. Two main classes of proteins, acting in opposing manner, regulate acetylation
and deacetylation. Histone acetyltransferases (HATs) and HDACs control several cel-
lular processes through regulating transcription factors [170]. The best characterized
HATs are p300 and CREB-binding protein (CBP) [170]. These HATs add an acetyl
group on lysine residues of histones 3 and 4 (H3 and H4). It is believed that addition of
acetyl groups leads to chromatin relaxation and access to transcription factors. Involve-
ment of HATs and HDACs in diabetic complications becomes evident when we consider
that transcription factors such as NF-kB remain inactive even after nuclear translocation
without the association of p300 [170, 171]. We and others have also shown that NF-
kB activity in diabetes is regulated by p300 [128, 172]. In addition, FN expression, in
both cultured ECs and the retina of diabetic rats, is mediated by p300 induction [128].
Whether HDACs also modulate these pathways is not clear.
Another mode of chromatin remodeling is regulated by enzymes that add or remove
a methyl group. Similar to acetylation/deacetylation, methylation/demethylation may
also lead to increased or decreased expression of the target genes. Recently, Reddy et al.
[173] showed that smooth muscle cells isolated from diabetic animals exhibit increased
monocyte chemotactic protein-1 and interleukin expression via methylation of histone-3
lysine-4 (H3K4). Interestingly, this methylation was found near the NF-kB response
element. The same group has also shown reduced histone-3 lysine-9 trimethylation at
the promoter region of these target genes [174]. A similar phenomenon is also evident
in ECs [175, 176]. A brief exposure of aortic ECs to high glucose levels was associated
with increased NF-kB p65 expression and H3K4 monomethylation at the NF-kB p65
promoter region [176]. What is fascinating is that these modifications produce long-term
phenotypic changes in the cultured cells even following removal of the high glucose
stimulus. This has lead to the concept that histone modification may indeed dictate dia-
betic/metabolic/hyperglycemic memory.
CONCLUDING REMARKS
Diabetes leads to vascular disruption in selected organs that include the retina.
Experimental evidence from animal models and cultured cells suggests that various
signaling pathways in concert lead to the pathogenetic changes in the retinal vascular
bed. Early adverse effects of high glucose levels may be mediated by metabolic changes
(polyol pathway, hexosamine pathway), vasoactive factors (ET and NO), and oxidative
stress (leading to EC dysfunction and loss). Aberrations in EC function may then be
perpetuated by continued activation of intracellular signaling proteins such as PKC,
PKB, MAPK/ERK, and transcriptional regulators (NF-kB and AP-1, p300). Further
investigation as to how these signaling pathways interact is timely. Recent evidence of
epigenetic changes producing the “diabetic phenotype” supports the notion that a solid
understanding of the hyperglycemia-induced transcription machinery is the only means
to identifying the molecular signature and point of convergence in DR.
ACKNOWLEDGMENTS
The authors acknowledge grant supports from the Canadian Diabetes Association
(SC; ZAK), Canadian Institutes of Health Research (SC), and Lawson Health Research
Institute (ZAK). ZAK is a recipient of the New Investigator Award from the Heart &
Stroke Foundation of Canada.
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14
IGFBP-3 as a Regulator of the Growth-Hormone/
Insulin-Like Growth Factor Pathway
in Proliferative Retinopathies
Andreas Stahl, Ann Hellstrom,

Chatarina Lofqvist, and Lois Smith
CONTENTS
Introduction
The Growth-Hormone/Insulin-Like Growth Factor Pathway
in Proliferative Retinopathies
IGFBP-3 as a Regulator of the Growth-Hormone/Insulin-Like
Growth Factor Pathway
Therapeutic Considerations for IGFBP-3 in Proliferative Retinopathies
Conclusion
References
Keywords Insulin-like growth factor • IGF • IGF-binding protein • IGFBP-3 • Diabetic retin-
opathy • Retinopathy of prematurity • ROP • Growth hormone • GH • Angiogenesis • Neovas-
cularization
INTRODUCTION
Growth of retinal vessels is not only a crucial factor for retinal development but also
one of the hallmarks of two of the most common causes of blindness in the industri-
alized world: retinopathy of prematurity (ROP) and proliferative diabetic retinopathy
(PDR). Visual impairment in both diseases is causally linked to the growth of abnormal
blood vessels in the retina. The current clinically established laser treatments for both
conditions aim at destroying avascular areas of the affected retina to reduce the produc-
tion of angiogenic mediators [1]. However, laser treatment is only partially effective and
associated with the destruction of healthy retina and subsequent local visual field loss
[2]. Over the recent years, considerable progress has been made in both understand-
ing and treating proliferative retinopathies using medical instead of surgical or laser

233
234 Stahl et al.
approaches. One medical treatment that has advanced furthest from basic science into
clinical practice is the inhibition of vascular endothelial growth factor (VEGF). Anti-
VEGF compounds were initially developed for treatment of wet age-related macular
degeneration (AMD) but have recently also found their way into clinical trials for PDR
(reviewed in [3]) and are considered for treatment of ROP [4–9].
VEGF has been extensively studied and is rightfully considered a “master switch”
for angiogenesis [10]. It is unquestionably one of the major players in proliferative
retinopathies and a valid target for anti-angioproliferative treatment approaches. How-
ever, both ROP as well as PDR have underlying pathomechanisms that are regulated
by extensive and intricate metabolic pathways both locally in the retina as well as on
a systemic level. It is therefore not only legitimate but rather essential to further inves-
tigate the underlying pathomechanisms of ROP and PDR to unveil angiogenic media-
tors that function upstream of VEGF expression. In proliferative retinopathies as well
as in other angiogenesis-related diseases, VEGF can be viewed as possibly the most
important mediator of a final common angiogenic pathway that is, however, activated
through a variety of upstream mechanisms that can be very disease-specific [11]. Instead
of targeting VEGF at the end of the angiogenic cascade, altering these disease-specific
mediators upstream of VEGF might be a more effective approach to treating PDR and
ROP. By summarizing our current knowledge about IGFBP-3 in regard to proliferative
retinopathies, this chapter aims at evaluating the pathogenetic relevance as well as the
potential therapeutic potential of one of the factors that might alter disease mechanisms
upstream of VEGF expression in proliferative retinopathies.
THE GROWTH-HORMONE/INSULIN-LIKE GROWTH FACTOR

PATHWAY IN PROLIFERATIVE RETINOPATHIES
Proliferative Diabetic Retinopathy (PDR)
Various systemic factors have been identified in diabetic patients that affect the severity
of PDR: Obesity, smoking, and unstable control of blood glucose have all been found to
be associated with increased severity of PDR. A potential role of growth hormone (GH)
in PDR has been first suggested in the 1950s after anecdotal observations of attenuated
diabetic retinopathy in women with postpartum hemorrhagic necrosis of the pituitary gland
(Sheehan syndrome) [12]. Numerous studies thereafter have found that pituitary dysfunction
can prevent or reverse proliferative retinopathy in diabetes patients [13–20]. Additionally,
it was reported that GH replacement therapy for patients with GH deficiency can induce a
diabetic-like retinopathy, which is attenuated after discontinuation of GH treatment [21].
These early observations about the role of GH in PDR have led to intense research
into the downstream mediators of GH signaling. In this respect, insulin-like growth fac-
tor 1 (IGF-1) appears not only interesting as one of GH’s prime downstream effectors
but also because IGF-1 shares receptor-binding affinities with insulin, the disease-defining
hormone in diabetes. Clinical studies have found increased levels of IGF-1 in serum and
vitreous of patients with PDR [22–31]. However, a clear correlation between disease
stage or progression and IGF-1 levels could not be confirmed in all studies [32–34].
These differing results may in part be attributed to differing methodologies for meas-
uring IGF-1. Some studies did not distinguish between free IGF-1 and IGF-1 bound
IGFBP-3 as a Regulator of the Growth-Hormone 235
to binding proteins (IGFBPs; reviewed in [2]). The role of IGFBPs in regulating IGF
bioavailability and action will be the focus of Section “IGFBP-3 as a Regulator of the
Growth-Hormone/Insulin-Like Growth Factor Pathway” of this chapter.
Retinopathy of Prematurity (ROP)

Early investigations in humans have found that the severity of ROP is mainly deter-
mined by (1) postnatal oxygen exposure, (2) low gestational age/birth weight, and (3)
slow postpartum weight gain [35–43]. The fact that prematurity is the most significant
risk factor for ROP suggests that factors involved in growth and development are criti-
cal. Hellstrom et al. were the first to describe a direct link between low growth hormone
levels and reduced retinal vascularization in children with congenital GH deficiency
[44]. Consequent studies focused on one of the prime downstream mediators of GH
function: IGF-1. IGF-1 is expressed in liver cells when they are exposed to GH stimu-
lation [45, 46] and plays an important role in fetal growth and development during all
stages of pregnancy but particularly in the third trimester [47]. The serum concentration
of IGF-1, but not IGF-2, increases with gestational age and correlates with fetal size
[48, 49]. IGF-1 levels rise significantly in the third trimester of pregnancy, but after birth
decrease due to the loss of IGF-1 provided by the placenta [47]. Intriguingly, low levels
of IGF-1 in preterm infants postpartum have been found to prevent normal retinal vascu-
lar growth [50] and correlated directly with the severity of clinical ROP [51–54].
The role of IGF-1 in ROP, however, becomes more complex when later disease stages
are considered: While physiologic IGF-1 levels might be necessary during early retinal
development to prevent ROP, IGF-1 might play a detrimental role during the proliferative
stages of ROP. If during the course of postnatal retinal development in the preterm infant
the retinal vascular development fails to keep up with the increased retinal demand for
oxygen, the peripheral avascular parts of the developing retina will eventually respond
to this oxygen shortage by expressing pathologically high levels of pro-angiogenic
mediators like VEGF to boost retinal vessel growth. Due to this pro-angiogenic over-
stimulation retinal vessel growth becomes erratic and abnormal vessels begin to sprout
from the retina into the vitreous. These disorganized neovascular tufts eventually lead to
severe complications like intravitreal bleeding or retinal detachment caused by traction
of the abnormal vessels on the underlying retina. In this second phase of ROP, IGF-1 can
act as a permissive factor for retinal neovascularization amplifying VEGF-stimulated
pathological vessel growth in the hypoxic retina. The detrimental role of IGF-1 dur-
ing this phase of proliferative retinopathy is illustrated by the observation that inhibi-
tion of IGF-1 prevents hypoxia-induced retinal neovascularization despite high levels of
intraocular VEGF [55]. Targeting IGF-1 in ROP infants therefore needs to be carefully
timed and correlated to the clinical stage of the disease: During the early stages, when
normal vascularization of the retina can still be achieved, IGF-1 levels should be moni-
tored and increased to physiologic levels if needed. This first phase of ROP occurs from
birth to approximately postmenstrual age 30–32 weeks. If by this time the retinal vas-
culature has not developed sufficiently to meet the demands of the maturing retina, high
growth factor concentrations from the avascular parts of the retina will induce pathologi-
cal neovascularization. This marks the second phase of ROP. During the second phase of
ROP, IGF-1 supplementation can have detrimental effects by augmenting the growth of
pathologic neovessels (reviewed in [50]).
236 Stahl et al.
Animal Models of Proliferative Retinopathies

Most of our understanding regarding the underlying mechanisms of proliferative
retinopathies comes from the use of animal models of oxygen-induced retinopathy
(OIR) that closely mimic the disease process of ROP in humans. In contrast to humans,
many animals such as mice, rats, kittens, and beagle pups have incompletely vascu-
larized retinas at birth and therefore resemble the immature retinal state of premature
infants. The model that is most widely used to study disease mechanisms and possible
interventions is a mouse model of OIR that was first described in 1994 [56]. In this
model, neonatal mice are exposed to 75% oxygen from postnatal day 7–12. During this
5-day exposure to hyperoxia, vessel regression and the cessation of normal radial vessel
growth occurs, mimicking the first phase of ROP. Other animal models also mimic this
early phase of oxygen-induced vessel regression [57, 58]. The second phase of ROP that
is characterized by abnormal vessel formation can also be studied in the OIR mouse
model: When mice are returned to room air on postnatal day 12, the non-perfused parts
of the retina become hypoxic and induce the expression of angiogenic growth factors.
As a consequence, formation of abnormal retinal vascular tufts can be observed that
closely resemble the erratic neovascularizations seen during the second phase of ROP in
human preterm infants. Diabetic retinopathy shows a similar pattern with a first phase
characterized by slow loss of retinal capillaries and a second phase of retinal neovas-
cularization. The OIR model can therefore also be used as a tool to investigate some
aspects of PDR. This is important as the currently established diabetic animal models do
not develop proliferative retinopathy.
The OIR model has greatly promoted our understanding of the growth-hormone/
insulin-like growth factor pathway in ROP. Early animal studies have found that normal
retinal blood vessels grow more slowly in IGF-1 knockout mouse than in wild-type con-
trols, a pattern very similar to that seen in premature babies with ROP [51]. Subsequent
studies using the OIR model have found that mice with low IGF-1 levels and transgenic
mice expressing a GH receptor antagonist are resistant to hypoxia-induced retinopathy
[59]. Direct proof of the pro-angiogenic role of IGF-1 in the second phase of ROP was
established using an IGF-1 receptor antagonist, which was found to suppress retinal
neovascularization without altering retinal VEGF levels [55]. Additionally, mice with
vascular endothelial cell-specific knockout of either the IGF-1 receptor or insulin recep-
tor show a substantial reduction in retinal neovascularization compared to control mice
[60]. Mechanistically, it was suggested that IGF-1 regulates retinal neovascularization
at least in part through control of VEGF activation of p44/42 MAPK, establishing a
hierarchical relationship between IGF-1 and VEGF receptors [51, 55].
As outlined earlier in this chapter, no good animal models for PDR exist to date.
However, an animal study of normoglycemic/normoinsulinemic transgenic mice over-
expressing IGF-1 through an insulin promoter at supraphysiological levels in the retina
showed loss of pericytes and thickening of basement membrane of retinal capillaries
[61]. In older transgenic mice overexpressing IGF-1, neovascularization of the retina
and vitreous cavity was observed which was consistent with increased IGF-1 induc-
tion of VEGF expression in retinal cells [62]. These accumulated findings suggest that
once proliferative neovascular (and therefore leaky) vessels occur in the retina, leaked
serum IGF-1 may further promote the proliferation of retinal vessels through stimulation
of VEGF. However, it has not been established that serum IGF-1 in the absence of leaky
vessels causes proliferative disease. Although local production of IGF-1 in the retina
appears to play only a minor role compared to the considerably higher levels of IGF-1
in the serum, local expression of other components of the GH/IGF-1 signaling pathway
in the retina might have an impact on the response of retinal neovessels to IGF-1. This
possibility will be discussed in the next chapter with regard to retinal expression of
IGFBP-3 as locally regulating the GH/IGF-1 pathway.
IGFBP-3 AS A REGULATOR OF THE GROWTH-HORMONE/

INSULIN-LIKE GROWTH FACTOR PATHWAY
As outlined above, the growth-hormone/insulin-like growth factor pathway appears to
be involved in both the development of PDR as well as ROP. This leads to the questions
of how GH/IGF-1 signaling might be regulated both endogenously as well as by putative
interventions using pharmacological approaches. The IGF-binding proteins (IGFBPs)
have been found to play an important role in this respect by regulating both the actions
as well as the bioavailability of IGF-1 [63]. Systemically, the vast majority of IGF-1
(up to 98%) is bound to one of the six IGFBPs. Within the IGFBP family, IGFBP-3 is
by far the most abundant binding protein, with concentrations in the range of 100 nM,
compared with the 2–15-nM concentrations of other binding proteins [64]. IGFBP-3
is bound to IGF-1 or IGF-2 in a ternary complex with a glycoprotein, the acid-labile
subunit (ALS). This complexation of IGF-1 with IGFBP-3 and ALS leads to a greatly
extended circulating half-life of IGF-1. By increasing IGF’s serum half-life, IGFBP-3
might theoretically increase the biological effects of IGF-1 [65]. Once in the tissue,
however, IGFBPs can either potentiate IGF signaling by releasing IGF-1 in proximity of
its receptors or, conversely, hinder signaling by sequestering IGF-1 (reviewed in [66]).
IGFBP-3 specifically has been found to have mainly inhibitory functions on IGF signal-
ing. IGFBP-3 can inhibit IGF-1 effects by interfering with IGF signaling or by direct,
IGF-independent effects (reviewed in [67]). In vitro, addition of IGFBP-3 to HUVECs
stimulated with IGF-1 or VEGF reversed both IGF-1- and VEGF-induced proliferation
and prevented the survival induced by these factors [68]. IGFBP-3 can directly bind to
the retinoid X receptor-alpha independent of IGF. Binding to this receptor can modulate
cell cycle and apoptosis through interference with TGF beta and other signaling path-
ways (reviewed in [66]).
In regard to proliferative retinopathies, IGFBP-3 has been found to be increased in
the vitreous of diabetic rats and human diabetic patients. Interestingly, vitreal IGFBPs
were elevated even before the onset of overt retinopathy. This was interpreted as vitreal
IGFBPs being involved in early ocular events in the diabetic process as opposed to being
the result of end-stage retinopathy [69]. Another study measuring serum free and total
IGF-1 as well as IGFBP-3 levels in 56 insulin-treated diabetic patients and 52 healthy
sex- and age-matched controls found lower serum levels both for IGF-1 and IGFBP-3
in diabetic patients. However, age-adjusted free IGF-1 levels in subjects with diabetic
retinopathy were higher than those in subjects without diabetic retinopathy [32].
Similar to IGF-1, IGFBP-3 is not only present in the serum but also produced locally
in the eye [70]. Retinal expression of IGFBP-3 was found to be highly elevated in rats
238 Stahl et al.
that were exposed to hypoxia [71]. Another study investigated the retinal expression
of several IGF-linked genes in greater detail using laser-capture microdissection [72].
This study could localize the hypoxia-induced surge in retinal IGFBP-3 to the neo-
vascular tufts suggesting a direct role for IGFBP-3 during the course of proliferative
retinopathy. It has not been investigated if IGFBP-3 alters IGF-1 signaling or has a
direct, IGF-independent effect in this context. Considering the fact that IGFBP-3 can
affect such divergent cellular functions as mobility, adhesion, apoptosis, survival, and
the cell cycle, it would be of great interest for future studies to investigate the exact cel-
lular pathways affected by hypoxia-induced local expression of IGFBP-3 in neovascular
tufts. Especially in the light of IGFBP-3 having pro-angiogenic effects in some systems
while inhibiting it in others [73], it remains open at this point if IGFBP-3 expression in
neovascular tufts plays a role in inducing or rather limiting pathologic retinal neovas-
cularization, although lower mRNA expression levels of IGFBP-3 are associated with
more retinopathy [75].
In addition to the direct effects of IGFBP-3 on local angiogenesis, recent work from
Chang et al. found that IGFBP-3 also has a critical role in promoting migration, tube
formation, and differentiation of endothelial progenitor cells (EPCs) [74]. Recruitment
of EPCs to neovascular tufts in the hypoxic retina may thus be another possible role for
local IGFBP-3 in proliferative retinopathy. At this point it can only be speculated that
increased EPC recruitment through retinal IGFBP-3 might lead to a more organized
regrowth of normal vessels as opposed to the erratic growth observed in neovascular
tuft formation. EPC recruitment might be one of the mechanisms by which IGFBP-3
promotes retinal repair after oxygen-induced vessel loss [75].
THERAPEUTIC CONSIDERATIONS FOR IGFBP-3

IN PROLIFERATIVE RETINOPATHIES
In children with ROP, serum levels of IGF-1 are inversely correlated with disease
severity (see Section “Retinopathy of Prematurity (ROP)” of this chapter). Thus,
increasing IGF-1 by exogenous administration might appear as a reasonable treatment
option to improve ROP risk in premature babies with low IGF-1 levels. However, bolus
injections of IGF-1 potentially can induce hypoglycemic episodes [76]. IGF-induced
hypoglycemia, however, can be blocked by coadministering equimolar concentrations
of IGFBP-3 together with IGF-1. This finding emphasizes the important regulatory
role of IGFBP-3 on serum IGF-1 levels and systemic IGF-1 activity. It also stresses
the importance of IGFBP-3 for therapeutic interventions involving the GH/IGF-1 path-
way in human patients. The importance of IGFBP-3 substitution along with IGF-1 is
further stressed by the fact that in premature infants of 30–35 weeks postmenstrual
age, IGFBP-3 levels were found to be significantly diminished in infants with ROP
compared to those without [75]. Further, in IGFBP-3-deficient mice, there is a dose-
dependent increase in oxygen-induced retinal vessel loss. Wild-type mice treated with
exogenous IGFBP-3 had a significant increase in vessel regrowth without any change
in IGF-1 levels. This correlated with a 30% increase in EPCs in the retina at postnatal
day 15, indicating that IGFBP-3 could be serving as a progenitor cell chemoattractant.
These results suggest that IGFBP-3, acting independently of IGF-1, helps to prevent
oxygen-induced vessel loss and to promote vascular regrowth after vascular destruction
in vivo in a dose-dependent manner, resulting in less retinal neovascularization [75]. As
a consequence, clinical trials aiming at correcting IGF-1 deficiency in premature infants
use equimolar combinations of IGF-1 and IGFBP-3 [77].
In regard to diabetic retinopathy, there is a substantial body of work indicating that
hyperglycemia is associated with reduced serum IGF-1 concentrations [32, 78]. Simi-
lar to ROP, the early stages of diabetic retinopathy are associated with low levels of
systemic IGF-1. From a therapeutic point of view, it has been shown in clinical studies
that restoring normal IGF-1 levels in insulin-treated patients using combined IGF-1/
IGFBP-3 regimens results in a concomitant reduction in insulin requirement to maintain
euglycemia [79, 80].
One other critical event during the course of diabetic retinopathy is an event known
as “early worsening” of proliferative retinopathy. This term refers to an acute increase
in retinal proliferative disease coinciding with the onset of exogenous insulin adminis-
tration. This phenomenon is thought to be linked to an insulin-induced stimulation of
the GH/IGF-1 axis. A recent case series with poorly controlled type 1 diabetic patients
found that after glycemic control was improved by intensified insulin therapy, serum
IGF-1 levels acutely increased and PDR progressed with development of macular edema
and proliferation of new vessels [81]. Similarly, a prospective study with 103 pregnant
women with type 1 diabetes found that progression of retinopathy during pregnancy was
significantly associated with a pregnancy-related increase in IGF-1 levels [82].
It appears likely that the above-described increased serum levels of IGF-1 during
“early worsening” of PDR are major contributors to increased retinal IGF-1 signaling.
First, serum IGF-1 and IGFBP-3 levels are 10–100 times higher than those measured
in the vitreous [26]. Second, patients with PDR show a significant positive correla-
tion between serum and vitreous levels of IGF-1 and the increase in vitreous levels of
IGF-1, IGF-2, and IGFBP-3 parallels the increase in vitreous of liver-derived serum
proteins [25]. This correlation between serum and vitreal levels is likely due to a disease-
associated increase in leakiness of the blood-retina barrier of patients with PDR [26, 83].
Measuring serum levels of IGF-1 and IGFBP-3 in diabetic patients can therefore give
a good indication of the retina’s exposure to these growth factors. From a therapeu-
tic point of view, it can be speculated that exogenously administered IGFBP-3 could
blunt the observed surge of serum IGF-1 by complexing free IGF-1 in the serum and
thus preventing IGF-1 from accumulating in the retina. However, the safety of IGFBP-3
administration in PDR patients must be carefully evaluated especially in the context of
pregnancy-induced IGF-1 increase.
CONCLUSION
The data on GH, IGF-1, and IGFBP-3 summarized in this chapter illustrate the close
association of these three molecules with the development of proliferative retinopathies
both in the setting of PDR as well as ROP. This chapter also suggests a number of pos-
sibilities to intervene medically in the development of retinopathy by targeting the GH/
IGF-1 pathway. IGFBP-3 is one candidate for therapeutic interventions due to its role
as a regulator of the GH/IGF-1 pathway. However, it must be emphasized that timing
240 Stahl et al.
is critical to any intervention targeting proliferative retinopathies. Inhibition of IGF-1

early after birth in premature babies or during the early phases of diabetic retinopa-
thy might prevent normal blood vessel development or increase the loss of established
retinal vasculature. Instead of IGF inhibition, careful supplementation of IGF-1 might
be needed during these early phases of retinopathy. In these cases, IGFBP-3 should be
used as an adjunct to IGF-1 supplementation to regulate the bioavailability and activity
of exogenously administered IGF-1 and to avoid IGF-induced hypoglycemic episodes.
Once active proliferation in the retina has developed (stage II of ROP or PDR), further
supplementation of IGF-1 might be deleterious to the retina. At these stages, IGF-1
acts as a permissive factor for proliferative retinopathy and inhibition of IGF-1 might
be needed to limit retinal neovascularization. IGFBP-3 might play a role in this context
through its inhibitory role on IGF-1 signaling. However, before IGFBP-3 can be sug-
gested for clinical use during the proliferative stages of ROP or PDR, more work needs
to be done deciphering the exact effects of IGFBP-3 both on IGF-1 signaling as well as
on IGFBP-3’s direct actions independent of IGF-1.
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15
Neurotrophic Factors in Diabetic Retinopathy
Anne R. Murray and Jian-xing Ma
CONTENTS
Diabetic Retinopathy
Neurotrophic Factors
Neurotrophins and Others
Anti-angiogenic Neurotrophic Factors
The Double-Edged Swords: Pro-angiogenic Neurotrophic Factors
Neurotrophic Factors and the Future of DR Research
References
Keywords Angiogenesis • Diabetic retinopathy • Neurotrophic factors • PEDF • VEGF
DIABETIC RETINOPATHY
The incidence of diabetes worldwide is staggering. Millions of people have been
diagnosed with either Type 1 or Type 2 diabetes, and it is estimated that approximately
10% of diabetes cases are Type 1 [1], while approximately 90% of patients diagnosed
with diabetes are Type 2. Type 2 diabetes currently affects more than 150 million people
worldwide [1, 2], and it has been estimated that with an increasingly sedentary lifestyle
and prevalence of obesity, the incidence of diabetes worldwide is expected to reach
366 million by the year 2020 [2, 3].
The maintenance of normal glucose levels is essential for the health of most organs.
In fact, it has been shown that the incidence of issues such as peripheral neuropathy
[4], oxidative stress [5], and vascular complications [4, 6, 7] increases greatly upon
chronic exposure of elevated glucose levels. One severe diabetic complication involves
the eye. Chronic exposure of the retina to elevated glucose levels leads to proliferative
diabetic retinopathy (DR), a condition that is characterized by retinal inflammation,
vascular leakage, abnormal blood vessel formation (neovascularization), and intraretinal
hemorrhages [8]. Upon the progression of DR, the microvascular circulation in the retina
fails, leading to ischemia (Fig. 1) [8]. If not properly monitored and regulated, the newly

245
246 Murray and Ma
Fig. 1. The molecular pathway leading to decreased retinal function as well as to the
neovascularization, fibrosis, and retinal detachment in diabetic retinopathy. Neurotrophic factors
in the retina play essential roles in the development and progression of symptomatic DR. Upon
oxidative stress signals in the retina, there is a decrease in most neurotrophic factors along with
an increase in inflammatory factors and Müller cell dysfunction. The Müller cell then signals the
release of several neurotrophic factors to aid in the survival of the retina. Upon the progression
of DR and prolonged hyperglycemia, the retinal cells succumb to apoptosis and necrosis with a
concomitant increase in vascular leakage and macular edema leading to vision loss.
formed retinal blood vessels will extend into the vitreous, which can lead to hemorrhage
and retinal detachment. In addition to the ischemia and new vessel growth, another
DR complication is the development of macular edema. Breakdown of the blood-retinal
barrier (BRB) that maintains the retinal environment leads to leakage of macromol-
ecules from the vessels into the retina and swelling of the central portion of the retina,
the macula. This swelling will often progress and affect the patient’s central vision. This
combination of complications will often, if untreated, lead to irreversible vision loss and
blindness.
Although proliferation of the retinal vasculature and macular edema are the devastat-
ing end points of proliferative DR, it has been suggested that at early stages of DR, there
are changes in the retinal neurons and glia [8–10]. Experimental models have shown that
changes in functional molecules and the viability of neurons in the retina occur imme-
diately after the onset of diabetes [11, 12]. Prior to sight-threatening signs of abnormal
angiogenesis, damages to the neurons in the inner [12] and outer retina [13] as well as
Neurotrophic Factors in Diabetic Retinopathy 247
glial cell activation [14] have been observed. The changes in these cells lead to retinal
hypoxia, a damaging precursor to the angiogenesis, and further DR pathologies.
NEUROTROPHIC FACTORS
The retina is comprised of several cell types that each play a specific role in main-
taining normal visual function. In order to ensure neuronal cell survival, several of
these cells produce neurotrophic factors (NF). NFs have several functions in the neu-
ron including neuronal cell development, synapse formation, synaptic plasticity, proper
neuronal cell function, and the promotion of neuronal cell survival [15]. Several NFs
promote these cellular functions via two classes of transmembrane receptor proteins, the
tropomyosin receptor kinase (Trk) and neurotrophin receptor p75 (Fig. 2 and Table 1)
[16]. Binding of the NF to the p75 receptor acts to signal cell death, while binding of a
NF to the Trk family promotes signaling for cell survival and differentiation [16].
Several studies have shown that in the diabetic retina, even before the onset of DR
and DR-associated retinal neovascularization, there is an increase in neuronal cell
death along with glial changes and a reduction in the levels of several NFs [11, 17–19].
A caveat to this phenomenon is that although a decrease is observed in many of the
retinal NFs, there is an increase in the pro-angiogenic NF VEGF [20–22]. The disrup-
tion in NF function observed in the pre-DR retina can be caused by several potential
Fig. 2. Neurotrophic factors in the retina are responsible for several functions via two
receptor families. Some neurotrophic factors, such as BDNF, can interact with two cell-surface
receptors, the Trk and/or the p75 family. Upon binding to the Trk family of receptors, neuro-
trophic factor-associated intracellular signaling can occur through three major pathways, the Ras/
Raf/MEK/MAPK, PKB/Akt, or PLCg/PKC, to induce neuronal cell differentiation, cell survival,
or neurotrophin-mediated neurotrophin release. Binding of a neurotrophic factor to the p75 recep-
tor results in activation of the JNK signaling pathway and leads to the promotion of cell death.
Table 1. Neurotrophic factors involved in diabetic retinopathy
Neurotrophic factor Secreted by Additional function(s) Known receptor(s) References
Nerve growth Müller cells Growth factor p75NGFR (low affinity) and [16, 63, 109]
factor (NGF) NGFRTrkA
Glial cell-derived Müller cells Glial differentiation Complex composed of GFRa1 [27, 110]
neurotrophic factor and the transmembrane pro-
(GDNF) tein kinase Ret
Ciliary neurotrophic Müller cells Protect retina against light damage; Receptor complex: CNTFRa, [32, 37, 63,
factor (CNTF) axonal regeneration of RGCs; neuronal LIFRb + GP130 in Müller, 77, 111]
differentiation factor; growth factor RGCs, amacrine, horizontal,
RPE, rods, and cones
Pigment-epithelium- RPE, RCEC, and Retinal development; neuron PEDFR [53, 112–115]
derived factor (PEDF) Müller cells differentiation; angiogenesis inhibitor;
anti-inflammatory factor
SERPINA3K Unknown Anti-fibrosis; angiogenesis inhibitor Low-density lipoprotein recep- [116, 117]
tor-like protein 6 (LRP6)
Brain-derived Retinal ganglion Retinal development; synaptic modulator; Gp140TrkB (signaling) and [11, 16, 63,
neurotrophic factor cells (RGCs) hypertrophy of the retinal dopaminer- p75NGFR (low affinity) 64, 70, 77,
(BDNF) and Müller cells gic system in the retina; protect retina 109, 118]
against light damage; angiogenesis
Fibroblast growth RPE Retinal development; angiogenesis; FGFR1 and FGFR2 [37, 71, 77,
factor (FGF) growth factor; protect retina against 119]
light damage
Insulin Pancreas Growth factor Insulin receptor [37]
Insulin-like growth RPE Retinal development; neurogenesis; ang- Insulin receptor [78–81, 120]
factor (IGF) iogenesis
Erythropoietin (EPO) Neural cells Angiogenesis EpoR [87, 89, 90]
Vascular endothelial Retinal pigment Proliferation and migration; angiogen- VEGFR-1, VEGFR-2 (receptor [92, 121, 122]
growth factor (VEGF) epithelium (RPE) esis; neurogenesis; increasing axonal tyrosine kinase); neuropilins
and Müller cells outgrowth; vascular permeability (NP) 1 and 2 (nonreceptor
enhancer; apoptosis inhibitor tyrosine kinase)
features (1) decreased NF synthesis, (2) disrupted transport of the NF in the neuronal
cell, (3) modifications in the NF-associated signal transduction pathways, or (4) the
ability of the cells that produce the NF is affected, including those cells that produce NF
responsible for neuron survival [23].
Although the list of NFs associated with neural diseases is extensive, the roles that
they play in DR have not been exhaustively studied. Several NFs are expressed in the
retina, but some have not been confirmed to be expressed in retinal diseases including
DR. Currently, there are several potential therapies employing the use of neurotrophic
factors in neurological diseases in diseases such as DR. In fact, there are several ongoing
studies that endeavor to develop practical therapies for DR using neurotrophic factors.
The following sections provide a brief description of what is known about DR-associated
neurotrophic factors.
NEUROTROPHINS AND OTHERS

Nerve Growth Factor
Nerve growth factor (NGF), a member of the neurotrophin gene family, has been
widely studied in diabetic neuropathy [24]. However, a definitive characterization of
this factor has not been examined in DR. The low-affinity NGF receptor, p75NGR, is
expressed in both the Müller and retinal ganglion cells (RGCs) [12, 25]. Streptozotocin
(STZ) injected rat retinas showed increased immunoreactivity of the receptor in the
retina, including throughout the RGC and the outer nuclear layer [12]. Further examina-
tion revealed that upon the induction of diabetes, the Müller cells are the major source
of the receptor upregulation [12].
Therapeutic intervention using NGF found that NGF prevented programmed cell
death in both RGC and Müller cells in the diabetes-induced rat retina [12]. NGF’s thera-
peutic potential will need to be examined further to determine its efficacy in treating
patients with DR.
Glial-Cell-Derived Neurotrophic Factor

Glial-cell-derived neurotrophic factor (GDNF) was originally characterized as a neu-
rotrophic differentiation factor in the central nervous system and retina [26]. GDNF
and its receptor have been well documented in DR and have been shown to be secreted
by the glial cells of the retina [27]. GDNF’s role in maintaining neural cell survival is
known, but GDNF has also been linked to proper glial cell development [28, 29]. Along
with its roles in development and cell survival, GDNF may also modulate vascular per-
meability in the BRB via modulating the function of tight junctions [30].
The therapeutic potential of GDNF in the treatment of DR has not been studied.
Ciliary Neurotrophic Factor

Ciliary neurotrophic factor (CNTF) was first identified as a factor that supported the
survival of ciliary neurons in the chick embryo [31]. It is a member of the interleukin-6
(IL-6) family of cytokines and binds to two common IL-6 family receptor compo-
nents, gp130 and LIFRb [32, 33]. In order to facilitate proper function, CNTF also
250 Murray and Ma
requires the CNTFRa receptor subunit [34]. CNTF is primarily localized in Müller
cells and is expressed in both the developing and mature retina in the rat [35, 36]. The
CNTF receptor is located in the retinal Müller, horizontal, amacrine, and ganglion
cells [35].
CNTF has several functions in the retina including, but not limited to, promoting the
survival and axonal regeneration of RGCs, promoting green cone cell differentiation,
and inhibiting rod cell differentiation [31, 32]. The majority of CNTF’s functions are
through the JAK/STAT intracellular signaling pathway [37], although it can also activate
the ERK [38] and PI3-K/Akt pathways [39].
CNTF has been shown to aid in the survival of the retinal neurons in several retinal
degenerative disorders [31, 40]. Intravitreal injection of recombinant CNTF into a reti-
nal degeneration model led to a short-term rescue of photoreceptors [35, 40]. In another
study, injection of an adenovirus expressing CNTF delayed photoreceptor degeneration
in retinal degeneration (rd/rd) mice [41, 42]. Future studies are considering the use of
an intravitreal implant that would apply a prolonged delivery of CNTF to the retina for
longer neuronal protection [43].
ANTI-ANGIOGENIC NEUROTROPHIC FACTORS

Pigment-Epithelium-Derived Factor
Pigment-epithelium-derived factor (PEDF) is a member of the SERPIN gene family
[44] and was first isolated from fetal retinal pigment epithelial cells [8, 45]. PEDF’s
actions were initially characterized as being primarily involved in neuronal differen-
tiation [46]. However, as more information was gathered about PEDF, its role as an
angiogenic inhibitor was revealed [47]. In fact, PEDF and another neurotrophic factor,
vascular endothelial growth factor (VEGF), play reciprocal roles in the angiogenic proc-
ess [8]. In models of oxygen-induced retinopathy (OIR) and DR, as the levels of the pro-
angiogenic factor (VEGF) increase, the levels of PEDF decrease in the aqueous humor
and vitreous of the eye [17, 18, 48–51]. This intricate balance between VEGF and PEDF
levels is essential in maintaining the BRB integrity through prevention of vascular per-
meability [47, 52]. However, a reduced level of PEDF in the ischemic, nondiabetic eye
has also been observed. This indicates that the reduced level of PEDF observed in DR is
due to hypoxia rather than hyperglycemia [17]. In addition to its potent anti-angiogenic
properties, recent findings have shown that PEDF is also an anti-inflammatory factor in
the eye [53]. PEDF plays a role in inhibiting reactive oxygen species (ROS) as well as
the subsequent VEGF increase that is seen in DR [47].
The effects of exogenous PEDF treatments on angiogenesis and other DR-associated
symptoms have been studied. For instance, intraperitoneal administration of PEDF was
shown to inhibit retinal neovascularization in a neonatal mouse exposed to hypoxic con-
ditions [54]. A second study used an adenovirus expressing PEDF (AAV-PEDF). Intra-
vitreal injection of AAV-PEDF inhibited both retinal and choroidal neovascularization
in the mouse [8, 55]. In a third study, retinal vascular permeability and inflammatory
factors were reduced in animal models of DR and OIR after intravitreal injection of
PEDF [53].
SERPINA3K
SERPINA3K, a member of the SERPIN family, is a specific inhibitor of tissue
kallikrein (a serine proteinase) and is often referred to as kallikrein-binding protein
(KBP) [56, 57]. The kallikrein-kinin system was originally characterized to have func-
tions in inflammation, local blood flow, and vasodilation regulation [58, 59]. As research
continued on SERPINA3K, additional functions were uncovered, including its role as an
anti-angiogenic factor [60].
In the STZ-induced diabetic rat model, the retinal levels of KBP are decreased, hint-
ing at an essential role in the progression of DR [61]. In 2008, it was uncovered that
SERPINA3K can function in a protective manner in both Müller and retinal neuronal
cells against oxidative stress-induced damage, conditions seen in DR [62]. This protec-
tive effect occurs through blocking the intracellular calcium overload induced by oxida-
tive stress [62].
THE DOUBLE-EDGED SWORDS: PRO-ANGIOGENIC

NEUROTROPHIC FACTORS
As the knowledge increases about the anti-angiogenic neurotrophic factors in the
retina, the relationship between neuronal cell protection and pro-angiogenic factors has
broadened. Several pro-angiogenic factors, to be described below, have dual functions
in the cell: promoting angiogenesis while promoting neuronal cell maintenance, differ-
entiation, and development.
Brain-Derived Neurotrophic Factor

Brain-derived neurotrophic factor (BDNF) shares a similar structure to the most
highly studied neurotrophic factor, NGF, as both are members of the neurotrophin gene
family [63]. In the retinal tissue, BDNF targets (and is expressed in) RGCs and Müller
glia [64] and has been shown to be important for the survival of RGCs and bipolar
cells [11, 65, 66]. In addition, it has been shown that BDNF can prevent amacrine cell
death [67, 68]. Upon the degeneration of dopaminergic amacrine cells in the retinas of
STZ-induced diabetic rats, there is a reduction in the levels of BDNF in both RGCs and
Müller cells [11]. BDNF’s ability to bind to both the Trk and p75-type receptors facili-
tates its action in both retinal development and survival [69]. However, a recent study
has suggested a novel pro-angiogenic role for BDNF in ischemic tissues [70].
The therapeutic potential of BDNF has been examined. Upon intraocular injection,
BDNF prevented dopaminergic amacrine cell neurodegeneration [11]. In order to gather
more information on BDNF and its usefulness in treating DR-associated pathological
phenotypes, more studies remain to be conducted.
Fibroblast Growth Factors

Fibroblast growth factor (FGF) was first characterized as a growth and differentia-
tion factor for mesoderm- and neuroectoderm-derived cells [71]. However, research-
ers have isolated two derivatives of the FGF family from the bovine retina, basic FGF
(bFGF) and acidic FGF (aFGF) [71, 72]. bFGF is constitutively expressed by the RPE at
252 Murray and Ma
considerably higher amounts than aFGF [71, 73]. During retinal ischemia and instances
of proliferative DR, the retinal levels of bFGF are increased [22, 71]. In fact, it is specu-
lated that during retinal hemorrhage, infiltrative macrophages in the vitreous may induce
an enhanced secretion of bFGF [71, 74].
Although early studies on FGF had showed a link between its elevated expression and
angiogenesis, now the primary function of FGF is thought to be neurotrophic and neu-
roprotective [22, 75]. Although bFGF has not been utilized for DR therapies, injections
of bFGF into the eye of rats with either inherited retinal degeneration or ischemic injury
led to a delay in the progression of degeneration [76, 77].
Insulin and Insulin-Like Growth Factor 1

Insulin and Insulin-like growth factor 1 (IGF-1) have been shown to prolong the sur-
vival of retinal neurons in culture as well as decrease apoptosis and stimulate cell prolif-
eration, differentiation, and maturation [78–80]. In DR, increased levels of IGF-1 were
observed in the vitreous of patients; IGF-2 levels do not increase [81, 82].
The use of IGF-1 has been examined as a possible therapeutic agent in the treatment
of DR. Exogenous exposure of IGF-1 to cultured retinal neurons led to the enhanced
survival of amacrine neurons [83]. Exposure of high levels of either insulin or IGF-2
led to the same effects [83]. Furthermore, upon depletion of these factors, there was an
increase in amacrine apoptosis [83].
Erythropoietin
Erythropoietin (EPO) was initially described as a regulator of red blood cell produc-
tion, or erythropoiesis, throughout the body [84, 85]. However, as the information about
EPO broadened, it was found to be expressed in the retina [86]. In the retina, as well
as in the brain, EPO is both a neurotrophic factor and an endothelial survival factor
[22, 87]. EPO is elevated in the diabetic eye, and although it is neuroprotective in the
retina, it has been shown in both in vitro and in vivo studies to stimulate angiogenesis
[87]. EPO is regulated by hypoxia-inducible factor (HIF), and oxidative stress stimulates
EPO production in the eye [88]. However, EPO’s production is not solely dependent on
the presence of oxidative stress because elevated levels of EPO were observed in cases of
macular edema, a condition that is not solely dependent on hypoxic conditions [84, 86].
Intravitreal injection of EPO has been found to prevent apoptosis during early stages
of DR [89]. In addition, suberythropoietic administration of EPO reduces the unneces-
sary side effects that can be associated with other potential EPO therapies, such as induc-
tion of angiogenesis, oxidative stress, and pericyte loss [87]. Another study explored the
possibility of using siRNAs to EPO as a novel therapeutic agent for DR. Intravitreal
injections of siRNA to EPO resulted in reduced levels of EPO and subsequent suppres-
sion of retinal neovascularization [90]. Although the results from the siRNA study are
promising, methods to knock down EPO are risky due to its dual role as both an ang-
iogenic stimulator and a neurotrophic factor in the retina.
Vascular Endothelial Growth Factor

VEGF is constitutively secreted by the retinal pigment epithelium [8, 91]. There
are at least five different splice forms of VEGF, and each shows a differing amount
of angiogenic activity [92, 93]. A combination of the isoforms can stimulate a higher
degree of angiogenesis than a single isoform and provide prolonged efficacy in acceler-
ating angiogenesis [94]. VEGFA165 is the most commonly studied isoform and displays
both neurotrophic and angiogenic properties [92].
Low levels of VEGF secretion are presumed to be responsible for its neurotrophic
functions in the eye [9, 95]. However, VEGF is found prominently in the vitreous of
patients with proliferative DR, pre-proliferative DR, and nondiabetics with choroidal
neovascularization [9]. Under ischemic conditions and the appearance of new vessels,
such as those observed in DR, VEGF levels increase [9, 96, 97]. In fact, VEGF expres-
sion is noted in Müller cells of the retina before any noticeable neovascularization has
occurred in DR [9]. The induction of angiogenesis and vascular leakage that occur in DR
are thought to occur when higher levels of VEGF are secreted due to the pathological
conditions (e.g., ischemia) observed in DR [9]. VEGF increases vascular permeability
[98] and thus has been suggested to play a role in the breakdown of the BRB, perhaps
leading to diabetic macular edema [9, 99, 100].
Systemic anti-VEGF therapies have disadvantages when considered as possi-
ble therapies for patients with DR. Its dual roles as both a neurotrophic and a pro-
angiogenic factor, though beneficial in some aspects, could prove detrimental in DR
patients with systemic vascular problems [8]. Therefore, direct intraocular adminis-
tration of a VEGF therapy is favorable. Currently, an aptamer consisting of a 28-base
oligonucleotide that binds to the VEGF is in clinical trials toward the treatment of
age-related macular degeneration, a condition that involves neovascularization of the
choroid [101]. Another therapeutic potential is the use of ranibizumab, an antibody
with high affinity to inhibit all VEGF isoforms. Clinical trials are underway to deter-
mine if this drug would be a useful therapy in the treatment of DR [102]. Regulat-
ing the expression of VEGF receptors (VEGFR-1 and 2) may be another therapeutic
option. In fact, a drug that blocks VEGFR-2 has undergone initial tests as an ang-
iogenesis inhibitor for the treatment of cancer [103], but it has not been tested as a
treatment of DR.
NEUROTROPHIC FACTORS AND THE FUTURE OF DR RESEARCH

There are several additional NFs that are expressed in the retina that have yet to be
studied in the diabetic retina. Although these factors may play a role in retinal develop-
ment or have been shown to be modulated during retinal degeneration, they have not
been studied in DR. These factors include, but are not limited to, neurturin [104, 105]
and members of the neurotrophin family (NT-3, 4, 5, and 6) [106–108].
It is important to realize that characterization of retinal NFs in both the normal
and DR retina would be a useful tool to further the development of therapies in the
treatment and/or prevention of DR. As the incidence rates for diabetes increase and
the world population’s life expectancy increases, there is an ever-increasing desire to
prolong quality of life. This includes delaying the progression or halting the onset of
DR. A useful therapeutic tool, such as some that have been mentioned above, to promote
neuronal survival through the manipulation of neurotrophic factors in the retina could
be a powerful technique in order to halt or reverse the progression of the pathological
manifestations of DR.
254 Murray and Ma
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16
The Role of CTGF in Diabetic Retinopathy
R.J. van Geest, E.J. Kuiper, I. Klaassen,

C.J.F. van Noorden, and R.O. Schlingemann
CONTENTS
Introduction
ECM Remodeling and Wound Healing Mechanisms
in Diabetic Retinopathy
CTGF Structure and Function
CTGF in the Eye
CTGF in Diabetic Retinopathy
Conclusions
References
Keywords CTGF • VEGF • TGF-b • Preclinical diabetic retinopathy • Proliferative diabetic

retinopathy • Basal lamina (thickening) • Basement membrane • ECM (remodeling) • Wound
healing • AGEs • Angiofibrotic switch
INTRODUCTION
Diabetic retinopathy (DR) is a leading cause of ocular morbidity [1]. The pathogen-
esis of DR is only partly understood. Before development of clinical signs, it involves a
complex sequence of events, a phase called preclinical DR (PCDR), finally leading to
retinal vascular occlusion and ischemia. This causes the clinical manifestations of the
disease: vision-threatening vascular leakage and macular edema, and preretinal neovas-
cularization [2, 3]. The latter condition, proliferative DR (PDR), is essentially a wound
healing-like response.
In PCDR, the capillary basal lamina (BL) thickens, along with pericyte and endothe-
lial cell apoptosis, and diffusely increased vascular permeability [2, 4]. In experimental
rodent models of DR, retinal VEGF and VEGF-receptor (VEGF-R) mRNA are increased
in this stage, suggesting an early role of VEGF in DR, possibly as a result of high
glucose levels, advanced glycation end products (AGEs), and/or other factors altered by

261
262 van Geest et al.
the diabetic milieu [2, 3]. Although the exact sequence of events and the relative impor-
tance of the early changes are poorly understood, capillary BL thickening is a hallmark
of early DR and may be causal in endothelial and pericyte dysfunction. BL thickening is
the result of extracellular matrix (ECM) remodeling, resulting in increased deposition of
BL components such as collagen type IV, laminin, and fibronectin.
In addition, tissue fibrosis plays a role in PDR. Uncontrolled retinal neovasculariza-
tion is followed by fibrosis, scarring, tractional retinal detachment, and blindness. PDR
patients with established neovascularization and imminent fibrosis find themselves in a
situation associated with poor prognosis, despite aggressive laser treatment or surgical
procedures. The major mediator of vascular leakage and angiogenesis in PDR is VEGF-
A, which is overexpressed in ischemic retina [2, 3, 5, 6]. However, little is known about
growth factors that are involved in the subsequent fibrotic phase in PDR.
Connective tissue growth factor (CTGF) is a candidate for contributing to the fibrotic
responses observed in both PCDR and PDR. CTGF acts as a mitogen for fibroblasts and
induces increased ECM production [7–11]. CTGF functions as a downstream mediator
of transforming growth factor (TGF)-b signaling in certain cell types and seems essen-
tial for effectuation of the profibrotic actions of TGF-b, such as ECM production [12].
In long-standing diabetes, structural and functional ECM alterations, including
BL thickening, lead to microvascular diabetic complications, such as DR, nephrop-
athy, cardiomyopathy, peripheral vascular disease, cerebrovascular disorders, and
atherosclerosis [13, 14]. CTGF is involved in these diabetic microvascular complica-
tions [15–17]. In diabetic nephropathy, CTGF is strongly overexpressed in the kidney
glomerulus [16, 18], and its levels in urine and plasma correlate with progression of the
disease [19, 20].
Similarly to its involvement in fibrosis in diabetic nephropathy [7, 9, 10, 21], CTGF
may have a causal role in capillary BL thickening in PCDR and in fibrosis in PDR.
This chapter discusses the roles of CTGF in the pathogenesis of DR in relation to ECM
remodeling and wound healing mechanisms, and explores whether CTGF is be a novel
therapeutic target in the clinical management of early as well as late stages of DR.
ECM REMODELING AND WOUND HEALING MECHANISMS

IN DIABETIC RETINOPATHY
ECM Remodeling in PCDR
Normal constituents of the retinal capillary BL are collagen type IV, which is the pre-
dominant component, laminin, and fibronectin. The latter is mainly located at pericyte-
endothelial cell contacts [22, 23]. Changes in the BL in diabetes are considered to result
from a disturbed balance between synthesis and degradation of these matrix components
[4, 24, 25]. The thickening BL may consist of matrix proteins that are normally found
in the ECM, or proteins that are not present in the BL under physiological conditions,
or both [4, 22, 26–28].
ECM alterations including BL thickening are hallmarks in all target organs affected
by diabetes [29] and are directly related to loss of function of these organs [30]. It is
considered to represent a pathological response to prolonged hyperglycemia, which is
the major factor associated with the onset of microvascular complications, as has been
The Role of CTGF in Diabetic Retinopathy 263
Fig. 1. Vascular basal lamina (BL) thickening in diabetic retinal capillaries. Electron micro-
scopy of rat retina shows that retinal capillary BL (arrows) is susceptible to thickening after
12 months diabetes (compare nondiabetic (A) with diabetic (B)). (Reprinted by permission from
Macmillan Publishers Ltd: Eye [34]Copyright (2009)).
shown in prospective studies for both type I and type II diabetes (DCCT and UKPDS,
respectively) [31, 32].
The early thickening of the retinal capillary BL in diabetes was recognized already
60 years ago [33]. In the following decades, numerous electron microscopic studies
have demonstrated increased thickness of the BL in diabetic humans and animals
(Fig. 1) [34–36]. The only clear structural retinal change after 1–3 years of diabetes
was capillary BL thickening in a canine model of diabetes, which eventually displays

all early features of diabetic retinal microvascular damage – BL thickening, loss of peri-
cytes, the formation of microaneurysms, and capillary closure [37]. In this model, wide-
spread loss of pericytes was noted only after 4 years of diabetes. BL thickening is likely
to be instrumental in progression of early DR [38]. In an experimental model of diabetes
in galactose-fed rats, downregulation of synthesis of the BL component fibronectin with
the use of antisense oligos not only downregulated retinal BL thickening at least partly
but also reduced other more advanced features of PCDR, such as apoptosis of pericytes
and endothelial cells, as well as the development of acellular capillaries. In another
study, concomitant downregulation of fibronectin, laminin, and collagen type IV expres-
sion with the use of antisense oligos injected in eyes of rats with streptozotocin-induced
diabetes reduced vascular leakage [23]. These findings indicate that BL thickening is a
crucial step in the progression of DR.
Thickening of the BL, often incorrectly referred to as “basement membrane,” is
characterized by accumulation of ECM components, as well as a qualitative change
in ECM composition [30]. Structurally, ECM consists of a complex network of col-
lagens, elastins, structural glycoproteins, and proteoglycan–hyaluronans, and differs
quantitatively and qualitatively in the various tissues. ECM provides mechanical sup-
port to cells in tissues, is involved in differentiation of cells, and regulates interactions
between (vascular) cells and the ECM itself [39]. Under physiological circumstances,
ECM continuously undergoes remodeling by synthesis and degradation, with a bal-
anced turnover. ECM remodeling is required for maintaining the normal structure and
function of tissues [40]. Multiple growth factors are involved in the induction of ECM
synthesis, such as TGF-b [41], CTGF [42], insulin-like growth factor I (IGF-I), fibrob-
last growth factor (FGF), epidermal growth factor (EGF), and platelet-derived growth
factor (PDGF) [30]. ECM degradation and remodeling is regulated by proteases such
as the matrix metalloproteinases (MMPs) [43] and serine proteases [44], as well as
their respective inhibitors, the tissue inhibitors of metalloproteinases (TIMPs) [45] and
plasminogen activator inhibitor-I (PAI-1) [43].
Different metabolic mechanisms underlie the hyperglycemia-induced changes in
expression of growth factors and ECM turnover [35, 46]. Hyperglycemia affects vari-
ous biochemical pathways, among which increased formation of glucose-derived AGEs
[24, 47]. In DR, AGE formation has a causal role in changes in growth factor expression
and ECM turnover [25, 48]. AGE formation also increases synthesis of BL components,
most likely via upregulation of TGF-b signaling and its downstream effectors, including
CTGF [49].
Wound Healing Mechanisms in PDR

The early features of retinal microvascular diabetic damage such as BL thickening
eventually lead to retinal vascular occlusion and ischemia. In response, new vessels
develop from the preexisting retinal vasculature, which hallmarks the progression of clin-
ical DR from nonproliferative to proliferative disease. VEGF is the major mediator of this
hypoxia-driven neovascularization [2, 3, 5, 6] and may act in concert with other angiogenic
factors, such as angiopoietin-2 (Ang-2) [50]. The initial step in retinal neovascularization
is degradation of the BL and ECM components surrounding the vascular cells, followed
by invasion, migration, and proliferation of endothelial cells, and finally the formation of
new vascular tubes [51]. Remodeling of the ECM in angiogenesis is exerted by MMPs,
which are induced by angiogenic stimuli such as VEGF and Ang-2 [52].
Neovascularization and the switch to subsequent fibrosis in PDR can be considered
as a wound healing-like response [53]. Fibrosis is the deposition and cross-linking of
collagen in the terminal phase of the normal wound healing response [54, 55], which has
mainly been studied in the skin. Wound healing in the skin is initiated by tissue injury
[56–58], which involves vascular damage, hemorrhage, and activation of the clotting
system. The subsequent response can be divided into three phases: an inflammatory
phase, a proliferative phase, and a maturation phase [56].
During the inflammatory phase, angiogenic and profibrotic cytokines and growth
factors are released from activated cells, such as platelets and macrophages. In the pro-
liferation phase, fibroblasts contribute to the synthesis of the ECM [59], and endothe-
lial cells form “sprouts” and new capillaries. Sprouting angiogenesis is initiated by the
presence of a fibrin matrix and growth factors at the wound healing edge [60]. Besides
ECM components, fibroblasts also produce growth factors and various enzymes such as
proteases which are of importance for reepithelialization and angiogenesis. During the
wound healing response, the ECM itself serves as a reservoir for growth factors, thereby
regulating their activity and presentation to receptors. In the proliferation phase, forma-
tion of ECM, angiogenesis, and reepithelialization take place [56].
In the maturation phase, angiogenesis ceases whereas the production of ECM con-
tinues [56]. Under normal conditions, after this switch from angiogenesis to fibrosis,
ECM production ceases when sufficient quantities of collagen have been synthesized
[56, 61–63]. Then, remodeling of the newly formed ECM reduces the wound thickness
and increases the strength of the regenerating tissue. This breakdown of collagen is
tightly regulated by a balance between proteases such as MMPs and their endogenous
inhibitors such as TIMPs [64, 65].
Most features of the wound healing response in human skin can also be recognized
in pathological wound healing responses characterizing various disease states in other
organs. These pathological conditions have in common that tissue-specific wound heal-
ing responses are initiated, but that the wound healing process is not properly terminated,
leading to pathological fibrosis [54, 66]. This is a situation in which normal scarring
progresses to excessive production, limited degradation, altered deposition, and/or con-
traction of the ECM, probably due to an imbalance between pro- and antifibrotic factors
causing a profibrotic state.
Several eye conditions lead to blindness by the involvement of wound healing-like
responses culminating in scarring or excessive fibrosis (see Section on “CTGF in the
Eye”). Although the initial wound healing response may have a functional meaning
in restoring ocular integrity, it also results in loss of visual function and is therefore
deemed to be pathological [67, 68].
CTGF STRUCTURE AND FUNCTION

CTGF is a member of the CCN family of growth factors, named after the first three
members identified, Cyr61 (CCN1), CTGF (CCN2), and Nov (CCN3), but also includes
CCN4 (WISP-1), CCN5 (WISP-2), and CCN6 (WISP-3) as well [69–71]. CTGF exhib-
its a unique domain structure, made up of five modules including a signal peptide,
Fig. 2. Modular structure of the CTGF protein. CTGF consists of an N-terminal secretory
signaling peptide (SP) and four distinct domains, through which CTGF binds extracellular ligands
like VEGF, TGF-b, and fibronectin, and cell surface proteins like integrins and heparin-sulfate
proteoglycans. (Asterisks) Hinge region. CTGF can be cleaved by proteases, such as MMPs, in
between the domains. Cleavage products can accumulate in biological fluids and may serve as
clinical markers.
encoded by five exons (Fig. 2) [71]. CTGF exerts its biological activities by interactions
with ECM components, such as fibronectin, extracellular signaling molecules, and cell
surface proteins, such as integrins, through its various interaction domains [70, 72–76].
Most likely, CTGF also indirectly regulates signaling by modulating the activity of other
growth factors [77, 78]. For instance, binding of CTGF and VEGF suppresses VEGF-
induced angiogenesis, and cleavage of CTGF by MMPs recovers the angiogenic activity
of VEGF [79].
The biological functions of CTGF are diverse and cell and context dependent.
CTGF was first discovered in conditioned media of endothelial cells as a molecule
affecting the activity of fibroblasts [80]. CTGF is induced during wound healing [81],
is overexpressed in fibrosis [82, 83], and acts as an essential downstream mediator
for most of the profibrotic activity of TGF-b, in particular in stimulation of ECM
production [66], and fibroblast proliferation [84–86]. The synergy between CTGF
and TGF-b1 may be explained by binding of the unique TGF-b response element of
CTGF, which enhances receptor binding and signaling activity of TGF-b (Fig. 2).
For example, skin fibrosis in newborn mice was persistent only after coinjection of
both TGF-b1 and CTGF, and not after injection of TGF-b1 or CTGF alone [87, 88].
In humans, CTGF is upregulated in diseases that are characterized by pathological
fibrosis including renal diseases of various etiology, liver, lung, cardiovascular dis-
eases, and in the eye.
Biological functions of CTGF include induction of angiogenesis, chondrogenesis,
osteogenesis, and control of cell proliferation and differentiation, migration, adhesion,
apoptosis, and survival of fibroblasts [10, 89], but the exact function of CTGF in normal
tissues is not known yet; CTGF is expressed in the placenta during embryo implantation
[90] and during the development of ovarian follicles [91]. Recently, a role CTGF was
suggested in (nonfibrotic) tissue repair in the eye, as it was required for reepithelializa-
tion in human cornea [92].
CTGF IN THE EYE

CTGF in Ocular Fibrosis
It has been suggested that CTGF functions in the eye primarily as a profibrotic
growth factor. In the human eye, CTGF has been identified in various diseases com-
plicated by fibrosis, both in the anterior and posterior segments [93–100]. Several
major eye conditions lead to blindness due to scarring or pathological fibrosis [101]
as a consequence of tissue-specific wound healing responses. In subretinal neovas-
cularization as well as in PDR and other ischemic retinopathies, these responses
are driven by neovascularization, like in skin wound healing. In other conditions
such as proliferative vitreoretinopathy (PVR), these responses are mainly avascular.
There is accumulating evidence that CTGF is an important pathogenic factor in these
conditions. For instance, in the vitreous of patients with PVR, CTGF is present in
higher levels as compared to nonproliferative retinal diseases [101, 102], in correla-
tion with TGF-b [103]. In human PVR membranes, CTGF has been identified as well
[104–106].
CTGF in Ocular Angiogenesis

CTGF has been suggested to play a role in ocular angiogenesis. In the rat eye, corneal
micropocket implants containing murine CTGF induced neovascularization [7]. Moreo-
ver, CTGF and VEGF colocalized in vascular cells in human choroidal neovascular
membranes, and levels of CTGF were increased in the vitreous of patients with active
PDR [107]. However, VEGF-induced angiogenesis was inhibited by combined exog-
enous administration of CTGF and VEGF in the back of mice, as well as in a mouse
model of hindlimb ischemia, as a result of binding of VEGF by CTGF [108, 109]. When
CTGF is upregulated by VEGF [11], it can reduce the bioavailability of VEGF through
direct binding. The involvement of CTGF in angiogenesis in ocular disease in gen-
eral and in DR in particular is also questionable because of findings in human PDR
and in distinct angiogenesis models applied to CTGF transgenic mice [101, 110, 111].
In human PDR, CTGF levels consistently correlated with degree of fibrosis and not
with angiogenesis activity [101, 111]. In studies in transgenic mice lacking the CTGF
gene, vascular outgrowth from metatarsals of 17-day-old CTGF−/− embryos, cultured
in the presence or absence of VEGF, did not differ significantly from outgrowth of
wild-type or heterozygous CTGF+/− metatarsals [110]. These data indicate that CTGF
is not required for (VEGF-induced) angiogenesis in this model. Secondly, the effect of
CTGF gene deletion was investigated in two ocular angiogenesis models. In the oxygen-
induced retinopathy model [112], in which retinal hypoxia-induced VEGF overexpres-
sion causes preretinal angiogenesis, differences between CTGF+/+ and CTGF+/− mice
were not observed. In another ocular angiogenesis model, choroidal neovascularization
was induced in CTGF+/+ and CTGF+/− mice by laser burns [113, 114], but statistical
differences between CTGF+/+ and CTGF+/− mice were not found [110]. Taken together,
these data suggest that CTGF is a dispensable factor in the complex interplay of hypoxic
signaling and VEGF- or wound healing-driven ocular angiogenesis.
CTGF IN DIABETIC RETINOPATHY

In various organs other than the eye, CTGF (in combination with TGF-b) is consid-
ered to cause ECM accumulation and fibrosis as a consequence of diabetic pathology
[30]. This is based on experimental diabetic models, where CTGF mRNA and protein
were found to be upregulated in kidney, heart, and liver [115]. TGF-b1 is generally
considered to be the main profibrotic factor in diabetic nephropathy [75], with CTGF
as an important downstream mediator. Diabetes-induced thickening of glomerular BL
in mouse kidney, analogous to BL thickening of retinal capillaries, was shown to be
diminished in CTGF-deficient mice [115]. CTGF expression is not only induced by
TGF-b but also by high glucose levels, AGEs, RAAS, TNF-a, mechanical stress, and
CTGF itself [15–17, 49, 116–118]. There is increasing evidence confirming this role
of CTGF in diabetic nephropathy. In diabetic patients, glomerular CTGF mRNA lev-
els were upregulated, both in patients with microalbuminuria as well as in overt neph-
ropathy [18]. Moreover, CTGF mRNA levels correlated with the degree of albuminuria
[119]. In a baboon model of type I diabetes, expression levels of tubular CTGF protein
after 5 years predicted albuminuria after 10 years [120]. Accordingly, in human diabetic
patients, CTGF levels in urine [19] and plasma [20] correlated with progression of dia-
betic nephropathy.
The role of CTGF in the development of DR was less clear. However, recent evidence
suggests that CTGF is involved in both the early stages and in the late proliferative
stage of DR.
CTGF in BL Thickening in PCDR

In the light of its known role in matrix remodeling in other diabetic microvascu-
lar complications, CTGF is a candidate causal factor in diabetic BL thickening in the
human retina. We studied CTGF expression in a series of 36 diabetic patients and 18
nondiabetic controls [121]. Immunohistochemical staining with a highly-specific anti-
body against CTGF revealed a distinct and specific cellular cytoplasmic staining in the
retina, suggesting local cellular expression of the CTGF protein. In the normal human
retina, CTGF staining was present in paravascular microglia. However, in the retina
of diabetic subjects, microglial staining was significantly decreased whereas expres-
sion of CTGF in microvascular pericytes was significantly increased. Therefore, two
main patterns of CTGF expression can be distinguished: either predominant staining
of microglia or predominant staining of pericytes. The predominant pericyte staining
correlated almost exclusively with the presence of diabetes. The constitutive expression
in paravascular microglia in the normal retina suggests a role in retinal microvascu-
lar physiology. In the light of known functions of CTGF in other cells and tissues, it
is tempting to speculate that microglia-derived CTGF is involved in retinal matrix or
vascular BL homeostasis in normal conditions. However, Abu El-Asrar et al. [104] did
not find immunostaining of CTGF in the nondiabetic retina, whereas the diabetic retina
showed CTGF staining in ganglion cells, cells in the inner nuclear layer, and in cells
identified as microglia, in agreement with the study by Kuiper et al. The difference in the
two studies may be explained by the different antibodies used. It was also investigated
whether altered CTGF expression in diabetes was associated with established DR [121].
Fig. 3. Model of CTGF expression patterns during the development of DR. Progressive
degrees of nonproliferative DR are indicated by an increase in PAL-E-positive endothelial cells
(red). (A) Control subject without PAL-E staining, showing CTGF-positive microglia only
(yellow). (B–D) Diabetic subjects with or without PAL-E staining, showing decreased CTGF-
positive microglia (yellow) and increased CTGF-positive pericytes (orange). (Reproduced from
[121] with permission from BMJ Publishing Group Ltd.).
Staining with the use of the endothelium-specific monoclonal antibody PAL-E recogniz-
ing plasmalemma vesicle-associated protein (PLVAP), a marker associated with local
vascular leakage [122, 123], revealed no correlation with CTGF staining patterns in per-
icytes or microglia. In fact, CTGF seemed to be evenly distributed in diabetes, irrespec-
tive of PAL-E staining (Fig. 3). Apparently, CTGF expression patterns in pericytes of the
diabetic retina are not related to clinical DR, but rather are associated with preclinical
changes in the retina in diabetes. Increased pericyte CTGF expression may be related to
BL thickening and/or pericyte apoptosis, both important early events in PCDR.
AGEs and CTGF in BL Thickening in PCDR

One of the proposed mechanisms of BL thickening in PCDR is the formation of AGEs.
Treatment of diabetic rats with the AGE-inhibitor aminoguanidine markedly reduced
AGE formation in the retinal vasculature, but also protected against retinal capillary BL
thickening [46]. AGEs can also induce synthesis of ECM in diabetic rat kidney [117].
A similar induction of ECM synthesis is mediated by CTGF, both in diabetic kidney
[115] and retina [124]. In the diabetic rat kidney, AGEs induce expression of fibronectin
and collagen type IV, possibly partly through CTGF [125, 126]. Furthermore, AGEs
induced CTGF expression in cultured retinal vascular cells [125].
Therefore, it seems likely that AGE-induced BL thickening in the retina is mediated
by CTGF. We recently investigated the levels of CTGF and ECM-related molecules
in both the STZ-induced diabetic rat retina, treated with or without aminoguanidine,
and in the retina of mice infused with AGEs [49]. In rats, STZ treatment resulted in a
significant increase in carboxy-methyl-lysine (CML) plasma levels, a marker for AGE
formation, at 6 and 12 weeks of diabetes. Aminoguanidine treatment had no effect on
CML levels at 6 weeks, but decreased CML levels by 25% after 12 weeks. At this time
point, retinal CTGF mRNA levels were elevated twofold in diabetic rats compared to
nondiabetic controls, but treatment with aminoguanidine almost completely prevented
this increase. Similarly, CTGF protein levels were increased in the retina of diabetic rats,
and aminoguanidine prevented this effect. Other ECM components, such as collagen
type IV and TIMP-1, also showed elevated mRNA levels after 6 or 12 weeks of diabetes,
which were significantly reduced by aminoguanidine treatment. TGF-b and fibronectin

levels in the retina were unaffected at 6 and 12 weeks of diabetes in this model.
Retinal mRNA analysis in mice that received exogenous AGEs daily for 7 consecu-
tive days revealed a twofold increase in CTGF levels as compared with control mice.
Expression levels of Cyr61 (CCN1) were also elevated in the AGE-treated animals, but
other CCN family members were not affected [49]. Taken together, these data present
evidence that AGEs are both necessary and sufficient to cause increased levels of CTGF
in the diabetic retina, concomitantly with ECM-related molecules [49]. Therefore,
CTGF, and possibly Cyr61 as well, may have a role in thickening of the BL.
Another crucial feature of PCDR is loss of retinal capillary pericytes. Pericytes main-
tain capillary structure and integrity and regulate homeostasis of the endothelium. Cul-
tured rat retinal pericytes exposed to AGEs expressed increased levels of CTGF [125].
In these cells, AGEs induced anoikis, a form of apoptosis caused by loss of cell–matrix
interactions. Likewise, overexpression of CTGF promoted detachment and anoikis of
retinal pericytes. The authors suggested that accumulation of CTGF in the retinal capil-
laries at the onset of diabetes may alter vascular structure and organization and have a
role in pericyte apoptosis in PCDR.
Role of VEGF in BL Thickening

VEGF, a potent vascular permeability and angiogenic factor in PDR, is also increased
early in PCDR [6, 127, 128]. Neutralizing VEGF with an antibody partly prevented
diabetes-induced BL thickening in the retina of obese type 2 diabetic mice [129]. To
test whether VEGF itself is capable to induce expression of genes that contribute to
BL thickening in PCDR, we investigated the effect of VEGF injected in the vitreous of
rat eyes on the retinal expression of CTGF, other CCN family members, TGF-b, and
ECM-related molecules [26]. Adult Wistar rats were injected intravitreously with recom-
binant rat VEGF164 in one eye and with solvent only in the contralateral eye. Retinal gene
expression and protein levels were examined at various time points afterwards. At 24 h
after injection, CTGF mRNA expression showed a 2.3-fold increase. TGF-b1 mRNA,
but not TGF-b2 mRNA, was also induced significantly at 24 h after injection. Of the
ECM-related molecules examined, fibronectin and TIMP-1 were significantly upregu-
lated at 24 h. TIMP-2, collagen type IV, and laminin B1 mRNA levels were unaffected
by VEGF. At the protein level, CTGF and fibronectin were clearly increased at 48 h
after injection in VEGF-injected eyes. TGF-b and fibronectin immunostaining in retinal
sections was more intense in the microvasculature in VEGF-injected eyes as compared
to PBS-injected and noninjected eyes. VEGF stimulation in bovine retinal endothelial
cells (BRECs) resulted in an early increase of CTGF, TGF-b1, TGF-b2, and fibronec-
tin expression. At 24 h, TIMP-1 mRNA was significantly increased. In bovine retinal
pericytes (BRPCs), fibronectin, collagen type IV, and TIMP-1 mRNA levels were sig-
nificantly upregulated at 24 h after VEGF stimulation. CTGF, TGF-b1, and TGF-b2
expression was not affected by VEGF in BRPCs.
Overall, VEGF was able to induce expression of genes related to ECM remodeling in
the rat retina. The specificity of this response was demonstrated by the fact that induc-
tion of expression of ECM-related genes was selective and that the expression profile
correlated to changes in protein levels. In vitro, comparable gene expression profiles
Fig. 4. Hypothetical model of diabetes-induced BL thickening. The model was developed

on the basis of data obtained in both the VEGF-induced retinopathy model and the STZ-induced
diabetes study, and what is know from the literature [42]. During diabetes, levels of AGEs
and VEGF increase, and ECM molecules are induced at different time points after the onset of
diabetes. Both AGEs and VEGF contribute to the induction of CTGF expression.
were found in retinal endothelial cells and pericytes, suggesting that the retinal vascu-
lature plays an important role in the altered gene expression profile found in rat retina.
Thus, early expression of VEGF in PCDR may contribute directly, and/or via CTGF, to
BL thickening and further development of DR. Based on the VEGF-induced retinopathy
model and the STZ-induced diabetes study, we developed a model of the expression of
profibrotic genes involved in diabetes-induced BL thickening (Fig. 4).
TGF-b and CTGF in BL Thickening

TGF-b plays a causal role in BL thickening in mouse brain capillaries [130] and in the
diabetic kidney [131, 132]. However, evidence for such a role in DR is scarce or indirect.
Recently, it was shown that two drugs that are effective in the suppression of experi-
mental DR had in common that upregulation of expression of members of the TGF-b
pathway was suppressed, suggesting that TGF-b signaling plays a major role in the early
pathogenesis of DR [133]. More specifically, retinal vessels in diabetic rats showed both
increased TGF-b activity and increased CTGF mRNA expression [133].
To further identify the possible role of TGF-b in BL thickening in DR, its downstream
effects were characterized in cultured retinal vascular cells [134]. BRECs and BRPCs
were incubated with both low and high concentrations of TGF-b1, and expression lev-
els of ECM-related molecules downstream of TGF-b were analyzed. In BRECs, only
high concentrations of TGF-b induced mRNA expression of specific downstream TGF-
b effector genes, including fibronectin, but not of CTGF. In BRPCs, both low and high
concentrations of TGF-b induced expression of fibronectin and CTGF. Specific inhibi-
tion of the TGF-b receptor ALK5 significantly decreased expression levels of fibronec-
tin in both cell types. CTGF expression was decreased with TGF-b inhibition in BRPCs
only. Fibronectin protein was present in higher levels in BRPCs. These results show that
TGF-b has differential effects on ECM-related gene expression in BRECs and BRPCs.
Pericytes are more responsive to TGF-b, and CTGF expression seemed to be regulated
by TGF-b in pericytes and not in endothelial cells.
In summary, this study showed that retinal pericytes in particular have the essential
characteristics to allow for a role of TGF-b in BL thickening in PCDR. Pericytes are of
mesenchymal origin like fibroblasts, which may explain their TGF-b-dependent CTGF
regulation. These results suggest that in retinal endothelial cells, CTGF expression is
regulated by other pathways and factors, acting independently of TGF-b, such as VEGF,
AGEs, and/or high glucose levels [26].
BL Thickening in Diabetic CTGF-Knockout Mice

As indicated above, STZ-induced diabetes in rodents is associated with a twofold
increase in CTGF gene expression in total retina, which can be attenuated by treat-
ment with the ACE-inhibitor perindopril or aminoguanidine, respectively [49, 135].
We studied the effects of STZ-induced diabetes on retinal capillary BL thickness
in transgenic CTGF+/− mice [136] and wild-type mice (CTGF+/+) [124]. BL thick-
ness was calculated by quantitative analysis of electron microscopic (EM) images
of transversally sectioned capillaries in and around the inner nuclear layer of the
retina. In the retinal capillaries, a significant increase in particularly the endothelial
cell BL was detected in diabetic CTGF+/+ mice as compared to control CTGF+/+ mice,
using two independent quantitative methods in EM images (Fig. 5). This preferential
thickening of the endothelial BL and pericyte BL in diabetic mice had been observed
previously [137].
In this study, the CTGF+/− and CTGF+/+ mice were in a similar diabetic state with
respect to blood glucose levels. However, there was a clear genotype effect on CTGF
expression in the CTGF+/− mice. Approximately 50% lower CTGF protein expression
levels in plasma and urine were found in control animals lacking one CTGF allele. Reti-
nal CTGF levels were not analyzed in this study. However, renal CTGF mRNA levels
in diabetic CTGF+/− mice were 50% of those in diabetic CTGF+/+ mice. This suggests
that retinal CTGF protein levels may also have been lower and prevented the diabetes-
induced BL thickening of the retinal capillaries. Renal TGF-b1 mRNA levels were sig-
nificantly increased due to diabetes, irrespective of the CTGF genotype. Similarly to the
retinal vessels, a genotypic effect on the BL of glomeruli was found in diabetic mouse
kidney [115].
Taken together, the data of this study indicate that CTGF is necessary for BL thicken-
ing in diabetes. This provides important direct evidence for an essential role of CTGF in
diabetic retinal BL thickening. In concert with the supportive indirect evidence for such
a role as described above, these data identify CTGF as a possible therapeutic target to
prevent early changes in PCDR. This may be clinically relevant, as experimental animal
studies have shown that prevention of BL thickening can ameliorate the subsequent
development of other preclinical changes in DR [38].
Fig. 5. Examples of retinal capillaries analyzed for BL thickness. Distinct regions of the BL
are identified as endothelial BL (eBL), pericyte BL (pBL), and joint endothelial cell and pericyte
BL (jBL). Note the diabetes-induced BL thickening in diabetic CTGF+/+ mice (B) as compared
with control CTGF+/+ mice (A) and the absence of this effect in diabetic CTGF+/− mice (D) com-
pared with control CTGF+/− mice (C). Bar = 1 mm. (Reproduced from: Journal of Histochemistry
and Cytochemistry. Online by Kuiper EJ et al. Copyright 2008 by Histochemical Society Inc.
Reproduced with permission of Histochemical Society Inc in the format Trade book via Copy-
right Clearance Center).
CTGF in PDR
In PDR, CTGF was found in fibrovascular membranes, predominantly localized
in myofibroblasts [104, 107], with a significant correlation between the number of
a-SMA-positive myofibroblasts and the number of myofibroblasts expressing CTGF
[104]. Myofibroblasts are activated matrix-producing fibroblasts, associated with (per-
sistent) fibrosis [59]. Furthermore, CTGF was detected in endothelial cells in these
membranes [104]. In the vitreous of a small series of patients with active PDR, levels
of the N-terminal CTGF fragment were increased as compared to nondiabetic patients
and patients with quiescent PDR [107]. Vitreous levels of full-length CTGF were similar
in all groups, whereas the C-terminal fragment was not detectable. N-terminal CTGF
levels were also higher in diabetic patients with vitreous hemorrhage than in nondia-
betic patients with vitreous hemorrhage, who had similar N-CTGF levels as nondiabetic
controls. This finding suggests that local synthesis of CTGF plays a role in PDR. On
the basis of the association between CTGF levels and PDR, these authors concluded
that CTGF has a role in angiogenesis. However, we showed that elevated CTGF levels
are associated with degree of fibrosis and not with angiogenic activity in vitreoretinal
conditions, including PDR, in a series of vitreous samples of 119 patients (Fig. 6) [101].
Fig. 6. Geometric mean of CTGF levels in relation to degree of fibrosis. Fibrosis was graded
as 0 when no fibrosis was present, 1 with only a few preretinal membranes present, 2 with some
proliferative membranes/PVR grade a/b, or 3 with abundant proliferative membranes/PVR grade
c/d. Error bars represent the 95% confidence intervals. (Reproduced from [101] Copyright ©
(2006) American Medical Association. All rights reserved).
In addition, the degree of fibrosis was best predicted by CTGF levels. Possibly, TGF-b
has a role in regulating CTGF levels intravitreally and thereby fibrosis in DR. An earlier
study has shown that TGF-b2 was associated with fibrotic proliferation in the vitreous
of patients with PDR [138]. Furthermore, vitreous levels of both TGF-b2 and CTGF in
patients with PDR were significantly higher than in those with nonproliferative diseases,
with a correlation between the levels of TGF-b2 and CTGF [103].
Role of CTGF and VEGF in the “Angiofibrotic Switch” in PDR

In PDR, neovascularization progresses to a fibrotic phase. VEGF is considered to be
the primary angiogenesis factor in this process [2, 6]. In vitreoretinal disorders (includ-
ing PDR), N-terminal CTGF levels in the vitreous are elevated [107] and are strongly
correlated with the degree of fibrosis [101]. Therefore, it was proposed that CTGF is a
causal factor of fibrosis and scarring in PDR.
In vitreous of PDR and PVR patients, Kita et al. [139] found no significant correla-
tion between the levels of CTGF and VEGF, even though concentrations of CTGF and
VEGF were both significantly higher compared to those in vitreous from patients with
nonproliferative diseases. With regard to a possible role of CTGF in retinal neovascu-
larization, it was concluded that CTGF may have no direct effect on retinal neovasculari-
zation, but possibly works indirectly by modulation of VEGF levels.
We investigated the correlation between VEGF and CTGF levels and the degree of
fibrosis and neovascularization in the vitreous of a series of 68 patients with PDR and
other vitreoretinal disorders (macular hole or macular pucker) [111]. Neovascularization
Fig. 7. Mean levels of CTFG (A, D), geometric mean levels of VEGF (B, D), and mean
ratio CTGF/log10(VEGF) (c, f) in relation with degree of neovascularization (A–C) and degree
of fibrosis (D–F) in the vitreous of 32 PDR patients. Vertical bars represent 95% confidence
intervals. Significant differences between groups are indicated. (From [101]).
and fibrosis in various degrees occurred almost exclusively in PDR patients, in which
vitreous CTGF levels were significantly associated with the degree of fibrosis and with
VEGF levels, but not with neovascularization. On the other hand, VEGF levels were
associated only with neovascularization, in agreement with the widely accepted role of
VEGF as the major angiogenic factor in PDR (Fig. 7). As the ratio of CTGF and VEGF
levels was the strongest predictor of the degree of fibrosis, the results suggested that the
balance of VEGF and CTGF levels in the vitreous determines progression of fibrovas-
cular proliferation in PDR.
These findings led to the following concept of regulation of angiogenesis and fibrosis
in ocular disease and in wound healing in general: angiogenesis in the vitreous is driven
by VEGF, which upregulates the profibrotic factor CTGF in various cell types in the
newly formed neovascular membranes. The elevated CTGF levels do not significantly
Fig. 8. Hypothesis of the angiofibrotic switch in PDR. Angiogenesis in the vitreous is driven
by VEGF, which upregulates the profibrotic factor CTGF. Increasing levels of CTGF inactivate
VEGF, and when the balance between these two factors shifts to a certain threshold ratio, the
angiofibrotic switch occurs: angiogenesis ceases, and fibrosis driven by excess of CTGF leads to
scarring and blindness.
Fig. 9. Fundus photographs of a patient with PDR and new vessels along the lower vas-
cular arcade, before (A) and at 8 months after (B) an injection with bevacizumab followed by
pan-retinal photocoagulation. Note the increase in fibrosis after combined anti-VEGF and laser
treatment (B).
contribute to ocular angiogenesis. In contrast, increased levels of CTGF sequester VEGF,

and when the balance between these two factors shifts to a certain threshold ratio, the
angiofibrotic switch occurs: angiogenesis ceases, and fibrosis driven by excess CTGF
leads to scarring and blindness (Fig. 8).
This concept predicts that a sharp decline in VEGF levels in a patient with active neo-
vascularization due to PDR inhibits angiogenesis, causes the angiofibrotic switch, and
temporarily increases fibrosis. This is supported by clinical observations in patients with
active neovascularization treated with intravitreal inhibitors of VEGF, such as bevacizu-
mab and ranibizumab, and/or pan-retinal laser photocoagulation, which destroys large
areas of retina and markedly reduces intraocular VEGF levels [5]. Regression of neo-
vascularization and the predicted temporary increase in fibrosis was observed in a non-
systematic survey of a small series of patients (Fig. 9) [111]. Others have also reported
exacerbation and subsequent contraction of fibrous tissue leading to tractional retinal

detachment in patients who received anti-VEGF treatment for active PDR [140, 141].
PDR patients treated with bevacizumab also showed a remarkable inhibition of angio-
genesis, suggesting that the elevated CTGF levels, which remain in the vitreous after
VEGF inhibition, are not able to maintain the angiogenic response, providing further
evidence that CTGF has no proangiogenic role in PDR.
As indicated, it appears from the available evidence that CTGF, in a critical balance
with VEGF, drives the angiofibrotic switch and subsequent fibrosis in PDR. This indi-
cates that CTGF-targeted therapy, in particular in combination with anti-VEGF agents,
is a possible novel option to prevent sight-threatening fibrosis in PDR and other ocular
diseases that are associated with neovascularization and fibrosis.
CONCLUSIONS
We conclude that in DR, CTGF has a role in two important stages of the disease.
Early in the pathogenesis, CTGF contributes to thickening of the retinal capillary BL,
which is a crucial step in the progression of DR. In this stage, CTGF interacts with
AGEs, and growth factors such as VEGF and TGF-b are involved as well. Designing
treatment strategies against TGF-b, a major inducer of fibrosis in many diabetic compli-
cations, is unfavorable, as this growth factor also exhibits (beneficial) immunosuppres-
sive and anti-inflammatory activity. Targeting CTGF, a major regulator of profibrotic
TGF-b action, may therefore be a much more suitable option in the preclinical stage of
the disease.
In a later stage of the disease, the switch from neovascularization to a fibrotic phase
in PDR is driven by CTGF, in a critical balance with VEGF. This indicates that CTGF-
targeted therapy, in particular in combination with anti-VEGF agents, is a possible novel
option to prevent sight-threatening fibrosis in PDR and other ocular diseases that are
associated with neovascularization and fibrosis.
On the basis of these and other data, CTGF has been suggested to be useful as a
biomarker for a wide range of fibrotic disorders [142]. A simple tool as ELISAs can
be used to monitor the expression of CTGF and VEGF proteins in the vitreous of PDR
patients, which enables the monitoring of disease progression and drug efficacy in
clinical trials.
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Part IV
How Can Vision Loss Be Limited:
Experimental Therapies
17
Ranibizumab and Other VEGF Antagonists
for Diabetic Macular Edema
Ben J. Kim, Diana V. Do, and Quan Dong Nguyen
CONTENTS
Introduction
Pathogenesis of DME and Current Standard of Care
Ranibizumab for DME
Pegaptanib for DME
Bevacizumab for DME
VEGF Trap-Eye for DME
Other Considerations in the Management of DME
Combination Treatment for DME
DME and Quality of Life
Conclusions
References
Keywords Tractional retinal detachment • Neovascularization • Microaneurysms • Vascular

endothelial growth factor • Early Treatment of Diabetic Retinopathy Study • Combination laser
treatment
INTRODUCTION
Vision loss from diabetic retinopathy has a tremendous impact on society as it is the
most prevalent cause of vision loss in the working-age population of developed coun-
tries. By 2025, it is expected that there will be more than 300 million people worldwide
with diabetes [1]. While severe loss can be caused by vitreous hemorrhage or tractional
retinal detachment, diabetic macular edema (DME) is the most common cause of moder-
ate vision loss [2]. The prevalence of DME is estimated at 10–25% of the diabetic popu-
lation, with this percentage being higher in those patients with more severe retinopathy
[3, 4]. While patients can strive to optimize glycemic control, blood pressure, and weight

289
290 Kim et al.
loss, these efforts alone often do not cause significant improvement of DME. Thus, the
development of treatments is critical to relieve the burden that DME causes on soci-
ety. This chapter will discuss the recent development of ranibizumab and other therapy
directed against vascular endothelial growth factor (VEGF) for the treatment of DME.
PATHOGENESIS OF DME AND CURRENT STANDARD OF CARE

DME occurs when plasma leaks out of vessels and accumulates within the retinal
tissue of the macula. Hyperglycemia leads to impairment of pericytes and subsequent
loss of the normal integrity of the retinal vasculature [5] and the blood-retina barrier [6].
As visualized by fluorescein angiography (Fig. 1A, B), this plasma leakage can be focal
leakage from microaneurysms or more diffuse leakage. In the latter case, there are no
structural abnormalities seen on angiography, and nonfocal leakage from retinal capil-
laries occurs. For both focal and diffuse edema, the interstitial fluid distorts the structure
of the macula, leading to visual dysfunction. This fluid accumulation can be imaged by
optical coherence tomography (OCT) (Fig. 1C). Normal vision can be restored if the
leakage ceases and the excess fluid resorbs. However, the chronic presence of fluid can
lead to permanent damage to neurons, thus limiting the potential for vision restoration.
Treatments for DME are aimed at reducing leakage by physically changing the vascula-
ture or by reducing permeability through molecular signaling pathways.
While the pathogenesis of DME at the molecular level is not completely understood,
VEGF is thought to have a significant role. VEGF contributes to the pathogenesis of
numerous retinal diseases that involve abnormal vessels, including choroidal neovascu-
larization from age-related macular degeneration (AMD). There has been an explosion
of basic science knowledge about this protein that ultimately has led to therapeutic devel-
opment. VEGF is a 45-kDa glycoprotein that is a potent stimulator of vascular perme-
ability and neovascularization [7, 8]. VEGF is a family of growth factors, and the most
studied member is VEGF-A, which was known simply as VEGF before the discovery of
other members. Different exon splicing pathways of the human VEGF-A gene can lead
to the production of at least nine isoforms of VEGF-A [9]. In particular, the VEGF 165
isoform is thought to have a key part in disease development [10, 11]. The expression
of VEGF is associated with DME, as it has been found that vitreous levels of VEGF are
significantly higher in patients with DME as compared to patients without diabetes [12].
Hypoxia contributes to the development of DME [13], and VEGF expression is stimu-
lated by hypoxia as it is regulated by the transcription factor hypoxia-inducible factor-1
[14]. Hyperglycemia also stimulates VEGF expression [15]. Once there is increased
VEGF production in the setting of poorly controlled diabetes, the VEGF can affect the
tight junction complexes that are a significant component of the blood-retina barrier.
Specifically, it has been shown that VEGF may cause vascular permeability by down-
regulating the tight junctional protein occludin in retinal endothelial cells [16]. Using a
primate model, Ozaki et al. found that intravitreal injection of a sustained release VEGF
pellet causes breakdown of the blood-retinal barrier. This finding was accompanied by
significant leakage of fluorescein from vessels and macular edema [17]. Together, these
studies suggested that VEGF antagonists may serve as a treatment for DME.
Ranibizumab and Other VEGF Antagonists 291
Fig. 1. Early transit (A) and late transit (B) images from the fluorescein angiogram of a
55-year-old patient with severe nonproliferative diabetic retinopathy and diabetic macular edema
(DME). Staining from prior focal laser scars is seen superotemporally. There are multiple micro-
aneurysms and enlargement of the foveal avascular zone. Leakage is seen in the late frame. An
optical coherence tomography image (C) from the same patient demonstrates intraretinal fluid.
292 Kim et al.
The first study examining this possibility involved an orally active nonselective blocker
of VEGF receptors called PKC412 [18]. PKC412 is a kinase inhibitor that blocks VEGF
receptors 1 and 2, platelet-derived growth factor, the receptors for stem cell factor, and
several isoforms of protein kinase C [19, 20]. In a dose-dependent manner, PKC412
reduced macular thickening and modestly improved visual acuity in patients with DME.
However, the therapeutic dose also caused liver toxicity, and thus the study pointed to
a need for a more selective and locally administered medication. Before anti-VEGF
therapy for DME is discussed further, it is important to discuss other treatments in use to
understand the potential impact that anti-VEGF therapy may have on patient care.
Currently, the standard of care for the treatment of DME is focal/grid laser. With
this treatment, laser is applied focally to leaking microaneurysms or applied in a grid
pattern to areas of diffuse leakage. Laser was the first evidence-based treatment devel-
oped for DME as delineated by the Early Treatment of Diabetic Retinopathy Study
(ETDRS) [21]. The ETDRS demonstrated that laser treatment reduces the risk of mod-
erate vision loss by 50% (30–15%) at 3 years. As one considers other treatments, it is
worthwhile to consider that the ETDRS showed reduction in vision loss with as much
as 3 years of follow-up. This demonstration of the long-term benefit of laser treatment
cannot be ignored. Nevertheless, the prevailing thought has been that laser treatment
effectively reduces the risk of vision loss, but laser is not effective at improving vision.
Yet it must be noted that many of the patients in the ETDRS study had good visual
acuities, and 85% of the patients had vision better than 20/40 [21]. This stems from the
fact that the study was not designed originally to demonstrate visual improvement from
laser. To investigate this question of vision improvement from laser treatment, a subset
of 114 eyes in the ETDRS was examined. These eyes had definite center thickening
on photographs, visual acuity worse than 20/32, and mild to moderate nonproliferative
retinopathy at baseline. It was found that laser treatment led to a median change from
baseline visual acuity of +4 letters at 2 years and that 29% improved ten or more letters
[22]. Thus, laser treatment reduces the risk of vision loss and, in some cases, can lead
to vision improvement. Since the ETDRS, laser treatment has been the gold standard to
which new treatments must be compared.
In addition to laser, intravitreal triamcinolone is a commonly used treatment for DME.
The rationale and evidence supporting its use is important to touch upon. It is known
that inflammation can lead to vascular permeability through leukocyte-mediated mecha-
nisms [23]. These mechanisms involve the increased expression of leukocyte adhesion
proteins such as intercellular adhesion molecule-1 (ICAM-1) and CD18. Corticosteroids
can reduce inflammatory signals that lead to vascular permeability as well as reduce
the expression of VEGF [24, 25]. These effects of corticosteroids form the basis for
the use of intravitreal triamcinolone as a treatment for DME. Gillies et al. conducted a
randomized clinical trial in which 69 eyes were treated with 4 mg of intravitreal triam-
cinolone or a placebo injection of subconjunctival saline [26]. All eyes entered into the
study were considered to have DME that persisted or recurred despite previous laser
treatment. Eyes received additional injections every 6 months as needed. After 2 years,
it was found that 56% of the treated eyes gained five or more letters compared to 26%
of the placebo eyes. The most concerning side effects were glaucoma and cataract. An
increase of intraocular pressure by 5 mmHg or more was seen in 68% of the treated
eyes vs. only 10% of the untreated eyes. Cataract surgery was performed in 54% of the
treated eyes and none of the untreated eyes. This study showed the potential benefits of
intravitreal triamcinolone, but it did not directly compare this treatment to laser.
A major randomized clinical trial of the Diabetic Retinopathy Clinical Research Network
(DRCR) recently compared laser and intravitreal triamcinolone for the treatment of DME
[22]. Eight hundred and forty eyes received either focal/grid photocoagulation, 1 mg of
intravitreal triamcinolone, or 4 mg of intravitreal triamcinolone. Additional treatments
were given every 4 months for persistent or new edema. This study found that after
2 years of follow-up, laser was superior to triamcinolone in preventing vision loss and
caused less complications. However, the differences in vision were modest. The average
change in visual acuity at 2 years was 1 ± 17 letters for the laser group, −2 ± 18 letters
for the 1-mg triamcinolone group, and −3 ± 22 letters for the 4-mg triamcinolone group.
This statistically significant difference was not caused by steroid-induced cataract; an
analysis of patients that were pseudophakic or without clinically relevant lens changes
did not show a benefit of triamcinolone over laser. Greater than or equal to 15 letters of
improvement was seen in 18% of the laser group, 14% of the 1-mg triamcinolone group,
and 17% of the 4-mg triamcinolone group. Overall, this study emphasized that laser
treatment remains the gold standard of treatment for DME. When considering these
treatments, potential drawbacks are that triamcinolone is limited by complications of
glaucoma and cataract, and both treatments lead to a relatively modest amount of vision
improvement. These issues set the stage for ranibizumab treatment. The use of ranibizu-
mab for DME can avoid the potential complications of triamcinolone while potentially
providing significant vision improvement.
RANIBIZUMAB FOR DME

Ranibizumab is the Fab fragment of a humanized monoclonal antibody that binds all
isoforms of VEGF-A, thereby inhibiting its signaling pathway. To produce ranibizumab,
the portion of an anti-VEGF murine monoclonal antibody that binds VEGF was mass
produced and then altered by affinity maturation [27, 28] (Fig. 2A). Ranibizumab was
originally developed for the treatment of AMD. The MARINA and ANCHOR clini-
cal trials demonstrated that after 2 years of follow-up, ranibizumab prevents moderate
visual loss in approximately 95% of patients [29, 30]. Moderate vision gain was seen in
approximately one-third of patients. While demonstrating the efficacy of ranibizumab
for AMD, these studies also established the safety profile of this treatment. The most
severe complications are endophthalmitis and retinal detachment, which have a risk of
only 1.3% and less than 1.0%, respectively [29]. With the proven safety and efficacy
of ranibizumab for neovascular AMD, it was logical to consider whether ranibizumab
could improve DME.
Nguyen et al. first studied ranibizumab for DME in a nonrandomized clinical trial
involving ten patients [31]. The investigation has been referred to as the READ-1 study
(Ranibizumab for Edema of the mAcula in Diabetes). In this study, each patient received
0.5 mg of ranibizumab at baseline and at 1, 2, 4, and 6 months. One week after the first
injection, the median and mean reductions in foveal thickness were 88 and 130 mm,
respectively. At the study’s primary end point of 7 months, the schedule of ranibizumab
294 Kim et al.
Fig. 2. Ranibizumab and bevacizumab were both created from an anti-VEGF murine mono-
clonal antibody (Anti-VEGF-A MAb). To create ranibizumab (A), the portion that binds VEGF
was inserted into a human FAb framework and mass produced using an Escherichia coli vector
to produce rhuFAb version 1. Through affinity maturation, rhuFAb V1 is modified to increase its
binding ability by approximately 140-fold. The final product is ranibizumab. To create bevaci-
zumab (B), the portion of the murine antibody that binds to VEGF was inserted into a different
humanized Fab variant. This antibody was then mass produced in Chinese hamster ovary (CHO)
cells to produce bevacizumab (courtesy of Genentech, Inc.).
injections led to median and mean reductions in foveal thickness of 261 and 246 mm,
respectively. This was a mean reduction in excess foveal thickening of 85%. While
READ-1 was not a masked, placebo-controlled trial, the visual acuity at 7 months also
improved from baseline with a median and mean of 11 and 12.3 letters gained, respec-
tively. Another study by Chun et al. evaluated five patients treated with 0.3 mg of ranibi-
zumab and another five patients treated with 0.5 mg of ranibizumab [32]. The patients
received injections at baseline, 1 and 2 months. At 3 months, both doses were associated
with an improvement in visual acuity and a decrease in central retinal thickness. The
0.3-mg group gained an average of 12 ± 20 letters, and the 0.5-mg group gained a mean
of 7.8 ± 8.1 letters. For central retinal thickness at 3 months, the 0.3-mg group had an
average decrease of 45.3 ± 196.3 mm, and the 0.5-mg group had an average decrease
of 197.8 ± 85.9 mm. Because of the small sample size, no conclusions can be drawn
about any potential differences of the dosing regimens. Interestingly, for both groups,
the mean amount of improvement in visual acuity fell after 3 months as the patients
were followed out to 6 months, while the mean central retinal thickness continued to
improve from month 3 to 6. With regard to the safety of ranibizumab injections for these
patients, Nguyen et al. found no adverse systemic or ocular side effects. Chun et al.
also did not see adverse systemic side effects, although five of the patients did have
intraocular inflammation that resolved within several weeks. The ranibizumab used in
Change from Baseline in Best Corrected Visual Acuity

10
8
ETDRS letters Read @ 4m
−2
−4
Baseline Month 3 Month 6
RBZ 0.00 3.93 7.24
Laser 0.00 −1.48 −0.43
RBZ+Laser 0.00 1.93 3.80
Fig. 3. Changes in visual acuity from baseline in patients with DME treated in the READ-2
study with ranibizumab, focal/grid laser, or a combination of ranibizumab and laser. The mean
(±standard error of the mean) change from baseline in number of letters read at 4 m at 3 and
6 months was significantly greater for ranibizumab alone vs. focal/grid laser alone. The com-
bination group was not significantly different from the other two groups at either time point.
*P = 0.01; †P = 0.0003 by one-way analysis of variance and Bonferroni post hoc analysis. RBZ
ranibizumab; ETDRS Early Treatment Diabetic Retinopathy Study [33].
the study by Chun et al. has been reformulated since then, with the ranibizumab used in
the READ-1 study and subsequent studies in DME and AMD having not induced any
reported inflammation. Thus, these studies suggested that ranibizumab is safe and can
play a key role in DME. However, the study also raised a question regarding the optimal
dosing schedule for ranibizumab and pointed to the need for a larger, double-masked,
randomized, controlled trial.
The READ-2 study took this next step. READ-2 is a prospective, controlled,
multicenter trial involving 126 patients with DME to be conducted over 36 months, with
the primary end point at 6 months [33]. Subjects were randomized 1:1:1 into three groups:
(group 1) 0.5 mg of ranibizumab at baseline and months 1, 3, and 5; (group 2) focal/grid
laser photocoagulation at baseline and month 3 if needed; and (group 3) a combination
of 0.5 mg of ranibizumab and focal/grid laser at baseline and month 3. Group 2 thus
provided a comparison to the current standard of care. Group 3 was designed because
it has been hypothesized that, in cases of extensive retinal thickening, laser may be
more effective if ranibizumab is first administered to reduce the retinal thickening. In
turn, the more effective laser treatment may then enable less frequent administration of
ranibizumab.
296 Kim et al.
The primary end point for the READ-2 study was the change from baseline visual
acuity at 6 months [33]. Study subjects who received ranibizumab only (group 1) had the
most improvement in visual acuity at 6 months with a mean gain of 7.24 letters (Fig. 3).
This was statistically significant from those that received laser only (group 2), as this
group had a mean loss of 0.43 letters. Those that received both ranibizumab and laser
(group 3) had a mean gain of 3.80 letters, and this was not statistically significant from
group 1 or 2. The mean reduction in excess foveal thickness was 50, 33, and 45% in
groups 1, 2, and 3, respectively. Thus, the OCT measurements showed similar trends
between the groups. However, it should be noted that the laser only group had no
improvement in visual acuity despite a 33% mean reduction in excess foveal thickness.
It is well known that a reduction in macular edema after laser photocoagulation is not
always accompanied by an improvement of visual acuity [34].
The randomized, controlled READ-2 clinical trial demonstrated that ranibizumab
may be superior to focal/grid laser. Nevertheless, this conclusion should be considered
carefully as the follow-up for the study was only 6 months and only included up to two
laser treatments. Patients in the READ-2 study are being followed until month 36. It is
certainly possible that longer follow-up may yield different results in the future, which
was exemplified by the previously mentioned DRCR study comparing focal/grid laser
with intravitreal triamcinolone acetonide [22]. In this study, 4 mg of triamcinolone led to
a greater improvement in mean visual acuity than the laser treated group after 4 months.
But as discussed earlier, the laser group had a superior visual acuity outcome compared
to triamcinolone at 2 years. The differences in visual acuity shifted in favor of the laser
group with longer follow-up. While the results of the READ-2 study are noteworthy,
it will be important to see the results of more extensive follow-up. The larger RISE
and RIDE phase III trials sponsored by Genentech (South San Francisco, CA) evaluate
monthly injections of ranibizumab (0.3 and 0.5 mg) with a 2-year primary end point;
patients in the control arm received sham injections. Rescue therapy with laser photo-
coagulation began at month 3 of these studies. The primary outcome measure for these
studies is the proportion of patients who gain 15 letters in BCVA compared to baseline.
These two studies have completed recruitment and should have completed data collec-
tion for the primary outcome by October 2012.
Yet another consideration highlighted by the READ-2 study is the optimal dosing reg-
imen of ranibizumab for DME. While it was a study with only ten patients, the READ-1
trial had a more aggressive regimen of injections (baseline, 1, 2, 4, and 6 months) com-
pared to the READ-2 study (baseline, 1, 3, and 5 months) [31]. This resulted in an 85%
reduction of excess foveal thickness as compared to the 50% achieved by the READ-2
study. The RISE and RIDE trials may help determine if monthly dosing of ranibizumab
for DME is more effective. Ultimately, it will be important to devise an effective anti-
VEGF treatment that is longer lasting.
PEGAPTANIB FOR DME

Ranibizumab is one of the several anti-VEGF treatments that have been studied for
the treatment of DME. The first anti-VEGF medication that was delivered by intravitreal
injection was pegaptanib, an aptamer that specifically inhibits the VEGF 165 isoform
[35]. Like ranibizumab, pegaptanib was originally developed for the treatment of neo-
vascular AMD and subsequently studied for DME. A phase II study with 172 patients
evaluated the use of pegaptanib (0.3, 1, and 3 mg) for DME compared to sham injections
[11]. Injections were given at baseline, week 6, 12, and then additional injections or
laser treatments were given as needed during the next 18 weeks. The 0.3-mg pegaptanib
group had the best vision results. 0.3 mg of pegaptanib led to a better mean visual
acuity change of +4.7 letters as compared to the sham group with −0.4 letters (P = 0.04).
Additionally, less patients within the 0.3-mg pegaptanib arm received laser as compared
to sham treatment (25 vs. 48%, P = 0.04). These results contribute to the conclusion that
VEGF plays a critical role in the pathogenesis of DME. The weaknesses of this study
are that it did not directly compare pegaptanib to laser treatment alone and had a limited
follow-up period.
BEVACIZUMAB FOR DME

Bevacizumab is another anti-VEGF medication that is being extensively studied for
DME. Similar to ranibizumab and also produced by Genentech (South San Francisco,
CA), bevacizumab is a humanized monoclonal antibody that inhibits all isoforms of
VEGF-A. It is a whole antibody instead of only a Fab fragment (Fig. 17.2B). Bevaci-
zumab is currently approved by the Food and Drug Administration (FDA) for meta-
static colorectal cancer, breast cancer, and non-small cell lung cancer [36]. Although
there have been no large-scale, randomized, ophthalmic clinical trials involving beva-
cizumab, many retina specialists are using this medication as an off-label treatment for
neovascular AMD [37]. The primary motivation for the use of bevacizumab instead of
ranibizumab is the significantly lower cost of bevacizumab. It is reasonable to consider
that bevacizumab may also be used widely for DME if clinical trials demonstrate effi-
cacy for ranibizumab.
The DRCR has completed a phase II clinical trial evaluating bevacizumab for
DME [36]. One hundred and twenty-one patients were randomized to one of five groups:
(A) laser at baseline, (B) 1.25 mg of bevacizumab at baseline and 6 weeks, (C) 2.5 mg of
bevacizumab at baseline and 6 weeks, (D) 1.25 mg of bevacizumab at baseline and sham
injection at 6 weeks, and (E) 1.25 mg of bevacizumab at baseline and 6 weeks with laser
at 3 weeks. Both doses of bevacizumab caused reduction in central retinal thickness, and
within the limits of the study, there was no clear difference between the two doses. The
similar efficacy of these doses has also been found by others [38]. Defining a signifi-
cant response as exceeding an 11% reduction in thickness compared to baseline, about
half of the eyes treated with bevacizumab had a significant response of retinal thick-
ness. While those eyes treated with bevacizumab had a greater reduction in thickness
as compared to laser at 3 weeks, there was no significant difference seen with longer
follow-up out to 12 weeks. The improvement in retinal thickness seemed to plateau or
decrease between the 3- and 6-week visits, suggesting that subsequent injections should
be sooner than 6 weeks. For visual acuity, groups B and C compared with laser, each
had a significant difference of about 1-line greater improvement at 12 weeks. Within the
short-term follow-up of the study, the combination treatment of bevacizumab and laser
did not show any additional benefit compared to the other groups. While there was one
298 Kim et al.
case of endophthalmitis, there were no complications that could clearly be attributed to

the medication. Overall, the study showed the potential efficacy of bevacizumab and
emphasized the need for a phase III trial to study both efficacy and safety.
A report by Kook et al. examined a population of 126 patients with chronic, diffuse
DME followed for 6–12 months after treatment with bevacizumab [39]. In this study,
“chronic” was defined as the presence of DME for more than 12 months. “Diffuse” edema
was defined as thickening that included the fovea and extended to the arcades. All of the
patients had received at least one previous treatment that included: focal laser (62%), vit-
rectomy with internal limiting membrane peeling (11%), and intravitreal triamcinolone
(41%). Eleven percent had more than one focal laser treatment, and about 9% had more
than one triamcinolone injection. Thirty-eight percent of the patients never had focal
laser treatment because the clinician believed that the edema was too severe to respond
to laser or that the source of leakage was too close to the fovea. None of the patients had
received treatment within 6 months of the first bevacizumab injection. Additional beva-
cizumab injections were given as frequently as every 4 weeks if there was improvement
from the prior injection or if there was significant recurrence of edema after injections
were stopped. For the 59 (47%) patients that completed 12 months of follow-up, the mean
number of injections was 2.7. While there was no significant improvement of visual
acuity at 6 months, there was a significant improvement of +5.1 letters for the 47% of
patients that completed 12 months of follow-up. Significant improvements of central
retinal thickness compared to baseline (463 mm) were seen at both 6 months (374 mm)
and 12 months (357 mm). While this study population was heterogeneous and lacked a
control group, the results suggest that bevacizumab may still be beneficial in recalcitrant
cases of DME. Importantly, the study raises the question of what subtypes of DME may
be resistant to a certain therapy.
Soheilian et al. recently reported the results of a randomized trial comparing bevaci-
zumab alone, bevacizumab with triamcinolone, and macular laser treatment for DME
[40]. In this study, 150 eyes were randomized to one of these arms. The primary out-
come was visual acuity at 24 weeks, but patients were followed out to 36 weeks. The
bevacizumab dose was the commonly used amount of 1.25 mg, but it should be noted
that the triamcinolone dose was only 2 mg. Instead of the more typical dose of 4 mg of
triamcinolone, a 2-mg dose was chosen to minimize side effects. For all groups, retreat-
ment was given every 12 weeks if the vision was not better than 20/40, and there was
persistent clinically significant macular edema. Only one injection was given in 72%
of the patients in the bevacizumab alone group. In this group, visual acuity improved
significantly from baseline at all follow-up visits up; at 24 weeks, there was a change
of −0.23 ± 0.22 logarithm of the minimum angle of resolution (log MAR). The bevaci-
zumab with triamcinolone group and the laser alone group did not have a significant
change in vision at 24 weeks compared to baseline. The percentage of patients with a
>2 Snellen lines improvement at 36 weeks was 37, 25, and 14.8% of the bevacizumab
alone, bevacizumab with triamcinolone, and laser alone groups, respectively. The cen-
tral macular thickness decreased significantly in all groups only at the sixth week visit,
and there was no significant difference among the groups. The authors suggested that
bevacizumab alone may be a better primary treatment than laser, although they acknowl-
edge that longer follow-up is needed to demonstrate a lasting benefit over laser. For this
Fig. 4. VEGF Trap-Eye is a fusion protein consisting of all human amino acid sequences.
As shown here, the key domain (A) from VEGF receptors 1 and 2 have been fused (B) with the
Fc portion of human IgG. This protein can penetrate the layers of the retina and binds with high
affinity to all VEGF-A isoforms and placental growth factor more tightly than the native recep-
tors (courtesy of Regeneron Pharmaceuticals, Inc.)
study, it is notable that only one injection was given to 72% of the bevacizumab alone
group. This finding again raises the question as to what is the optimal dosing regimen of
bevacizumab for DME.
VEGF TRAP-EYE FOR DME

VEGF Trap-Eye is another potential treatment on the horizon. It is a 115-kDa recom-
binant fusion protein designed such that the VEGF-binding domains of human VEGF
receptors 1 and 2 are fused to the Fc domain of IgG1 [41] (Fig. 4A, B). In contrast to
ranibizumab, VEGF Trap-Eye has a longer half-life and binds all VEGF-A isoforms as
well as placental growth factor. VEGF Trap-Eye has a binding constant of approximately
0.5 pM Kd, and this is about 140 times that of ranibizumab [42, 43]. It is estimated that
VEGF Trap-Eye has significant intravitreal activity for up to 10 weeks [42]. Thus, the
medication has the potential to be given less frequently than ranibizumab, while perhaps
being more efficacious.
300 Kim et al.
Do et al. evaluated the safety of VEGF Trap-Eye in five patients with DME [44].
A single intravitreal injection of 4.0 mg of the medication was administered, and patients
were followed for 6 weeks. There was no ocular toxicity or systemic adverse events
related to the treatment. Although there were only five patients, there was a median
improvement in visual acuity of nine letters at 1 month and three letters at 6 weeks.
The gain in visual acuity was highest between weeks 1 and 4, and there was less of a
gain after 6 weeks. When excess foveal thickness was examined, it was found that all
five patients showed a reduction. The median excess foveal thickness was 69 mm at
1 month and 74 mm at 6 weeks. Similar to the visual acuity trend, the greatest effect on
excess foveal thickness was seen between weeks 1 and 4. Two of the patients were able
to have a reduction into the normal range that was sustained at 6 weeks. This small pilot
study demonstrated the potential safety and efficacy of VEGF Trap-Eye for DME and
suggested that further investigation is warranted. The phase II study of VEGF Trap-Eye
in DME has finished recruitment; the trial investigates different doses and intervals of
administration of VEGF Trap-Eye compared to laser photocoagulation. It is expected
that detailed results of the 6 and 12 month outcomes will be available in late 2010 and
early 2011.
OTHER CONSIDERATIONS IN THE MANAGEMENT OF DME

Treatment based on subtypes of DME is a consideration that may become more
relevant in the future. Focal/grid laser is considered the gold standard for any type of
DME. However, as exemplified in the above-mentioned study by Kook et al., some
retina specialists think that laser treatment is less effective when there is extensive or
diffuse edema [39]. A criticism of the DRCR study that compared laser with triamci-
nolone [22] is that the study does not compare subtypes of DME. There is potential to
categorize DME more specifically based on the constellation of angiographic findings,
clinical exam, duration, and OCT measurements. Perhaps there are cases of DME that
are more responsive to one particular treatment over another. As these considerations
move forward, it will be important to define what exactly the DME subtypes are such
that effective comparisons can be made; currently, there are no established clinical trial
definitions of DME subtypes. This is emphasized in a report by Browning et al. [45].
While there are many papers using the terms “focal” and “diffuse,” there are varying
definitions for these terms. Browning et al. point out the need to arrive at a consensus
on how to categorize DME subtypes. If DME is to be divided into subtypes, then the
ability to grade the DME needs to be reproducible between clinicians and reading cent-
ers for clinical trials. Until such definitions are determined, one should be careful when
interpreting conclusions about subtypes of DME and suggesting that certain therapeutic
approaches may be more appropriate for certain types of DME.
In addition to subtypes based on angiography or clinical exam, future treatment of
DME could also be stratified by biomarkers. What is it that causes one patient to have
an astonishing improvement from ranibizumab while another patient’s response is only
modest? One possibility is that biomarkers could indicate what level of response a patient
may have to a treatment or whether a different treatment should be considered. There are
numerous potential cytokines at play in DME. As discussed above, ICAM-1 is thought to
have an important role in leukocyte-mediated vascular permeability [23]. A recent report
by Funatsu et al. suggests that vitreous levels of ICAM-1 and VEGF correlate independ-
ently with increased vascular permeability and the severity of DME [46]. Previous reports
have also implicated interleukin-6 (IL-6). IL-6 is a proinflammatory cytokine with mul-
tiple functions. It can be involved in the pathogenesis of uveitis [47], is associated with
breakdown of the blood-retina barrier, and can lead to VEGF expression [48]. After
analyzing aqueous humor samples obtained from 54 diabetic patients during cataract
surgery, Funatsu et al. also reported that aqueous levels of VEGF and IL-6 correlate
with the severity of DME [12]. In addition to VEGF, it is possible that the profile of
other proteins within a patient’s vitreous at a given point in time may affect the sever-
ity of DME and the response to treatment. Analysis of biomarkers may have a role in
the management of DME, especially as treatments with different mechanisms of action
become established. Nevertheless, care should be taken when interpreting such studies
as an elevated cytokine level does not necessarily prove that there is a role for it in the
pathophysiology of DME. If the receptor for the cytokine is downregulated or if a solu-
ble, inhibitory receptor is present, then the measured cytokine level may not have the
expected effect [49].
Another potentially important consideration is the balance between VEGF angiogenic
and antiangiogenic isoforms. Through differential splicing, an antiangiogenic VEGF-
A isoform called VEGF165b can be produced. VEGF165b has a different C-terminal
amino acid sequence from angiogenic forms of VEGF [50]. It inhibits angiogenesis by
binding to, but not activating, VEGF receptor 2. While studying colonic carcinoma cells,
Varey et al. found that bevacizumab inhibited the growth of cells predominantly express-
ing VEGF 165, while those cells predominantly expressing VEGF 165b were resistant to
treatment with bevacizumab [51]. Perrin et al. have found that under normal conditions,
the eye expresses VEGF165b and other potentially antiangiogenic isoforms of VEGF
[52]. They have suggested that a shift in the balance of antiangiogenic and angiogenic
isoforms of VEGF occurs in diabetic retinopathy. One would expect that patients with
DME would predominantly have the angiogenic isoforms of VEGF but still might have
some expression of VEGF165b. As discussed by Perrin et al., it is not known whether
current anti-VEGF treatments also target VEGF165b, potentially limiting their own effi-
cacy. Therefore, the levels of angiogenic vs. antiangiogenic VEGF isoforms could serve
as biomarkers that would predict the response to anti-VEGF treatment.
COMBINATION TREATMENT FOR DME

While ranibizumab and triamcinolone have been compared to laser treatment, it is
possible that combination laser treatment may be superior to any of these individual treat-
ments. As discussed with the READ-2 trial [33], laser may be more effective and provide
longer lasting benefit after an agent has been given to temporarily reduce the macular
edema. When the combination of ranibizumab and laser was studied by the READ-2
trial at 6 months, the improvement in BCVA was not statistically different from the
ranibizumab alone group or the laser alone group. However, as the follow-up period was
short at the primary end point in the READ-2 study, it is worthwhile to further inves-
tigate combination treatments that attack DME with complimentary mechanisms. The
DRCR has completed enrollment for a trial comparing combination treatments.
302 Kim et al.
The mentioned DRCR protocol compares four groups: (A) sham injections plus laser,
(B) 0.5 mg of ranibizumab followed by laser, (C) 0.5 mg of ranibizumab followed by
deferred laser, and (D) 4 mg of intravitreal triamcinolone followed by laser [53]. For groups
A, B, and D, the laser treatment occurs 3–10 days after the injection. For group C, there
is no laser during the first 24 weeks. After 24 weeks, patients within this group receive
laser treatment if there has been no improvement from the last two injections and there
is macular edema for which laser would be indicated. The primary outcome is the visual
acuity after 1 year of follow-up. With this study design, the trial may provide a more
definitive answer regarding the potential benefit of combination therapy for DME.
DME AND QUALITY OF LIFE

On a separate note from the details of VEGF mechanisms and the pathogenesis of
DME, clinicians must continuously listen to the visual needs of each individual patient.
Recommendations based on clinical trial data are based primarily on visual acuity out-
comes. Visual acuity measurements are not necessarily always the most comprehensive
means of quantifying how DME may affect a patient’s daily visual needs and emotional
well-being. One must ask if intensive treatments are actually making an improvement
on the patient’s visual needs and not just the patient’s visual acuity measurements. Such
visual needs may include the patient’s ability to read, to pick an item off the shelf at
a grocery store, to interact socially with others, and to perform well at work. It is not
surprising that past reports have shown an association between diabetic retinopathy and
psychosocial well-being [54–56]. The National Eye Institute 25-Item Visual Function
Questionnaire (NEI-VFQ-25) is a questionnaire that can assess the impact that an eye
disease can have on quality of life [57]. The NEI-VFQ-25 has been validated and used
for different eye diseases [58–63]. Recently, Bressler et al. have shown that treatment
of neovascular AMD patients with ranibizumab positively affects the NEI-VFQ-25
scores at 24 months [64]. Such data supports the use of ranibizumab for neovascular
AMD patients and demonstrates how qualify-of-life measurements can be used within
clinical trials. The NEI-VFQ-25 has utility as a measurement of central visual function
in patients with diabetes [60, 63]. However, there is limited literature on how visual
function is specifically affected by DME. With a group of 33 patients, Hariprasad has
shown that patients with DME can have NEI-VFQ-25 scores similar to patients with
AMD [65]. Lamoureux has used the vision-specific functioning scale (VF-11) to show
that patients with proliferative diabetic retinopathy (PDR) and vision-threatening dia-
betic retinopathy (VTDR) have difficulty with vision-specific daily activities [66]. In
this study, VTDR was defined as severe nonproliferative retinopathy, PDR, or macular
edema within 500 mm of the foveal center, or focal laser scars at the macula. Of the
357 study participants, only 5% had macular edema, and this was determined by pho-
tographs and not by clinical exam. There is a need for further studies demonstrating the
relationship between DME and vision-related quality of life. As future clinical trials are
developed for DME, it will be important to determine if new treatments positively affect
a patient’s quality of life. Lastly, considerations of quality of life should include low-
vision referrals as part of the management regimen. The sometimes overlooked benefits
that a patient may have from an evaluation by a low-vision specialist should be recog-
nized. While improved anti-VEGF treatments are on the forefront, a low-vision referral
for the patient with significantly decreased vision from refractory DME can be helpful
and improve their quality of life.
CONCLUSIONS
There is ample evidence that VEGF plays a critical role in the pathogenesis of
DME. Recent clinical trials, such as the READ-2 study and early studies with VEGF
Trap-Eye, have demonstrated that anti-VEGF therapy can be effective for DME [33].
Importantly, evidence suggests that such treatment may be more effective than the cur-
rent gold standard of focal/grid laser photocoagulation. As anti-VEGF therapy for DME
becomes more established, one can expect that ranibizumab and bevacizumab may be
used by practitioners for DME; currently, there is no clinical trial demonstrating that
one medication is inferior to the other. The optimal dosing schedule for these treatments
is unclear, but additional information will be forthcoming to help resolve this issue.
Depending on the results of further clinical trials, the use of these anti-VEGF treatments
in combination with laser or other therapies is a possible trend that will emerge. There
are many reasons to be optimistic about these new treatment regimens for DME. Nev-
ertheless, one limitation of current anti-VEGF therapies is the requirement of frequent
dosing. If a safe and long-lasting anti-VEGF therapy is developed, then it would be
especially effective in reducing the societal burden of DME.
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18
Neurodegeneration, Neuropeptides,
and Diabetic Retinopathy
Cristina Hernández, Marta Villarroel, and Rafael Simó
CONTENTS
Introduction
Neurodegeneration as an Early Event in the Pathogenesis of DR
In Vivo Experimental Models to Study Retinal
Neurodegeneration in the Setting of Diabetic Retinopathy
Neuropeptides Involved in the Pathogenesis of DR
Glutamate
Angiotensin II
Pigment Epithelial-Derived Factor
Somatostatin
Erythropoietin
Docosahexaenoic Acid and Neuroprotectin D1
Brain-Derived Neurotrophic Factor
Glial Cell Line-Derived Neurotrophic Factor
Ciliary Neurotrophic Factor
Adrenomedullin
Concluding Remarks and Therapeutic Implications
References
Keywords Adrenomedullin • Angiotensin II • Brain-derived neurotrophic factor • Ciliary neu-

rotrophic factor • Erythropoietin • Glial cell line-derived neurotrophic factor • Neuroprotectin
D1 • Neurodegeneration • Neuropeptides • Pigment epithelial-derived factor • Renin-angiotensin
system • Somatostatin

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308 Hernández et al.
INTRODUCTION
Diabetic retinopathy (DR) is the leading cause of blindness in working-age individuals
in developed countries [1]. The tight control of blood glucose levels and blood pres-
sure is essential in preventing or arresting DR development. However, the therapeutic
objectives are difficult to achieve, and in consequence, DR appears in a high propor-
tion of patients. When DR appears, laser photocoagulation remains as the main tool
in the therapeutic armamentarium. The objective of laser photocoagulation is not to
improve visual acuity but to stabilize DR, thus preventing severe visual loss. When laser
photocoagulation is indicated in time, the risk of blindness is reduced by 90% in the
following 5 years, and the loss of visual acuity is reduced in 50% in those patients
with macular edema [2]. However, timely indication is often passed, and therefore, the
effectiveness of laser photocoagulation in current clinical practice is significantly lower.
In addition, laser photocoagulation destroys a part of the healthy retina, and in conse-
quence, side effects such as loss in visual acuity, impairment of both dark adaptation
and color vision, and visual field loss may appear. Vitreoretinal surgery could be indi-
cated in advanced stages of DR (i.e., hemovitreous, retinal detachment). However, this
therapeutic option requires a skillful team of ophthalmologists, is expensive, and fails in
more than 30% of cases. With this scenario, it seems clear that new treatments based on
greater physiopathological knowledge of DR are needed.
DR has been classically considered to be a microcirculatory disease of the retina due
to the deleterious metabolic effects of hyperglycemia per se and the metabolic pathways
triggered by hyperglycemia (polyol pathway, hexosamine pathway, DAG-PKC pathway,
advanced glycation end products [AGEs], and oxidative stress). However, before any
microcirculatory abnormalities can be detected in ophthalmoscopic examination, retinal
neurodegeneration is already present. In other words, retinal neurodegeneration is an
early event in the pathogenesis of DR which antedates and participates in the microcir-
culatory abnormalities that occur in DR [3, 4]. Therefore, the study of the mechanisms
that lead to neurodegeneration will be essential for identifying new therapeutic targets
in the early stages of DR.
NEURODEGENERATION AS AN EARLY EVENT

IN THE PATHOGENESIS OF DR
The concept of neurodegeneration as an early event in the pathogenesis of DR was
first introduced by Barber et al. [5]. These authors observed that 1 month after inducing
diabetes in rats by using streptozotocin, there was a high rate of apoptosis (TUNEL-
positive cells) in the neuroretina without a significant apoptosis in endothelial cells.
In the same paper, the authors found a higher rate of apoptosis in the neuroretina from
diabetic donors in comparison with nondiabetic donors, even in the case of a diabetic
donor without microvascular abnormalities. These findings have been further confirmed
in experimental models. In addition, it has been demonstrated that, apart from apopto-
sis, another of the features of retinal neurodegeneration is glial activation [3–7]. Our
research group has been able to demonstrate that both apoptosis and glial activation
occur in the retina of diabetic patients and precede microvascular abnormalities [8, 9]
(Fig. 1). This is important because the experimental model in which these findings had
Neurodegeneration, Neuropeptides, and Diabetic Retinopathy 309
Fig. 1. Comparison of the two key elements of neurodegeneration (glial activation and apop-
tosis) between a representative case of diabetic patient without DR and a nondiabetic subject. As
can be seen, neurodegeneration is higher in the retina from the diabetic donor. (A) Glial activa-
tion in the human retina. Glial fibrillar acidic protein (GFAP) immunofluorescence (green) from
a nondiabetic donor (left panel) and a diabetic donor (right panel). (B) Apoptosis in the human
retina. Upper panel: nondiabetic donor (a: propidium iodide, b: TUNEL immunofluorescence).
Low panel: diabetic donor (c: propidium iodide, d: TUNEL immunofluorescence). RPE retinal
pigment epithelium; ONL outer nuclear layer; INL inner nuclear layer; GCL ganglion cell layer.
The bar represents 20 mm.
been observed was the rat with streptozotocin-induced diabetes (STZ-DM). Streptozo-
tocin is a potent neurotoxic agent and is able to produce neural degeneration. Therefore,
neurodegeneration (apoptosis + glial activation) observed in rats with STZ-DM could
be due to STZ itself rather than the metabolic pathways related to diabetes. However,
our observation that these changes also occur in the retina of diabetic patients and the
further demonstration that they are also present in retinal explants cultured with a media
with a high content of AGEs [10] clearly demonstrate that neurodegeneration is a crucial
pathogenic factor of DR.
Neuroretinal damage produces functional abnormalities such as the loss of both
chromatic discrimination and contrast sensitivity. These alterations can be detected by
means of electrophysiological studies in diabetic patients with less than 2 years of dia-
betes duration, that is before microvascular lesions can be detected in ophthalmologic
examination. In addition, neuroretinal degeneration will initiate and/or activate several
metabolic and signaling pathways which will participate in the microangiopathic process,
as well as in the disruption of the blood-retinal barrier (a crucial element in the patho-
genesis of DR). Nevertheless, these metabolic pathways remain to be characterized.
The mechanisms involved in DR neurodegeneration are poorly understood. In addi-
tion, it is unknown which of the two primordial pathological elements (apoptosis or glial
activation) is the first to appear and is, in consequence, the primary event. Nevertheless,
it seems that these diabetes-induced changes occur in the early stages of DR, and that
they are closely related.
IN VIVO EXPERIMENTAL MODELS TO STUDY

RETINAL NEURODEGENERATION IN THE SETTING
OF DIABETIC RETINOPATHY
Since neurodegeneration is an early event in the pathogenesis of DR, it is not necessary
to use animal models with microangiopathic lesions in the eye such us Torii or Goto-
Kakizaki rats. The experimental model currently used to study retinal neurodegeneration in
DR is the rat with streptozotocin-induced diabetes (STZ-DM). In this model, electroretino-
graphic abnormalities are present 2 weeks after inducing diabetes, and the presence of
neural apoptosis and glial reaction can be clearly detected 1 month after starting diabetes.
Retinal ganglion cells (RGCs) are the earliest cells affected and with the highest rate of
apoptosis [11]. However, an elevated rate of apoptosis has been also observed in the outer
nuclear layer (photoreceptors) [12] and in the retinal pigment epithelium (RPE) [13].
As commented above, the interpretation of the results of retinal neurodegeneration
in STZ-DM rats is hampered by the neurotoxic effect of STZ. It is worthy of mention
that pathological changes to the brain after intraventricular injection of STZ are very
similar to the neurodegeneration reported in DR [14]. Therefore, it may be advisable to
use murine models with a spontaneous development of diabetes or at least experimental
models in which diabetes has not been induced by a neurotoxic drug.
Mice have been much less used than rats as experimental models for the study of DR
and retinal neurodegeneration. This is because they are more resistant to the STZ effect
(mice need 3–5 doses of STZ to induce diabetes, whereas in rats, one dose is sufficient),
have lower eyecups, and present a lower degree of lesions in comparison with rats. This
relative protection to developing pathological lesions related to diabetes can be partly
attributed to lower activity of aldose reductase (polyol pathway) in comparison with
rats [7]. Nevertheless, because of its great potential for genetic manipulation, the mouse
offers a unique opportunity to study the molecular pathways involved in disease devel-
opment. Among mice, C57BL/KsJ-db/db is the model that best reproduces the neuro-
degenerative features observed in patients with DR (Fig. 2). C57BL/KsJ-db/db mice
carry a mutation in the leptin receptor gene, and they are a model for obesity-induced
Fig. 2. Comparison of neurodegenerative features in the retina between C57BL/KsJ-db/db

(left panel) and nondiabetic wild-type mice (right panel). ONL outer nuclear layer; INL inner
nuclear layer; GCL ganglion cell layer.
type 2 diabetes. They develop hyperglycemia starting at ~8 weeks of age as a result

of excessive food consumption. It is noteworthy that they present an abundant expres-
sion of aldose reductase in the retina (this is an important differential trait from other
mouse models) [15]. Therefore, C57BL/KsJ-db/db seems appropriate for investigating
the underlying mechanisms of retinal neurodegeneration associated with diabetes and
for testing new drugs.
NEUROPEPTIDES INVOLVED IN THE PATHOGENESIS OF DR

The final result of retinal neurodegeneration is the loss of neurotransmitters such as
dopamine, adrenaline, noradrenaline, acetylcholine, and several neuropeptides, which
may play a critical role in the development of visual deficits in diabetes. However, rather
than focusing on these deficits, it may be more interesting from both the pathophysi-
ological and therapeutic point of views to go over the main factors accounting for this
deleterious effect.
The main neurotoxic metabolite involved in diabetic retinal neurodegeneration
is glutamate. In addition, there is emerging information on the neurotoxicity due to
angiotensin II in the setting of the renin-angiotensin system (RAS) overexpression that
exists in DR. The role of other neurotoxic factors has still to be elucidated. Among the
neuroprotective factors, pigment epithelial-derived factor (PEDF), somatostatin (SST),
erythropoietin (Epo), neuroprotectin D1 (NPD1), brain-derived neurotrophic factor
(BDNF), glial cell line-derived neurotrophic factor (GDNF), ciliary neurotrophic factor
(CNTF), and adrenomedullin (AM) have been the most extensively studied. Neverthe-
less, it should be noted that it is the balance between the neurotoxic and neuroprotective
factors that will determine the fate of the retinal neurons.
GLUTAMATE
Glutamate is the major excitatory neurotrasmitter in the retina and is involved in neu-
rotransmission from photoreceptors to bipolar cells and from bipolar cells to ganglion
cells. However, an elevated glutamate level (which results in excessive stimulation) is
implicated in the so-called “excitotoxicity” which leads to neurodegeneration. The exci-
toxicity of glutamate is the result of overactivation of N-methyl-d-aspartame (NMDA)
receptors, which have been found overexpressed in DM-STZ rat [16]. There are at least
two mechanisms involved in glutamate-induced apoptosis: a caspase-3-dependent path-

way and a caspase-independent pathway involving calpain and mitochondrial apoptosis-
inducing factor (AIF).
Elevated levels of glutamate in the retina have been found in experimental models of
diabetes, as well as in the vitreous fluid of diabetic patients with PDR. However, there is
no information concerning this issue in the earlier stages of DR.
The cause of the high levels of glutamate in DR has been related to a dysfunction of
macroglia in metabolizing glutamate [17]. The reason for this dysfunction seems to be
related to an impairment in the glutamate transporter of Müller cells due to diabetes-
induced oxidative stress [18]. In addition, two enzymatic abnormalities in glutamate
metabolism have been found in the diabetic retina: transamination to alpha-ketoglutarate
and amination to glutamine. The reduced flux through these pathways may be associ-
ated with the accumulation of glutamate [19].
ANGIOTENSIN II
The blockade of the RAS with a converting enzyme (ACE) inhibitor or by using angi-
otensin II type 1 (AT1) receptor blockers (ARBs) is one of the most used strategies for
hypertension treatment in diabetic patients. Apart from the kidney, the RAS system is
expressed in the eye. In the retina, RAS components are largely found and synthesized
in two sites: neurons and glia cells in the inner retina and in blood vessels [20]. The
finding of renin and angiotensin in glia and neurons suggests a role for these molecules
in neuromodulation.
There is growing evidence that RAS activation in the eye plays an important role
in the pathogenesis of DR [20]. Therefore, apart form lowering blood pressure, the
blockade of the RAS could also be beneficial “per se” in reducing the development
and progression of DR. In fact, recent evidence supports the concept that RAS block-
ade in normotensive patients has beneficial effects in the incidence and progression
of DR [21–23].
The major components of RAS have been identified in ocular tissues, and they are
overexpressed in the diabetic retina. Angiotensin II binds and activates two primary
receptors, AT1-R and AT2-R. In adult humans, activation of the AT1-R dominates the
pathological states. AT1-R activation by angiotensin II produced by the retina stimu-
lates several pathways involved in the pathogenesis of DR such as inflammation, oxi-
dative stress, cell proliferation, pericyte migration, remodeling of extracellular matrix
by increasing matrix metalloproteinases, angiogenesis, and fibrosis [20]. In addition,
AT1-R activation by angiotensin II promotes leukostasis (the inappropriate adherence of
leukocytes to the retinal capillaries) and neurodegeneration [20, 24]. Apart from reduc-
ing microvascular disease, there is growing evidence pointing to neuroprotection as a
relevant mechanism involved in the beneficial effects of ARBs in DR. In this regard,
it has been recently reported that candesartan (the ARB with the best diffusion across
the blood–brain barrier) has a neuroprotective effect after brain focal ischemia [25]. In
addition, telmisartan and valsartan inhibit the synaptophysin degradation that exists in
the retina of a murine model of DR [26]. Moreover, valsartan is able to prolong the sur-
vival of astrocytes and reduce glial activation in the retina of rats with hypoxia-induced
retinopathy [27]. Furthermore, mitochondrial oxidative stress associated with retinal
neurodegeneration has been improved using losartan in a model of spontaneously hyper-

tensive rats [28]. Taken together, it seems that neuroprotection is a relevant mechanism
involved in the beneficial effects of ARBs in DR.
PIGMENT EPITHELIAL-DERIVED FACTOR

PEDF is a 50-kDa protein encoded by a single gene that is preserved across phyla
from fish to mammals. It shares homology with the serine proteinase inhibitor (Serpin)
family, but lacks proteinase activity. PEDF was first purified from human RPE cells,
and it was described as a neurotrophic factor with neuroprotective properties [29].
In this regard, it should be noted that intraocular gene transfer of PEDF significantly
increases neuroretinal cells survival after ischemia-reperfusion injury and exces-
sive light exposure. In addition, PEDF protects neurons from glutamate-mediated
neurodegeneration.
Apart from its neurotrophic and neuroprotective properties, there is growing evidence
that PEDF is among the most important natural inhibitors of angiogenesis and that it is
the main factor accounting for the antiangiogenic activity of vitreous fluid where it is
found in abundant quantities [30]. PEDF is responsible for the avascularity of the cor-
nea and vitreous, and under hypoxic conditions, its secretion is decreased. In addition,
elevated glucose downregulates PEDF expression in RPE cells. In 2006, the human
Transport Secretion Protein-2.2 (TTS-2.2)/independent phospholipase A2 (PLA2) x, a
novel lipase critical for triglyceride metabolism (also known in mice as adipose trig-
lyceride lipase [ATGL], desnutrin, and patatin-like phospholipase domain-containing
protein [PNPLP2]), has been identified as a specific receptor for PEDF (PEDF-R) in
the retina [31]. In addition, it has been suggested that antiangiogenic and neurotrophic
activities reside in separate regions of the molecule, thus suggesting that more than one
receptor exists [32].
Therefore, there are enough arguments to propose PEDF as a serious new candidate
for diabetic retinopathy treatment. PEDF can successfully be delivered to the eye by viral
vectors. As an alternative to viral-mediated gene transfer, transplantation of autologous
cells transfected with plasmids encoding for PEDF delivers therapeutic doses of PEDF
to the eye. Another mechanism for delivering PEDF to the eye is to exploit its endog-
enous availability or production. It seems likely that much of the endogenous PEDF in
the eye is bound to extracellular matrix molecules and thus may not be active. Drugs that
release PEDF from these matrix molecules could increase free PEDF to therapeutic lev-
els. In addition, levels of PEDF mRNA and secreted protein could be increased by either
dexamethasone or retinoic acid [33]. Therefore, new strategies for diabetic retinopathy
treatment based on PEDF activation are warranted.
SOMATOSTATIN
SST is a peptide that was originally identified as the hypothalamic factor responsible
for the inhibition of the release of the growth hormone (GH) from the anterior pituitary.
Subsequent studies have shown that SST has a much broader spectrum of inhibitory
actions and that it is much more widely distributed in the body, occurring not only in
Fig. 3. (A) SST immunofluorescence (red ) in the human retina showing a higher expression
in RPE than in the neuroretina from human eye donors. (B) Higher content of SST in the retina
(RPE and neuroretina) of a nondiabetic subject (left panel ) than in a diabetic donor (right panel ).
RPE retinal pigment epithelium; ONL outer nuclear layer; INL inner nuclear layer; GCL ganglion
cell layer. The bar represents 20 mm.
many regions of the central nervous system but also in many tissues of the digestive tract
and in the retina [34]. SST mediates its multiple biologic effects via specific plasma
membrane receptors that belong to the family of G-protein-coupled receptors having
seven transmembrane domains. So far, five SST receptor subtypes (SSTRs) have been
identified (SSTRs 1–5).
Neuroretina and, in particular, the amacrine cells have been classically described as
the main source of SST in the retina. However, we have found that SST expression and
content is higher in RPE than in the neuroretina from human eye donors [8] (Fig. 3A).
Therefore, RPE rather than neuroretina is the main source of SST, at least in humans.
The amount of SST produced by the human retina is significant as can be deduced by
the strikingly high levels found in the vitreous fluid [35, 36]. Apart from SST, SSTRs are
also expressed in the retina, with SSTR1 and SSTR2 being the most widely expressed
[34, 37, 38]. The production of both SST and its receptors simultaneously suggests an
autocrine action in the human retina.
The main functions of SST for retinal homeostasis are the following: (1) SST acts
as a neuromodulator through multiple pathways, including intracellular Ca2+ signaling,
nitric oxide function, and glutamate release from the photoreceptors. In addition, a loss
of SST immunoreactivity occurs after degeneration of the ganglion cells. Therefore, the
neuroretinal damage that occurs in DR might be the reason for the decreased SST levels
detected in the vitreous fluid of these patients. In fact, we have recently found that low
SST expression and production is an early event in DR and is associated with retinal
neurodegeneration (apoptosis and glial activation) [8]. (2) SST is a potent angiostatic
factor. SST may reduce endothelial cell proliferation and neovascularization by multiple
mechanisms, including the inhibition of postreceptor signaling events of peptide growth
factors such as IGF-I, VEGF, epidermal growth factor (EGF), and PDGF [39]. (3) SST
has been involved in the transport of water and ions. Various ion/water transport systems
are located on the apical side of the RPE, adjacent to the subretinal space, and indeed, a
high expression of SST-2 has been shown in this apical membrane of the RPE [37].
In DR, there is a downregulation of SST (Fig. 3B) that is associated with retinal
neurodegeneration [8]. The lower expression of SST in RPE and neuroretina is associ-
ated with a dramatic decrease of intravitreal SST levels in both PDR [35, 36] and DME
[40]. As a result, the physiological role of SST in preventing both neovascularization
and fluid accumulation within the retina could be reduced, and consequently, the devel-
opment of PDR and DME is favored. In addition, the loss of neuromodulator activity
could also contribute to neuroretinal damage. For all these reasons, intravitreal injection
of SST analogues or gene therapy has been proposed as a new therapeutic approach
in DR [41].
ERYTHROPOIETIN
Erythropoietin (Epo) was first described as a glycoprotein produced exclusively in
fetal liver and adult kidney that acts as a major regulator of erythropoiesis. However,
Epo expression has also been found in the human brain and in the human retina [42, 43].
In recent years, we have demonstrated that not only Epo but also its receptor (EpoR) are
expressed in the adult human retina (Fig. 4) [44]. Epo and EpoR mRNAs are signifi-
cantly higher in RPE than in the neuroretina [44]. In addition, intravitreal levels of Epo
are ~3.5-fold higher that those found in plasma [43]. The role of Epo in the retina remains
to be elucidated, but it seems that it has a potent neuroprotective effect [45, 46].
Epo is upregulated in DR [43, 44, 47, 48]. Epo overexpression has been found in
both the RPE and neuroretina of diabetic eyes [43, 44]. This is in agreement with the
elevated concentrations of Epo found in the vitreous fluid of diabetic patients (~30-fold
higher than plasma and ~10-fold higher than in nondiabetic subjects) [43]. Hypoxia is
a major stimulus for both systemic and intraocular Epo production. In fact, high intra-
vitreous levels of Epo have recently been reported in ischemic retinal diseases such as
Fig. 4 Epo (green ) and Epo receptor (red ) immunofluorescence in the retinal pigment
epithelium of human retina. In the merged image (lower panel ), the nuclei have been stained
using DAPI (blue )
PDR [43, 47–49]. In addition, it has been reported that Epo has an angiogenic potential
equivalent to VEGF [48, 50]. Therefore, Epo could be an important factor involved in
stimulating retinal angiogenesis in PDR. However, intravitreal levels of Epo have been
found at a similar range in PDR to that in DME (a condition in which hypoxia is not a
predominant event). In addition, intravitreal Epo levels are not elevated in nondiabetic
patients with macular edema secondary to retinal vein occlusion [51]. Finally, a higher
expression of Epo has been detected in the retinas from diabetic donors at early stages
of DR in comparison with nondiabetic donors, and this overexpression is unrelated to
mRNA expression of hypoxic inducible factors (HIF-1a and HIF-1b) [44]. Therefore,
stimulating agents other than hypoxia/ischemia are involved in the upregulation of Epo
that exists in the diabetic eye.
The reason why Epo is increased in DR remains to be elucidated, but the bulk of the
available information points to a protective effect rather than a pathogenic effect, at least
in the early stages of DR. In addition, Epo is a potent physiological stimulus for the
mobilization of endothelial progenitor cells (EPCs), and therefore, it could play a relevant
role in regulating the traffic of circulating EPCs toward injured retinal sites [52]. In this
regard, the increase of intraocular synthesis of Epo that occurs in DR can be contemplated
as a compensatory mechanism to restore the damage induced by the diabetic milieu. In
fact, exogenous Epo administration by intravitreal injection in early diabetes may prevent
retinal cell death and protect the BRB function in STZ-DM rats [53]. Nevertheless, in
advanced stages, the elevated levels of Epo could potentiate the effects of VEGF, thus
contributing to neovascularization and, in consequence, worsening PDR [52, 54].
The potential advantages of Epo or EpoR agonists in the treatment of DR include neu-
roprotection, vessel stability, and enhanced recruitment of EPCs to the pathological area.
However, as mentioned above, timing is critical since if Epo is given at later hypoxic stages,
the severity of DR could even increase. However, in the case of the eye, disease progression
is easy to follow without invasive investigation and allows timing of the administration of
drugs to be carefully monitored, hopefully resulting in better clinical outcomes.
DOCOSAHEXAENOIC ACID AND NEUROPROTECTIN D1

Delivery of fatty acids such as docosahexaenoic acid (DHA) to the photoreceptors is
important for visual function [55]. DHA is an essential omega-3 fatty acid that cannot
be synthesized by neural tissue but is required as structural protein by the membranes
of neurons and photoreceptors. DHA is synthesized from its precursor, linolenic acid, in
the liver and transported in the blood bound to plasma lipoprotein where it is taken up
in a concentration-dependent manner. Apart from the RPE’s functional integrity, DHA
is the precursor of NPD1, a docosatriene that is required for the functional integrity of
RPE. NPD1 protects RPE cells from oxidative stress, has an antiapoptotic effect, and
inhibits the expression of IL-b-stimulated expression of COX-2 [56, 57]. Therefore,
NPD1 can be postulated as a retinal neuroprotective factor.
BRAIN-DERIVED NEUROTROPHIC FACTOR

BDNF is a neurotrophin expressed in RGCs, Müller cells, and amacrine cells (both
cholinergic and dopaminergic) in the retina [58]. BDNF expression is upregulated by
noradrenaline [59] and is important for the survival of RGCs and amacrine cells [60].
In addition, BDNF acts as a synaptic modulator and is essential for the development of
the dopaminergic network in the rodent retina [61]. Dopaminergic amacrine cell degen-
eration is accompanied by a reduction in BDNF levels in the retina of STZ-DM rats,
and BDNF intravitreal administration can rescue these cells from neurodegeneration
[62]. Furthermore, induction of BDNF expression by adrenergic agonists may provide a
therapeutic approach to retinal neurodegenerative disorders including DR.
GLIAL CELL LINE-DERIVED NEUROTROPHIC FACTOR

GDNF is a 20-kDa glycosylated homodimer belonging to the TGF-b superfamily
that has been recognized for its ability to increase the survival of dopaminergic cells in
animal models of Parkinson’s disease [63].
GDNF signals directly through the cell surface receptors (GFR-a1 and GFR-a2) and
indirectly through the transmembrane Ret receptor, tyrosine kinase [64]. Both receptors
have been identified on embryonic chick RGCs, as well as on amacrine and horizontal
cells [65]. GFR-a2 overexpression has also been found in the epiretinal membranes of
patients with PDR [66]. In addition, high levels of GFR-a2 have been detected in the
vitreous fluid of PDR patients [67]. Finally, several experimental studies support the
concept that GDNF exerts a neuroprotective effect in the retina.
CILIARY NEUROTROPHIC FACTOR

CNTF was first identified as a survival factor in studies involving ciliary ganglion
neurons in the chick eye. CNTF is a member of the IL-6 family of cytokines and acts
through a heterodimeric receptor complex composed of CNTF receptor a plus two
signal-transducing transmembrane subunits, leukemia inhibitory factor receptor b

(LIFR), and glycoprotein gp130 (gp-130) [68]. The CNTF-a receptor is located on
Müller glial membranes [69] and practically on all retinal layers [70]. CNTF is effective
in retarding retinal degeneration in several experimental models of retinitis pigmentosa,
amyotrophic lateral sclerosis, and in Huntington’s disease. CNTF administered as
eyedrops prevents retinal neurodegeneration in STZ-DM rats [71].
ADRENOMEDULLIN
Adrenomedullin (AM) is a multifunctional protein with neuroprotective actions [72].
Administration of AM is neuroprotective in cerebral ischemia through an increase in
astrocyte survival which is attributed to the inhibition of oxidative stress signaling path-
ways [73]. Recently, it has been demonstrated that the AM gene is one of those retinal
genes differentially expressed in the neuroprotection conferred by hypoxic precondi-
tioning [74] and, therefore, could be a new therapeutic target in retinal ischemic diseases
such as DR.
CONCLUDING REMARKS AND THERAPEUTIC IMPLICATIONS

Neurodegeneration is an early event in the pathogenesis of DR and, apart from its
own deleterious effects, participates in the microcirculatory abnormalities that occur
in DR. Whereas the role of neuropathy is essential at early stages of DR, in advanced
stages of DR, microangiopathy will be the main protagonist from the pathophysiological
point of view.
The two capital findings of retinal neurodegeneration are apoptosis and glial activa-
tion. Although the bulk of the information on this issue has been drawn from experimen-
tal models, it has also been demonstrated in the human diabetic retina. The experimental
model currently used for studying retinal neurodegeneration is the STZ-DM rat. How-
ever, STZ has neurotoxic effects, thus hampering our ability to elucidate whether the
neurotoxic effects are due to the diabetic milieu or to STZ. In this regard, the use of
genetically modified mice with spontaneous diabetes such as C57BL/KsJ-db/db seems
to be more appropriate.
Elevated levels of glutamate play an essential role in the neurodegenerative process
that occurs in the diabetic retina, and recent evidence suggests that overexpression of the
RAS system is also an important contributing factor. Among the neuroprotective factors,
PEDF, SST, and Epo seem to play a critical role, but the effect of other neurotrophic fac-
tors such as NPD1, BDNF, GDNF, CNTF, and AM should also be taken into account. In
fact, the balance between neurotoxic and neuroprotective factors rather than the levels of
neurotoxic factors alone is determinant for the presence or not of retinal neurodegenera-
tion in the diabetic eye.
Intravitreal injection permits neurotrophic drugs to effectively reach the retina and
overcome the potential adverse effects related to systemic administration. However, this
is an invasive procedure, with the potential for blinding sequelae such as endophthalmi-
tis and retinal detachment. Although the incidence of these serious complications is low,
cumulative risk exposure may be significant for patients requiring serial treatment over
many years. Therefore, attempts have been made to formulate alternative delivery vehicles
for these drugs. Gene therapy and stem cell therapy are new therapeutic strategies that
permit us to reduce the frequency of injections, thus reducing local side effects. The use
of eyedrops is another potential route of delivery for neurotrophic factors that is currently
being explored. However, clinical trials addressed to the evaluation of both the effectiveness
and safety of these new treatments in arresting or preventing DR are needed.
Finally, it should be underlined that at present, the milestones in DR treatment are
the optimization of blood glucose levels, lowering of blood pressure, and regular fun-
doscopic screening. Therefore, while we are awaiting the results of clinical research
on the use of neuroprotective agents, competent strategies targeting prevention are still
required to overcome this disease which is one of the major causes of blindness in the
Western world.
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19
Glial Cell–Derived Cytokines and Vascular
Integrity in Diabetic Retinopathy
Shuichiro Inatomi, Hiroshi Ohguro,

Nami Nishikiori, and Norimasa Sawada
CONTENTS
Introduction
Structural and Functional Aspects of the Blood-Retinal
Barrier (BRB)
Major Cytokines Derived from Glial Cells Affecting
Tight Junctions of the BRB
A Possible Treatment of the Retinopathy with Retinoic
Acid Analogues
Conclusion
References
Keywords Blood retinal barrier • Inflammatory cytokines • Tight junctions • Retinoic acid
INTRODUCTION
Normal functions and environments of the retina are preferentially performed under
homeostatic conditions which are exclusively maintained by the blood retinal barrier
(BRB) [1, 2]. The BRB is composed of the inner BRB and the outer BRB. Endothelial cells
of the retinal capillaries form the inner BRB, and pigment epithelial cells form the outer
BRB. The structure of the inner BRB is considered to be analogous to that of the blood–
brain barrier (BBB). The capillary endothelial cells of the BRB (hereafter, BRB is used
to indicate the inner BRB) have highly impermeable tight junctions between endothelial
cells composing the biological barrier, the most important cellular apparatus for the regu-
lation of the paracellular passage [3]. In addition, the retinal capillaries are surrounded by
end-feet of glial cells, similar to the BBB (Fig. 1A). It is believed that the glial cells have
been supposed to enhance the barrier function of the BRB whose permeability is known
to be regulated by glial cell–derived cytokines [4–6]. Thus, the retinal endothelial and
glial cells form a functional unit of the biological barrier of the BRB to maintain retinal

325
326 Inatomi et al.
Fig. 1. Schematic representation of TJ. (A) Left panel, in this structural model of TJ, there
are a number of intercrossing TJ strands (depicted as small dots) and three so-called kissing
points of TJ. Right panel, freeze-fracture replica of a TJ. The TJ consists of an anastomosing net-
work of strands that form irregular interstrand compartments and is comprised of a large number
of protein components, including membrane proteins such as occludin and claudins, as well as
cytoplasmic scaffolding proteins such as ZO-1. Scale bar, 50 nm. (B) In polarized cells, TJs are
positioned at the boundary of the apical and basolateral plasma membrane domains to maintain
cell polarity by forming a fence. TJs also seal cells together to generate the primary barrier and
prevent diffusion of solutes through the paracellular pathway. In addition, a certain type of TJ
protein such as occludin is a signaling molecule that has functions in receiving environmental
cues and transmitting signals inside the cells.
homeostatic conditions, and this is often destroyed under pathological conditions, such as
diabetic retinopathy [7, 8], uveitis [9], and other ocular inflammation and ischemia [10].
In diabetic retinopathy, microvascular complications such as macular edema and retinal
neovascularization cause adult blindness of patients with diabetes mellitus [11]. During
the pathological progression of diabetic retinopathy, leukocyte binding to the retinal vas-
cular endothelium detected as an initial event results in early BRB breakdown, capil-
lary nonperfusion, and endothelial cell death [12–15]. Also possible are molecular events
within the initial stage of the diabetic retinopathy, an increase of vascular permeability
caused by the breakdown of BRB, and upregulation of several cytokines and intracel-
lular adhesion molecules. These pathological events merge to contribute to the develop-
ment of retinal ischemia, diabetic macular edema, and neovascularization. In fact, during
this pathological progression of the diabetic retinopathy, several intracellular adhesion
molecules, including sICAM-1 and sVCAM-1 [16, 17], and inflammatory cytokines,
including TNF-a and IL-1b [18, 19], VEGF [17, 20], GDNF [21, 22], and IL-6 [23], and
Glial Cell–Derived Cytokines and Vascular Integrity 327
others, are induced by high levels of glucose in vitro and in vivo, and high concentra-
tions of these mediators are detected in vitreous or plasma specimens from patients with
diabetic retinopathy. Based upon the release profiles of these mediators from pericytes,
it was speculated that TNF-a and IL-1b are initially released and trigger the release of
intercellular adhesion molecule-1 (ICAM-1) and sVCAM-1, which affect leukostasis,
and VEGF, GDNF, and IL-6, which induce vascular permeability during the initial stage
of the diabetic retinopathy [24].
In this chapter, to get a better understanding of the pathophysiological roles of glial
cell–derived cytokines in the diabetic retinopathy, we focus on the structural and func-
tional aspects of the BRB and its modulation by cytokines derived from glial cells under
pathological conditions at an early phase of diabetic retinopathy. In addition, we also
describe the possible treatment and prevention of the retinopathy with retinoic acid ana-
logue that affects the glial cell–derived cytokines.
STRUCTURAL AND FUNCTIONAL ASPECTS

OF THE BLOOD-RETINAL BARRIER (BRB)
The BRB Functional Unit Composed of Glial and Endothelial Cells
The endothelial cells of the BRB form near continuous sheets because of imperme-
able tight junctions (Fig. 1B). They also show no fenestration and few pinocytic vesicles.
These distinctive features of the BRB-forming endothelial cells from capillary endothe-
lial cells in other tissues maintain unique microenvironment essential for functions of
retinal cells. Thus the tight junction of the BRB-forming endothelial cells is a substantial
barrier that strictly regulates the paracellular pathways between the cells. Another unique
feature of the endothelial cells that form the BRB and the BBB is that the capillaries
forming the barrier are almost all ensheathed by vascular feet of astrocytes [25]. The ana-
tomical relationship between the endothelial cells and astrocytes has prompted some of
the researchers to explore a functional relationship between these cells. In fact, the char-
acteristics of endothelial cells of the BBB are induced using chick-quail transplantation.
The transplantation of astrocytes into the avascular space of the anterior eye chamber
showed that the capillaries that invaded the chamber were similar in characteristics to
the BBB-forming endothelial cells. In vitro, a combination of an astrocyte-conditioned
medium and cAMP made a tight junction resistant to the paracellular passage [26–28].
Since paracellular passage between the endothelial cells, mostly provided by the struc-
tural organization of tight junctions, astrocytes are strongly suggested to secrete some
mediators that regulate paracellular passage, in terms of regulation of the tight junctions
between the endothelial cells [29]. These findings strongly suggest an important insight
into the permeability of the BBB between endothelial cells and astrocytes. In other
words, it is feasible that astrocytes regulate the barrier function of the BRB, in terms of
impermeability, in a paracrine manner.
Tight Junctions Between Endothelial Cells Are Substantial Barrier of the BRB
Tight junctions, the most apical component of intercellular junctional complexes,
separate the apex from the basolateral cell surface domains to establish cell polarity (per-
forming the function of a fence) [26–29] (Fig. 2). Tight junctions also possess a barrier
function, inhibiting the flow of solutes and water through the paracellular space [26–29].
328 Inatomi et al.
Fig. 2. Glial cell as a main component of BRB. (A) Schematic presentation of BRB. Note
that cytoplasm of glial cell associates both with neural cell and capillary endothelium (open cir-
cles). (B) BRB is a biological unit comprised of specialized endothelial cells firmly connected by
intercellular TJs and the endothelium-surrounding glial cells. Glial cell–derived cytokines such
as VEGF and GDNF closely associate with the vascular integrity, which is regulated by modu-
lating the TJ function of capillary endothelium in a paracrine manner. (C) BRB-forming glial
cell expresses GDNF in the murine retina. Glial cell is highlighted by red in the retina, which
is stained with anti-GFAP, a specific marker for glial cell in central nervous system and retina
(a, left panel). GDNF expression shows similar distribution in green, suggesting that glial cell
expresses GDNF protein (B, right panel).
They form a particular netlike meshwork of fibrils created by the integral membrane
proteins, occludin and claudin, and members of the Ig superfamilies JAM and CAR [30].
Several peripheral membrane proteins related to tight junctions, such as ZO-1, ZO-2,
ZO-3, 7H6 antigen, cingulin, symplekin, Rab3B, Ras target AF-6, and ASIP, an atypi-
cal protein kinase C-interacting protein, have been reported [3, 25, 31]. Recently, a new
integral membrane protein tricellulin was also identified at tricellular contacts, which
consist of three epithelial cells and have a barrier function [32].
ZO-1 and ZO-2 can independently determine whether and where claudins are polym-
erized [33]. Thus tight junctions are considered to be a large complex composed of at
least 40 known proteins. Within the tight junction proteins, claudins with 20–27 kDa are
the most indispensable proteins because they are solely capable of forming tight junction
strands. The claudin family consists of 24 members, and, in general, more than two clau-
din members are expressed in epithelial and endothelial cells. Claudins are tetraspam
proteins with a cytoplasmic N-terminus, two extracellular loops, and a C-terminus [30].
They have a PDZ (PSD-95/Dlg/ZO-1) binding motif at their C-terminus which is teth-
ered to a PDZ domain of scaffold proteins such as ZO-1 and ZO-2. Since claudin family
is solely able to form tight junction strands, endothelial permeability, in terms of the
barrier function, depends on claudin expression.
In the endothelial cell forming of the BBB and/or the BRB, expression of claudin-1,
claudin-3, claudin-5, and claudin-12 was identified by immunostaining and Western blot
analyses [31]. Despite four isoforms of claudin being expressed in the BBB, claudin-
5-deficient mice died in the first day after birth [34]. Furthermore, claudin-5 is shown
to be indispensable for the BBB because claudin-5 functions as a barrier against small
molecules. Expression of claudin-5 is regulated by a transcription factor SOX-18 in
endothelial cells [35]. Recently VE-cadherin has been shown to upregulate claudin-5
expression by inhibition of transcriptional factor Fox01 [36]. Claudin-5 is phosphor-
ylated at threonine 207 by PKA [37, 38] and Rho-A [39]. Regarding claudin-3, it has
been reported that the canonical Wnt signal upregulates claudin-3 expression in cultured
mouse brain microvascular endothelial cells, although the signal is very low after birth
[40]. On the other hand, the regulation and functions of the other isoforms of the claudin
family expressed in the BBB are yet unknown.
MAJOR CYTOKINES DERIVED FROM GLIAL CELLS AFFECTING

TIGHT JUNCTIONS OF THE BRB
As major cytokines involved in the pathogenesis of the diabetic retinopathy, TNF-
a, IL-1b, VEGF, GDNF, and IL-6 have been identified and characterized as described
below. These cytokines were identified within vitreous specimens and their concentra-
tions were significantly elevated in diabetic retinopathy [16–23].
TNF-a
TNF-a, a multifunctional proinflammatory cytokine belonging to the tumor necrosis
factor (TNF) superfamily, is mainly secreted by macrophages and binds and functions
through its specific receptors TNFRSF1A/TNFR1 and TNFRSF1B/TNFBR. Function-
ally, TNF-a is involved in the regulation of a wide spectrum of biological processes,
including cell proliferation, differentiation, apoptosis, lipid metabolism, and coagula-
tion. TNF-a has also been implicated in a variety of diseases, including autoimmune
diseases, insulin resistance, and cancer [41, 42]. In diabetic retinopathy, TNF-a is iden-
tified as playing a role in promoting angiogenesis by altering endothelial cell morphol-
ogy and stimulates mesenchymal cells to generate extracellular matrix proteins [43–45].
The susceptibility to diabetic retinopathy has been associated with the TNF-a gene pol-
ymorphism and expression of HLA-DR3 and HLA-DR-4 phenotypes [45]. As a possible
330 Inatomi et al.
contribution of TNF-a in the pathogenesis of the diabetic retinopathy, TNF-a induces

adhesion of leukocytes to vascular endothelium by mediating increased production of
adhesion molecules, such as ICAM-1 and platelet endothelial adhesion molecule-1
(PECAM-1) [12–16]. TNF-a is also known to affect the tight junctions between epithe-
lium cells, thus increasing the flow of solutes across the epithelium [46].
IL-1b
IL-1b is a member of the interleukin 1 cytokine family. IL-1b and eight other inter-
leukin 1 family genes form a cytokine gene cluster on chromosome 2. This is produced
by activated macrophages as a proprotein, which becomes active through the proteolytic
process by caspase 1 (CASP1/ICE). IL-1b is a pivotal mediator of the inflammatory
response and is involved in a variety of cellular activities, including cell proliferation,
differentiation, and apoptosis [47]. Similar to TNF-a, IL-1b also induces ICAM-1- and
PECAM-1-induced leukostasis during the initial stage of the diabetic retinopathy [12–
16]. IL-1b, in addition to acting directly, induces VEGF [48], TNF-a [49], and PEG2,
and PEG2, in turn, can induce VEGF [50], emphasizing the complex interaction. Thus,
TNF-a and IL-1b can increase vascular endothelial permeability.
VEGF
Vascular endothelial growth factor (VEGF) is a hypoxia-induced angiogenic and
vasopermeability factor which is mainly involved in the pathogenesis of diabetic retin-
opathy by playing a role of leukocyte-mediated breakdown of the BRB and retinal neo-
vascularization [51–55]. Based upon an experimental diabetes rat model, retinal VEGF
levels increase with associated upregulation of ICAM-1 in retinal endothelia cells and
its ligands, the b2-integrins, on the surfaces of peripheral blood neutrophils [56]. These
molecular events result in an increased adhesion of leukocytes, predominantly neu-
trophils, and a concomitant increase in retinal vascular permeability. In experimental
models, the intravitreal injection of VEGF in fact induced the retinal vascular changes
including retinal leukostasis and concomitant BRB breakdown [57, 58]. In turn, these
changes were abolished by the addition of inhibitors of VEGF, ICAM-1, or b2-integrin
[59, 60]. In terms of the effects of VEGF on tight junctions of the BRB, in diabetes, sev-
eral types of advanced glycation end-derivatives (AGEs), which are formed by a nonen-
zymatic reaction under hyperglycemic conditions, increase the expression of VEGF,
and hypoxia induces VEGF expression. These conditions result in the disruption of the
BRB, in diabetic retinopathy, because VEGF affects the expression of claudin-5 [61]
and occludin [62].
GDNF
Glial cell line–derived neurotrophic factor (GDNF) was originally identified as a
neurotrophic differentiation factor for dopaminergic neurons in the central nervous
system and retina, and much has subsequently been learned about the neuroprotec-
tive effects of GDNF [63]. In a series of studies, we demonstrated that BRB-forming
capillary endothelial cells express GDNF family receptor a1, a receptor for GDNF,
and that GDNF enhances the barrier function of tight junctions in cultured endothelial
cells [64]. We also demonstrated that glial cells in the retina show constitutive expres-
sion of GDNF, suggesting that retinal glia potentially regulates the permeability of the
BRB [65]. In addition, AGEs increase the expression of VEGF while simultaneously
decreasing GDNF expression from glial cells [4]. Additionally, they induce apoptosis in
pericytes in diabetic retinopathy. These findings suggest that AGE-mediated phenotypic
alterations of glial cells in hyperglycemia result in an increase of the vascular permeabil-
ity of the BRB in vitro and lead causally to BRB breakdown in the diabetic retina [4].
APKAP12
A-kinase anchor protein 12 (APKAP12) is a putative tumor suppressor linked with
protein A, and protein kinase C serves as a scaffolding protein in signal transduction.
Src-suppressed C-kinase substrate (SSeCKS), the rodent ortholog of human AKAP12,
is identified to be important for mouse brain homeostasis by regulating BBB formation
[66]. Recently, VEGF has been reported to be downregulated by A-kinase anchor protein
12 (APKAP12), which in turn causes upregulation of angiopoietin-1 in glia cells [67].
Thus, it is suggested that APKAP12 may be involved in the BRB formation through
antiangiogenesis and barriergenesis during the retinal development, and its defect can
lead to a loss of tight junction components resulting in BRB dysfunctions.
IL-6
IL-6 is a cytokine that functions in inflammation and the maturation of B cells. IL-6
is primarily produced at sites of acute and chronic inflammation, where it is secreted
into the serum and induces a transcriptional inflammatory response through the IL-6
receptor alpha. The functioning of IL-6 is implicated in a wide variety of inflammation-
associated disease states, such as diabetes mellitus and systemic juvenile rheumatoid
arthritis [47]. Similar to TNF-a, intravitreal injection of IL-6 has been reported to induce
an ocular inflammation by breaking the BRB [68].
A POSSIBLE TREATMENT OF THE RETINOPATHY WITH RETINOIC

ACID ANALOGUES
Retinoic acid (RA) is an established signaling molecule that is involved in a variety
of neuronal functions, such as the development, regeneration, and maintenance of the
nervous system [69, 70]. Such RA signaling is thought be assessed by binding to a tran-
scription factors comprising the heterodimer of the RA receptor (RAR) and retinoic X
receptor (RXR). In each receptors, three genes (a, b, and g) are present, and together,
the heterodimeric pair binds to a DNA sequence termed as a retinoic acid–response
element (RARE). In addition to ligand binding, phosphorylation of the receptors and
recruitment of coactivator or cosuppressors are required for the induction or suppres-
sion of gene transcription [71]. At present, more than 500 genes have been identified as
RA-responsive [72].
Thang et al. reported that RA also plays a pivotal role in the induction of GDNF
expression and its responsiveness in rat superior cervical ganglia [73]. This allows us to
speculate that RA may also enhance GDNF expression in the retina and affect the barrier
332 Inatomi et al.
function of TJ in the BRB resulting in suppression of the vascular permeability. Consist-

ent with this hypothesis, real-time PCR, semiquantitative RT-PCR, and ELISA dem-
onstrated significant upregulation of GDNF and downregulation of VEGF by all-trans
RA (atRA), a RAR pan-agonist and Am580 (4(5,6,7,8-tetrahydro-5,5,8,8-tetramethyl-
2-naphtamido) benzoic acid) in glial cells. In contrast, such effects were not observed
by 9-cis-RA, an RXR agonist, or RAR or RXR antagonists. In addition, RARa agonists
enhanced the expression of glial fibrillary acidic protein (GFAP), an intermediate fila-
ment protein that is thought to be specific for glial cell in central nervous system and
glial cells in the retina (Fig. 2).
We recently demonstrated that GDNF secreted from glia cells plays an important
role in the regulation of vascular permeability of the BRB and the BBB in a biological
unit comprised of capillary endothelial cells and glial cells [5, 6]. As shown in Fig. 3,
recombinant GDNF and RARa stimulants significantly enhanced the TER and inhib-
ited the flux through endothelial cells, which indicates enhancement of the permeability
of the BRB. Furthermore, these effects were affected by the addition of GDNF-specific
siRNA, which selectively silenced the constitutive expressed GDNF in glial cells.
Upon systemic administration of RARa stimulants to a mouse model with diabetic
retinopathy, vascular leakage of the mouse retina was significantly reduced (Fig. 4).
Taken together, this RARa-mediated enhancement of the barrier function of the BRB is
sufficient for significant reductions of vascular leakage and angiogenesis in the diabetic
retina, suggesting that RARa significantly antagonizes the loss of TJ integrity induced
under diabetes. As expected, upon administration with RARa stimulants, the expres-
sion levels of endothelial TJ proteins such as claudin-5, a major determinant of vascu-
lar permeability; occludin; and ZO-1 were markedly increased, indicating that RARa
stimulants regulate barrier functions through modulation of expression of a number
of TJ-associated genes [21]. Thus, it is very likely that RAs upregulate expression of
GDNF in glial cells and GDNF then induces the TJ-associated gene-expression altera-
tions in endothelial cells.
Regarding possible molecular mechanisms of RA-dependent upregulation of GDNF,
it has been reported that RARa transcriptionally may stimulate GDNF expression
through the p300/CREB-binding protein (CBP)–signal transducer and the activator of
the transcription 3 (STAT3) pathway [21]. Consistently, as indicated in Fig. 4, we found
that the treatments with atRA and Am580 remarkably increased the levels of p300/CBP,
STAT3, smad1, Notch, Hes-1, and Hes-5 mRNA in glial cells. To confirm this possible
mechanism responsible for the RAs-mediated GDNF upregulation, a ~1.8 kb putative
promoter fragment including the transcription initiation codon was isolated and made
into a deletion mutant (~1.2 kb) that lacked putative p300-binding motifs for promoter
assay. atRA and Am580 significantly enhanced the promoter activity of GDNF, whereas
a deletion mutant showed a marked decrease of the promoter activities. Furthermore,
p300 was selectively recruited to the GDNF promoter after treatments with RAs, indi-
cating that the expression of GDNF is exclusively regulated through the recruitment
of an RARa-driven trans-acting coactivator to the ~1.8 kb 5¢-flanking fragment of the
GDNF promoter.
Fig. 3. Glial cell–derived cytokines regulate the vascular permeability in vitro. (A) Semi-
quantitative RT-PCR analysis showing that expression of GDNF and VEGF is modulated in
human astrocytes after treatments with 100 nM atRA and 10 nM Am580. RAs such as atRA and
RARa stimulants Am580 upregulate GDNF mRNA expression and conversely decrease VEGF.
(B) atRA and Am580-mediated gene-expression alteration is sufficient to promote endothelial
barrier function. Primary cultures of bovine brain microvascular endothelial cell were grown to
confluence on transwell semipermeable membranes (pore size, 0.4 mm). In our coculture experi-
ments, glial cells cultured in the lower chamber of the transwell were treated with 100 nM atRA
or 10 nM Am580 for 8 h and cocultured with endothelial cells that were grown to confluence
on transwell membranes in the upper chamber. Transendothelial electrical resistance (TER) was
measured using an EVOM voltohmmeter, and electric resistance was expressed in standard units
of W cm2. Paracellular tracer flux was measured by applying [14C]-mannitol at 1 × 105 dpm/well
and [14C]-inulin at 5 × 105 dpm/well onto an endothelial monolayer in the apical compartment,
and the samples were collected from the basolateral compartment in a time-dependent manner.
Radioactivity of [14C] was counted by scintillation counter. Group 1: cells treated with vehicle
only; Group 2: cells treated with atRA; Group 3: cells treated with Am580. #: p < 0.05, vs. cells
treated with vehicle.
CONCLUSION
In this chapter, we described the BRB under physiological and diabetic conditions.
Three conclusions reached are as follows: (1) The BRB is composed of glia and endothe-
lial cells. The relationship between these cells is deeply functional as well as anatomical.
(2) The barrier function of endothelial tight junctions, in terms of permeability of the
BRB, is predominantly regulated by cytokines derived from glial cells. This fact clearly
shows that glial cells are a promising therapeutic target of diabetic retinopathy, even at an
334 Inatomi et al.
Fig. 4. RARa-mediated phenotypic transformation of glial cells antagonizes the loss of

TJ integrity induced under diabetes. C57BL/6 male mice (5 weeks old) were intraperitoneally
injected with 40 mg/kg streptozotocin for 5 consecutive days. Fourteen weeks after the verifica-
tion of diabetes, mice were treated with 1.0 mg/kg atRA every day or 3.75 mg/kg Am580 every
other day for 1 week. To examine the leakage of retinal vessels, we injected 50 mg/kg fluorescein
isothiocyanate (FITC) dextran dissolved in saline into mice via the vena cava, and the mice were
sacrificed and the bilateral eyes enucleated 5 min after the FITC injection under general anesthe-
sia. FITC concentration was measured using right eye. Left eyes were flat mounted, and the FITC
dextran–perfused retinas were analyzed by laser-scanning confocal analysis. To provide a quanti-
tative control, the FITC concentration in cardiac blood of each mouse was calculated. (A) Blood
sugar (BS) and urinal sugar (US) were increased in diabetic mice. US was assessed as follows:
score 0, negative (−); score 1, slightly positive (±); score 2, weakly positive (+); score 3, moderately
positive (++); and score 4, strongly positive (+++). Note that RAs did not affect these parameters,
indicating evidence that RA is not a drug for diabetes. (B) Western blot analysis to demonstrate
the increase of GDNF and decrease of VEGF expression in the mouse eye by the treatment of
RAs. (C, D) FITC leakage from diabetic retina was assessed by quantification of FITC (C) and
laser-scanning confocal microscope (D). FITC leakage is clearly observed in diabetic mice; how-
ever, phenotypic alterations mediated by RARa were sufficient for inhibiting the vascular leak-
age to maintain vascular integrity in the retinal microenvironment. Scale bars, 100 mm. Group 1:
control animals; Group 2: diabetic mice without the treatment; Group 3: atRA-treated diabetic
mice; and Group 4: Am580-treated diabetic mice. *: p < 0.05, vs. control animals; #: p < 0.05, vs.
animals treated without RAs.
early phase of the disease. (3) RAs are promising candidates to prevent the progression
of diabetic eye diseases, including retinopathy. It is worthy of mention that RAs down-
regulate VEGF expression in glial cells.
Lastly, we hope that many researchers focus their attention on the regulation of tight
junctions of the BRB from the viewpoints mentioned above. In particular, since
tight junctions of the BRB-forming endothelial cells are regulated by cytokines in a
paracrine manner, mechanisms of cytokine secretion from glial cells should be eluci-
dated to develop a new rational therapy of diabetic retinopathy.
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20
Impact of Islet Cell Transplantation on Diabetic
Retinopathy in Type 1 Diabetes
Iain S. Begg, Garth L. Warnock, and David M. Thompson
CONTENTS
Introduction
What Is the Association Between Glycemia and the Onset
and Progression of Retinopathy, Macular Edema,
and Proliferative Retinopathy in Type 1 Diabetes?
What Are the Benefits and Risks of Reducing Blood Glucose?
On Average, 3 Years Was Required to Demonstrate
the Beneficial Effect of Intensive Treatment
The Earlier in the Course of Diabetes That Intensive Therapy
Is Initiated, Even Before the Onset of Retinopathy, the Greater
the Long-Term Benefits
Risk Reduction in the Primary Prevention Cohort
Risk Reduction in the Secondary Prevention Cohort
There Was No Glycemic Threshold Regarding Progression
of Retinopathy
The Risk of Hypoglycemia Increased Continuously But Not
Proportionally as the Goal of Normoglycemia Was Approached
Diabetic Ketoacidosis (DKA)
Efforts to Normalize Blood Glucose Are Associated with Weight
Gain in People with Type 1 Diabetes
Connecting Peptide (C-Peptide) Responders Have Less Risk
of Progression of Retinopathy
The Validity of Generalizing the DCCT Results to Patients
with Insulin-Dependent Diabetes Mellitus in the General
Population Was Confirmed
What Are the Long-Term Effects of Intensive Insulin Therapy
on Micro- and Macrovascular Disease?
Effects of Improved Control on Retinopathy Were Sustained
in the Long-Term

339
340 Begg et al.
Intensive Diabetes Therapy Has Long-Term Beneficial Effects

on the Risk of Cardiovascular Disease and Mortality
Quality of Life Measure
“Metabolic Memory”: A Phenomenon Producing a Long-Term
Beneficial Influence of Early Metabolic Control on Clinical
Outcomes
Recent Decrease of Annual Incidence and Prevalence
of Retinopathy
Need for a More Physiologic Glycemic Control Regimen
Effect of Intensive Insulin Therapy on Hypoglycemia
Counterregulation
b Cell Function
Whole Pancreas Transplantation
Effect of SPK Transplantation on Diabetic Retinopathy
Islet Cell Transplantation
Adverse Effects of Chronic Immunosuppression
Effect of Islet Cell Transplantation on Retinopathy
References
Keywords Wisconsin Epidemiologic Study of Diabetic Retinopathy • Diabetes Control and

Complications Trial • Intensive insulin therapy • Diabetes Quality of Life Measure • Metabolic
memory • Pancreas transplantation • Islet cell transplantation
INTRODUCTION
Diabetes Mellitus is a risk factor for other diseases, often termed complications,
which impose a large and expanding healthcare problem. Type 1 diabetes accounts for
about 10% of all cases of diabetes. Currently, there is a global increase in incidence of
3% per year [1], and it is predicted that the incidence will be 40% higher in 2010 than in
1998 [2]. It can be confronted today because of increased emphasis on intensive control
of glycemia and control of blood pressure and lipids. The morbidity of diabetes includes
blindness from retinopathy (the leading cause of new cases of legal blindness in North
America in people in the age group 20–74 years [3]), end-stage renal disease, cardio-
vascular disease, and lower extremity amputations. In any individual, these complica-
tions are markers of the severity of the disease. In type 1 diabetes, amputation and poor
visual acuity are significantly associated with mortality [4]. Epidemiology contributes
to the etiology of type 1 and type 2 diabetes by refining the diagnosis and identifying
and quantifying the risk factors for diabetic complications. A landmark clinical trial and
observational follow-up of the efficacy of medical treatment, the Diabetes Control and
Complications Trial (DCCT) [5]/Epidemiology of Diabetes Intervention and Complica-
tions (EDIC) Study [6], extended the findings of the Wisconsin Epidemiologic Study of
Diabetic Retinopathy (WESDR) [7] to show beyond all doubt that diabetic microvascular
Impact of Islet Cell Transplantation on Diabetic 341
and macrovascular complications can be diminished or modified through the use of

intensive insulin therapy to lower HbA1c concentrations. The study also established a
causal role of hyperglycemia in the development and progression of the complications.
In some centers, annual incidence rates and prevalence of the complications of retinopa-
thy are now decreasing following translation of the DCCT findings into clinical practice.
Despite the benefits of improved blood glucose control in (1) reducing the incidence
and progression of retinopathy, renal disease and neuropathy, (2) diminishing the risk of
cardiovascular disease, and (3) increasing life expectancy, many patients fail to achieve
their glycemic targets. Those who maintain good blood glucose control endure for a life-
time the burden of a rigid lifestyle to avoid hypoglycemia. This chapter focuses on the
relationship between hyperglycemia and retinal microvascular disease and the benefits
and adverse effects of intensive insulin therapy to provide the rationale for pancreas islet
cell transplantation, an evolving treatment aimed at the lowest HbA1c that can be safely
achieved to minimize long-term diabetic complications.
WHAT IS THE ASSOCIATION BETWEEN GLYCEMIA AND THE ONSET

AND PROGRESSION OF RETINOPATHY, MACULAR EDEMA,
AND PROLIFERATIVE RETINOPATHY IN TYPE 1 DIABETES?
Data from the WESDR, initiated in 1979–1980, identified important independent pre-
dictors of the incidence and progression of retinopathy and decreased survival [7, 8].
The study examined a sample selected from 10,135 people consisting of (1) people with
diabetes developing before age 30 and taking insulin (defined as the equivalent of type
1 diabetes) and (2) people with diabetes developing after age 30 either taking insulin
or not taking insulin stratified by duration of disease (defined as the equivalent of type
2 diabetes). A total of 995 persons with type 1 diabetes participated at baseline and at
least one of the four follow-up examinations (including fundus photography) at 4, 10,
14, and 25 years, or died before the first follow-up examination [9–14]. This study popu-
lation underwent examinations that followed a similar protocol, structured interview
about medications, and objective masked recording of retinopathy using seven-standard
field stereoscopic fundus photographs with a validated grading protocol modified from
the Early Treatment Diabetic Retinopathy Study (ETDRS) adaptation of the modified
Airlie House classification of diabetic retinopathy [15, 16] and evaluated for inter- and
intraobserver errors.
With respect to the overall 25-year incidence of any retinopathy (97%), rates of pro-
gression of retinopathy (83%), progression to proliferative retinopathy (42%), improve-
ment in retinopathy (18%), incidence of macular edema (29%), and incidence of clinically
significant macular edema (17%), the strongest most consistent risk factor relationships
throughout the study were with glycemia [10, 14]. In those multivariate models that
included accurate baseline retinopathy severity level and baseline HbA1c, the duration
of diabetes was not an independent risk factor for progression [17, 18]. The finding of
a stepwise relationship between increasing HbA1c levels and increase in progression
of retinopathy suggested a possible benefit in the reduction of risk of progression of
retinopathy by lowering blood glucose at any level of hyperglycemia found within the
population, at any time during the course of diabetes and at any level of severity before
the onset of proliferative retinopathy [19].
342 Begg et al.
Preliminary reports of small randomized controlled clinical trials of glycemic

control recorded that after 8–12 months of follow-up, the frequency of deterioration of
background retinopathy was greater in the group treated with an insulin pump than in
the conventionally treated group [20, 21], especially in patients with the best glycemic
control [20]. However, after 2 years of treatment, improvement of retinopathy was
more frequent among patients treated with continuous subcutaneous insulin infusion
(CSII) than among patients treated conventionally, although the difference was marginal
[22–24]. The results of these studies and the findings of the WESDR prompted the
need for larger longer controlled clinical trials of treatment in type 1 diabetes to provide
unequivocal evidence as to whether or not intensive glycemic control aimed at lower
levels of glycemia would reduce the development and progression of retinopathy.
The Stockholm Diabetes Intervention Study (SDIS) evaluated the effect of intensified
(mean HbA1c 7.1%) compared with standard treatment (mean HbA1c 8.5%) in people
with type 1 diabetes. After 7.5 years of follow-up, intensified therapy reduced the
risk of progression of nonproliferative retinopathy and retarded the development of
“serious retinopathy” (proliferative retinopathy or macular edema requiring immediate
photocoagulation) by an absolute amount of 25% [25]. The results of this trial and five
other studies of more than 2 years duration were combined in a meta-analysis that
confirmed that intensive therapy reduced progression of diabetic retinopathy in people
with type 1 diabetes [26].
WHAT ARE THE BENEFITS AND RISKS OF REDUCING

BLOOD GLUCOSE?
The DCCT was designed to assess whether an intensive treatment regimen aimed at
achieving blood glucose values as close to the nondiabetic range as possible would affect
the rates of onset and progression, or regression, of early retinal, renal, and neurological
complications over time in insulin-dependent diabetes mellitus when compared with
conventional treatment [5]. The study was performed before other potential confounding
factors such as antihypertensives, blockers of the renin-angiotensin system, and lipid-
lowering agents came into common use. It was a multicenter randomized prospective
study (1983–1989) which involved 1,441 patients in good general health, aged 13–39
years and no severe complications and medical conditions, who were randomly assigned
to receive either conventional or intensive insulin treatment [6]. The primary prevention
group (n = 726) had duration of diabetes less than 5 years, while the secondary preven-
tion group (n = 715) had duration of diabetes 1–15 years.
The conventional therapy group injected insulin without daily adjustments, once
or twice daily and tested either urine or blood glucose daily, and received education
about exercise and diet. The goals were (1) absence of symptoms of hyperglycemia, (2)
absence of ketonuria, (3) maintenance of normal growth development and ideal body
weight, and (4) freedom from frequent or severe hypoglycemia. The intensive therapy
group received treatment with a three or more times daily insulin regimen either by
injection or insulin pump with doses adjusted on the basis of self-monitored blood
glucose measurements (four or more per day) and diet and exercise under the direction
of an expert team. The regimen was adjusted by telephone contact and examinations
were performed monthly [27]. It was determined that hemoglobin A1c (HbA1c) could be
used as a surrogate marker for glycemia [28]. The targets’ were preprandial blood glucose
3.9–6.7 mmol/L and postprandial blood glucose level lower than 10 mmol/L, weekly
blood glucose 3 a.m. measurement higher than 3.6 mmol/L, and HbA1c values within the
nondiabetic range (<6.05%) [29]. The most important primary outcome measures in the
primary prevention cohort were persistent development of any retinopathy (at least one
microaneurysm in either eye) at two consecutive visits scheduled at 6-month intervals,
and in the secondary prevention cohort, sustained (at least two consecutive 6-month
visits) three-step progression of diabetic retinopathy based on scores in both eyes.
At enrolment, the primary prevention group had no photographic evidence of retin-
opathy, visual acuity of 20/25 or better in each eye, and urinary albumin excretion less
than 40 mg/24 h. The secondary prevention group had presence of very mild to moder-
ate nonproliferative diabetic retinopathy (NPDR) in at least one eye and visual acuity of
20/32 or better in each eye [5].
Stereoscopic color fundus photographs of the seven-standard fields were taken every
6 months and graded in masked fashion at the University of Wisconsin Fundus Photo-
graph Reading Center using the protocol of the ETDRS. Grades of the various lesions
were used to construct an interim ETDRS score and a final score [15, 16]. Observations
were performed for a mean of 6.5 years (range 3–9 years) after randomization. The
study was completed by 99% of patients, and the assigned treatment was received 97%
of the time [30].
Over the 9-year period of the study of both the primary and secondary prevention
groups, the average difference in HbA1c between the two groups was statistically dif-
ferent, nearly 2% [29]. The average within-subject mean HbA1c was 9.1% in the con-
ventional group vs. 7.2% in the intensive group. With regard to the distribution of
HbA1c, 31% had a mean HbA1c between 8.5 and 9.49% in the conventional group
vs. 5% of the intensive group. Conversely, among those in the intensive group, 50%
had a mean HbA1c between 6.5 and 7.49% vs. 8% of the conventional group. Almost
exactly 23% of intensive and conventional group subjects had a mean HbA1c between
7.5 and 8.49%.
ON AVERAGE, 3 YEARS WAS REQUIRED TO DEMONSTRATE

THE BENEFICIAL EFFECT OF INTENSIVE TREATMENT
There was initial (“early”) worsening of retinopathy (13.1% of subjects in the inten-
sive insulin group and 7.6% in the conventional treatment group) in the first year of
treatment [31] (except in the group with no retinopathy) similar to reports in the early
feasibility studies [20–24]; then after 3 years, the rate of sustained progression was
lower and the beneficial effects of intensive therapy increased over time for all retin-
opathy groups except moderate NPDR (43/<43), which took longer to demonstrate a
beneficial effect. After 3 years, the magnitude of progression was also less as measured
by the number of steps on the severity scale. These differences increased with longer
follow-up and were associated with higher rates of recovery from progression of three
or more steps on the scale compared to conventional therapy [32].
344 Begg et al.
THE EARLIER IN THE COURSE OF DIABETES THAT INTENSIVE

THERAPY IS INITIATED, EVEN BEFORE THE ONSET OF
RETINOPATHY, THE GREATER THE LONG-TERM BENEFITS
In the primary prevention group on intensive insulin therapy, the 9-year cumulative
incidence of developing at least one microaneurysm in persons with no diabetic retin-
opathy at baseline was 70% in persons with 2.5 or fewer years of duration of diabetes
and 62% in persons with more than 2.5 years duration of diabetes at baseline. The 9-year
cumulative incidence of sustained three-step progression in persons with diabetes dura-
tion of 2.5 years or less without retinopathy at baseline was 7% compared with 20%
when the duration of diabetes was greater than 2.5 years. In the secondary prevention
group on intensive insulin therapy, the 9-year cumulative incidence of sustained three-
step progression in eyes with baseline level of severity 20/<20 to 35/<35 was lower
compared to eyes with retinopathy severity level 43/<43 (11.5–18.2 vs. 43.8%) [33].
RISK REDUCTION IN THE PRIMARY PREVENTION COHORT

The incidence of diabetic retinopathy was reduced by 27% by intensive treatment
over 9 years [33]. The adjusted mean risk of retinopathy sustained progression by three
or more steps was reduced by 76% [29].
RISK REDUCTION IN THE SECONDARY PREVENTION COHORT

Intensive therapy reduced the mean risk of sustained progression by three or more
steps by 65% during the entire study. Progression to severe NPDR or worse was reduced
by 47%. The need for laser treatment of macular edema or proliferative retinopathy was
reduced by 59%. The incidence of clinically significant macular edema in the intensive
therapy group decreased but not statistically significantly [33].
THERE WAS NO GLYCEMIC THRESHOLD REGARDING

PROGRESSION OF RETINOPATHY
There was significant reduction in the risk of retinopathy in an exponential relation-
ship along the entire range of HbA1c in the study [34]. Although the magnitude of
the absolute risk reduction declined with continuing proportional reductions in HbA1c,
there were still meaningful further reductions in risk as HbA1c was reduced toward the
normal range [35]. Each 10% reduction in HbA1c resulted in (a) 35% risk reduction in
sustained onset, (b) 39% reduction in progression of three or more steps of severity, and
(c) 37% reduction for development of severe NPDR or proliferative diabetic retinopa-
thy (PDR) [34]. A simple exponential regression model showed that, in the combined
groups, small differences in any given value of the HbA1c (assumed held constant over
time) correspond to large differences in the cumulative incidence of sustained retin-
opathy progression over a period of many years [35]. The short-term (within-day) vari-
ability in blood glucose around a patient’s mean value had no influence (independent
of conventional therapy or intensive therapy) on the development or the progression of
retinopathy [36]. However, glucose variability should be reduced as much as possible to

limit hypoglycemia unawareness and severe hypoglycemia and maintain quality of life.
Another study using DCCT data found that glycemic instability (SD of glucose profile
set samples for each visit) had little influence on the HbA1c value of a patient [37].
Longer-term variability in HbA1c adds to the mean value in predicting microvascular
complications. A 1% absolute increase in HbA1c SD results in at least a doubling in
retinopathy [38].
A re-examination of previously presented DCCT findings [34] and additional analy-
sis of DCCT data [39] show that virtually all (96%) of the beneficial effect of intensive
vs. conventional therapy on progression of retinopathy and other outcomes is explained
by the reductions in the mean HbA1c levels. The total glycemic exposure (HbA1c and
duration of diabetes) explains only ~11% of the variation in retinopathy risk in the com-
plete cohort. Subjects within the intensive and conventional treatment groups with simi-
lar HbA1c level over time have similar risks of retinopathy progression especially after
adjusting for factors in which they differ [39].
THE RISK OF HYPOGLYCEMIA INCREASED CONTINUOUSLY

BUT NOT PROPORTIONALLY AS THE GOAL OF NORMOGLYCEMIA
WAS APPROACHED
Severe hypoglycemia was three times more common in the intensive therapy group
compared with the conventional therapy group [29]. The rate of severe hypoglycemic
episodes requiring treatment was 62/100 patients years in the intensive insulin treatment
group compared with 19/100 patients years in the conventional arm of the study
[40, 41]. This risk persisted over the duration of the study and was inversely correlated
with the HbA1c. The risk of severe hypoglycemia within the intensive group increased
exponentially as the HbA1c was reduced. Although the risk of severe hypoglycemia
continues to increase at lower HbA1c values with intensive therapy, the risk gradient
flattens substantially [29]. Among all risk factors for hypoglycemia, the dominant pre-
dictor was history of prior episodes of hypoglycemia [40, 42]. Among patients with
HbA1c 6.0%, 21.3 events were predicted per 100 patient years.
DIABETIC KETOACIDOSIS (DKA)

In the DCCT, the risk of diabetic ketoacidosis (DKA) was similar between intensive
and conventional treatment groups (1.8–2/100 patient years), despite lower HbA1c
levels achieved in the intensive group [41]. Among the intensive treatment group, rates
were higher for patients using CSII compared with those on multiple injections (3.09
vs. 1.39 per 100 patient years) [41]. In a meta-analysis evaluating the effect of inten-
sive treatment on the risk of DKA using data from 14 randomized trials, the overall
risk of DKA was greater for patients treated with intensive vs. conventional therapy
largely due to the effect of CSII [43]. In the EURODIAB study, 8.6% of type 1 dia-
betes participants had been admitted to hospital for treatment of DKA in the previous
12 months [44].
346 Begg et al.
EFFORTS TO NORMALIZE BLOOD GLUCOSE ARE ASSOCIATED

WITH WEIGHT GAIN IN PEOPLE WITH TYPE 1 DIABETES
In the DCCT, the incidence of becoming overweight, defined as body mass index
(BMI) ³27.8 kg/m2 for men and BMI ³27.3 kg/m2 for women during the median 6.5
years of follow-up was 41.5% in the intensive therapy group compared to only 26.9%
in the conventional therapy group [41]. The rate of weight gain decreases with time up
to 9 years [45]. Weight gain includes an increase in fat mass. The strongest predictors of
weight gain were higher baseline HbA1c concentration and larger decrements in HbA1c
during intensive therapy from baseline to 1 year. After adjusting for baseline HbA1c,
weight, insulin dose (U/kg), and stimulated C-peptide, weight gain of experimental sub-
jects still remained significantly greater than that of standard subjects [46]. The greater
weight gain in people with severe hypoglycemia suggests that overeating is a causal
factor. Insulin-induced weight gain and heightened risk of obesity, if undesirable, could
diminish long-term compliance with intensive therapy and, if continued, could become
a risk factor for cardiovascular disease.
CONNECTING PEPTIDE (C-PEPTIDE) RESPONDERS HAVE

LESS RISK OF PROGRESSION OF RETINOPATHY
In the DCCT, 303 of 855 patients with type 1 diabetes of duration 1–5 years were
C-peptide responders (C-peptide levels 0.20–0.50 pmol/mL) after ingestion of a mixed
meal [47]. They were randomly assigned to receive either intensive or conventional
treatment. Responders with C-peptide levels >0.50 pmol/mL were excluded from enroll-
ment. Responders receiving intensive therapy maintained a higher stimulated C-peptide
level and a lower likelihood of becoming nonresponders than did responders receiving
conventional therapy. Among intensive therapy patients, responders had a lower HbA1c
value, reduced risk for retinopathy progression, and a lower risk for severe hypogly-
cemia compared with nonresponders [47, 48]. The risk of losing C-peptide responses
to stimulation was reduced by 57% by intensive treatment. The characteristic decline
in b cell function was prolonged to the sixth year after initiation of intensive therapy,
about 2 years beyond conventional therapy. Interestingly, no difference in the develop-
ment of complications was seen between the previous responders and nonresponders
in the conventional treatment group. Intensively treated nonresponders had the high-
est rate of severe hypoglycemia (17.3 episodes per 100 patient years). In the intensive
therapy group, the adjusted odds for retinopathy were 3.2-fold higher for those with
undetectable C-peptide than for those in the sustained C-peptide group. In those receiv-
ing conventional treatment, the odds of retinopathy were no different among C-peptide
groups [48]. These findings support early introduction of intensive therapy to sustain
endogenous insulin secretion which, in turn, is associated with better metabolic control
and lower risk for hypoglycemia and progression of retinopathy. The weaker benefit of
sustained C-peptide secretion in the conventional group compared with the intensive
therapy group on microvascular complications suggests that glycemic control is poten-
tially a more important factor in imparting the benefit of continuing b cell function than
the direct effect of C-peptide secretion itself.
THE VALIDITY OF GENERALIZING THE DCCT RESULTS

TO PATIENTS WITH INSULIN-DEPENDENT DIABETES MELLITUS
IN THE GENERAL POPULATION WAS CONFIRMED
The DCCT cohort was generally similar to IDDM patients in the WESDR in terms of
demography, rates of progression in the conventionally treated group, and association
between HbA1c levels and progression of retinopathy [49].
WHAT ARE THE LONG-TERM EFFECTS OF INTENSIVE INSULIN

THERAPY ON MICRO- AND MACROVASCULAR DISEASE?
The Epidemiology of Diabetes Interventions and Complications (EDIC) study was
a multicenter, longitudinal, observational study designed to use the well-characterized
DCCT cohort of >1,400 patients to determine the long-term effects of former separation
of glycemic levels on micro- and macrovascular outcomes [30]. At the end of the DCCT,
patients in the conventional treatment group were offered intensive therapy, and the care
of all patients was transferred to their own physicians. To assess whether the benefits
of intensive therapy persist, the EDIC study compared the effects of former intensive
and conventional therapy on the occurrence and severity of retinopathy, nephropathy,
neuropathy, and cardiovascular disease after the end of the DCCT. Retinopathy was
evaluated on the basis of centrally graded fundus photographs in 1,208 subjects during
the fourth year after the DCCT ended [50] and 1,211 subjects at year 10 [51].
EFFECTS OF IMPROVED CONTROL ON RETINOPATHY

WERE SUSTAINED IN THE LONG-TERM
The proportion of patients who had worsening of retinopathy including PDR, macular
edema, and the need for laser treatment was lower in the intensive therapy group than in
the conventional therapy group in the 10 years following DCCT closeout [51]. At entry
to the DCCT, the mean HbA1c level in each treatment group was 9.0%. Following 6.5
years of DCCT follow-up, the mean HbA1c levels were 7.3 and 9.0% in the intensive and
conventional therapy groups, respectively. One year after the DCCT closeout, the HbA1c
values had converged. Over 10 years in the EDIC study, the mean HbA1c levels in the
two groups were almost the same (8.0% in the conventional therapy group vs. 7.98% in
the intensive therapy group). Despite similar HbA1c levels over the period of observation
following the DCCT closeout, the ongoing risk of worsening of retinopathy remained
significantly reduced in the intensive compared with the conventional group (“metabolic
memory”). The decrease in HbA1c from approximately 9% to about 8% resulted in
only small reductions in the progression of retinopathy in the conventional group. After
4 years of follow-up in the EDIC study, 49% of the patients in the conventional treatment
group had progression of retinopathy of three or more steps from the DCCT baseline as
compared with 18% of the patients in the intensive therapy group [50]. After 10 years,
60.6% in the conventional group had progressed vs. 35.8% in the intensive therapy group.
An important benefit was the continued significant reductions at 4 and 10 years of the
EDIC follow-up in the adjusted odds of severe NPDR or worse, clinically significant
macular edema, and photocoagulation. However, the difference in retinopathy between
348 Begg et al.
the two groups was becoming less. The odds reductions at 10 years were less than that
observed at 4 years, except for those for photocoagulation. Metabolic memory waned
faster in patients with more severe retinopathy than in those with milder retinopathy. As
the severity of retinopathy increased at the DCCT closeout, the relative benefits of inten-
sive therapy decreased. The risk of further progression of diabetic retinopathy increased
significantly with higher HbA1c levels at DCCT baseline (19% increase in risk per 1%
increase in HbA1c level), higher mean blood pressure at DCCT closeout (11% increase
in risk per 5 mm increase in mean BP), and hyperlipidemia at DCCT closeout (70%
increase in risk for those with hyperlipidemia vs. those without). Eighty-nine percent of
the prolonged effect of DCCT intensive therapy treatment on further retinopathy progres-
sion was explained by the differences in the DCCT mean HbA1c levels, whereas the
EDIC mean HbA1c levels explained only 1.6% of the prolonged intensive effect.
INTENSIVE DIABETES THERAPY HAS LONG-TERM BENEFICIAL

EFFECTS ON THE RISK OF CARDIOVASCULAR DISEASE
AND MORTALITY
A statistically significant benefit of intensive insulin therapy on cardiovascular dis-
ease in the DCCT/EDIC study was observed at year 11 of the EDIC study beyond the
end of the DCCT. Patients who had been randomized to the intensive arm had a 42%
reduction in any cardiovascular disease outcomes and a 57% reduction in the risk of
nonfatal myocardial infarction, stroke, and cardiovascular death compared with those
who had received conventional treatment [52]. As is the case with microvascular com-
plications, it may be that a period of intensive diabetes management plays a greater role
in lessening cardiovascular risk before atherosclerosis is well developed.
QUALITY OF LIFE MEASURE

The Diabetes Quality of Life Measure (DQOL) was designed to evaluate the rela-
tive burden of an intensive regimen among patients with type 1 diabetes enrolled in the
DCCT [53]. During the DCCT, DQOL scores, functional health status, and psychologi-
cal distress were similar between treatment groups. However, among intensively treated
patients, symptoms of psychiatric distress rose with the frequency of hypoglycemic
episodes [54]. Following islet cell transplantation, the risk of short-term clinical con-
sequences found with intensive or conventional insulin therapy (DKA, hypoglycemia,
poor glycemic control) is abolished. Quality of life appears to improve initially after
islet cell transplantation due primarily to a reduced fear of hypoglycemia but declines
with the loss of insulin independence [55].
“METABOLIC MEMORY”: A PHENOMENON PRODUCING

A LONG-TERM BENEFICIAL INFLUENCE OF EARLY
METABOLIC CONTROL ON CLINICAL OUTCOMES
In the DCCT/EDIC studies, “metabolic memory” was used to describe the persist-
ent benefit of reduced progression of retinopathy which outlasted by at least 10 years
the period of good control of blood glucose on DCCT intensive insulin therapy [50].
An early glycemic environment is remembered in the target organs prone to hyperglyc-

emic damage. The benefit is an apparent discrepancy between the level of hyperglycemia
and the incidence and severity of diabetic complications. The duration of the metabolic
memory can be determined by quantifying the continuing differences in the long-term
clinical effects between the original treatment groups. It is not known how long the risk
of progression will be delayed by the memory effect. AGE (Advanced Glycation End
Products) is implicated in diabetic complications and metabolic memory [56, 57]. In the
DCCT/EDIC studies, AGE formation measured in skin biopsy 1 year before DCCT clo-
seout and 10 years later, was significantly lower in the intensive therapy subjects com-
pared with conventional therapy subjects [58], and levels of AGEs were significantly
associated with the 10-year incidence or progression of retinopathy [59].
The induction, maintenance, and “switching off” of the “metabolic memory” (a term
coined by Cahill [60]) were recently reviewed by Ceriello et al. [61]. with evidence
gathered in part from reviews on the pathobiology [62], reactive species [63], mitochon-
drial DNA mutators [64], endothelial dysfunction [65], and AGE [66]. In the hypothesis,
intracellular hyperglycemia induces overproduction of superoxide, a ROS, at the mito-
chondrial level as a possible cause of the metabolic memory of hyperglycemic stress after
glucose normalization. Overproduction of ROS is the first and key event in the activa-
tion of all other pathways involved in the pathogenesis of diabetic complications, such
as the polyol pathway flux, increased AGE formation, activation of protein kinase C, and
increased hexosamine pathway flux. Mitochondrial proteins are glycated in hyperglyc-
emia, and this effect induces mitochondria to overproduce superoxide anion, a condition
that does not depend on glycemic levels. Superoxide and similar reactive species tar-
get nucleic acid, proteins, and lipids/lipoproteins with a long half-life over a prolonged
time. Binding of AGEs to the receptor for AGE called “RAGE” results in intracellular
ROS generation, which promotes the expression of RAGE themselves. Mitochondrial
DNA may influence gene expression and, at the same time, may contribute to an over-
generation of free radicals at the mitochondrial level. These self-maintaining conditions,
leading to a persistent oxidative stress generation independent of the actual glycemic
levels, may contribute to the appearance of the metabolic memory. It was shown in
endothelial cells that reducing intracellular production of free radicals, particularly at
the mitochondrial level, was capable of “switching off” the metabolic memory [67].
Additional explanations such as genetic factors may be needed to explain susceptibility
to severe complications [68].
RECENT DECREASE OF ANNUAL INCIDENCE

AND PREVALENCE OF RETINOPATHY
Several recent cohort studies report decreases in the cumulative incidence of progres-
sion of retinopathy [14], proliferative retinopathy [14, 69, 70], macular edema [10, 70],
and new blindness in a diabetic population [71] with increasing calendar year of diag-
nosis. A meta-analysis, which reviewed rates of progression of diabetic retinopathy to
proliferative retinopathy and/or severe visual loss in a combined population of persons
with type 1 and type 2 diabetes, concluded that rates of these outcomes were lower
since 1985 [72]. Estimates of the annual rates of progression of diabetic retinopathy,
350 Begg et al.
incidence of PDR, improvement of retinopathy, and incidence of macular edema and

clinically significant macular edema for the four periods of the WESDR 25-year inci-
dence study reveal that in contrast to the first 10 years of follow-up when incidence rates
were constant, annualized incidence and progression rates decreased over the past 10–15
years [14]. Also, there was a lower prevalence and incidence of PDR in persons who
were more recently diagnosed with diabetes. Coincident with these declines, there was
gradual improvement in glycemic control. This data suggested the efficacy of improved
glycemic control in reducing the complications of diabetic retinopathy, or else the reason
for the decline in prevalence was explained by death, leading to survival of the healthi-
est. Also, there have been recent reports of lower prevalence of diabetic retinopathy [73],
and proliferative retinopathy [74], compared with previous reports of prevalences in the
WESDR baseline. However, a lower cumulative incidence of proliferative retinopathy
was not found in the Pittsburgh Study [75]. The environment of the population could
have changed because of an upward trend in the initiation of intensive blood glucose
control by physicians as well as improved adherence to treatment by patients because
of translation of the results of the DCCT. A greater percentage of people than before are
monitoring blood glucose four times per day and injecting insulin three or more times
daily. Also taking place is the aggressive management of both renal and cardiovascular
disease with improved control of blood pressure and lipids and use of renin-angiotensin
system blockers. Early blockade of the renin-angiotensin system with either an angi-
otensin-converting enzyme (ACE) inhibitor or an angiotensin system blocker (ARB) did
not slow nephropathy progression but slowed the progression of retinopathy independ-
ently of changes in blood pressure [76].
NEED FOR A MORE PHYSIOLOGIC GLYCEMIC CONTROL REGIMEN

Does it matter by what means a reduction in glycemia is obtained? Risk gradients
for progression of diabetic retinopathy as a function of mean HbA1c are similar for
both intensive therapy and conventional therapy, which suggests that a similar benefit
in the reduction of complications could be obtained with another less intensive, more
effective regimen [34]. Diabetes management is an integral part of daily living and
requires extensive education and lifestyle changes. It is difficult to sustain near-normal
blood glucose continuously even with frequent corrective adjustments of insulin dos-
age. Intensive therapy regimen is extremely demanding and requires substantial effort
and resources by the patients and the healthcare team to try to reach their goal of normal
glycemia. People with type 1 diabetes have the burden of hypoglycemia, ketoacido-
sis, injections three to four times per day, insulin pump manipulations, self-monitoring
blood glucose four times per day, adjusting insulin dose based on glucose level, meal
size and composition, and activity level. In the EDIC 4-year follow-up examination, less
than half of the patients in each group were performing self-monitoring of blood glucose
four or more times per day [50]. It is the increased likelihood of severe hypoglycemia
that reduces the capacity to increase administration of insulin to reach glycemic targets
[77]. Both hypoglycemia and weight gain deter many patients and physicians from aim-
ing at stringent control [78]. Insulin underuse may be adopted by patients attempting to
limit weight gain [79, 80], as well as for manipulation, or because of recklessness, error,
or fatigue in the day-to-day effort of managing diabetes. Failure to adhere to insulin

treatment, expressed as a prescribed vs. dispensed index, was shown to occur in 28%
of a cohort of adolescents and young adults with type 1 diabetes attending a teaching
clinic and was directly associated with failure to take insulin, poor glycemic control, and
acute hospital admissions for DKA [81]. Suboptimal adherence with diabetes treatment
increases healthcare costs [82]. The UK Hypoglycemic Study Group [83] reported an
incidence of severe hypoglycemia of 110 episodes per 100 patient years in patients with
type 1 diabetes who were necessarily treated with insulin for <5 years and an incidence
of 320 episodes per 100 patient years in those with type 1 diabetes for >15 years. The
prospective population-based study of Donnelly et al. [84]. indicated that the incidence
of any and of severe hypoglycemia was about 4,300 and 115 per 100 patient years,
respectively in type 1 diabetes.
Insulin analogues (Insulin Lispro, Aspart, Glulisine, Glargine, and Detemir) were
developed to provide greater efficacy, safety, and convenience compared with conven-
tional human insulin [85]. These are synthetic insulins which have undergone small
changes in amino acid sequence relative to human insulin with more rapid absorption
resulting in pharmacokinetic and pharmacodynamic profiles that mimic the action of
endogenous insulin more closely. Their effect, to reduce postprandial hyperglycemia,
and frequency of nocturnal hypoglycemia help improve adherence with therapy in type
1 diabetes. Detemir has ability to limit weight gain [86]. The combination of both long-
and short-acting insulin analogues leads to significant minor reductions in both HbA1c
and nocturnal hypoglycemia in adults compared with NPH insulin and unmodified
human insulin managed with a multiple injection regimen [87].
The limitations of long-acting insulin has driven the popularity of CSII but with the
drawback of subcutaneous administration, carbohydrate counting, and the continued
need for frequent adjustments of infusion rates based on intermittent self-monitoring of
blood glucose and training in the management. Trials of modern insulin pumps report
decreases of HbA1c 0.6–0.4% compared with multiple daily insulin injections with no
increase in hypoglycemia [88].
Continuous glucose monitoring devices which measure interstitial glucose every
5 min for 72 h show glycemic excursions, permit immediate adjustment of insulin,
and are able to alert patients to a falling glucose level. Alarm system specificity may
not yet be sufficient for reliable use [89]. A meta-analysis of clinical trials comparing
continuous glucose monitoring system with self-blood glucose monitoring in type 1
diabetes showed that the use of continuous monitoring did not significantly reduce
HbA1c levels [90].
In the DCCT in which subjects were carefully selected for adherence with care, and
received management from experts with access to full resources, 44% of patients in the
intensive therapy group achieved HbA1c less than or equal to 6.05 mol/L on one or more
occasions during the study. Fewer than 5% in the intensively treated group was able to
maintain their HbA1c level at less than or equal to 6.05% over the course of the study
[29]. At the upper limit of the nondiabetic range of 6.0%, it is estimated that there is still
some risk of retinopathy progression (risk 0.52/100 patient years) [34]. Over a lifetime,
even a small increment or decrement of mean HbA1c could substantially increase or
decrease, respectively, the risk of progression to more severe complications.
352 Begg et al.
Most countries’ diabetes associations recommend achieving and monitoring an HbA1c

level lower than 7.0%. European guidelines recommend HbA1c <6.5% [91]. The ADA
recommends <7.0% and less than 6.0% for the individual patient [92] in whom it can be
safely achieved. The Canadian Diabetes Association Clinical Practice Guidelines rec-
ommend <7.0% [93].
EFFECT OF INTENSIVE INSULIN THERAPY ON HYPOGLYCEMIA

COUNTERREGULATION
The major limitation of near-normoglycemia is the increased risk of hypoglycemia
due to lower blood glucose levels and/or defective hypoglycemia counterregulation.
The pathophysiology of glucose counterregulation was recently reviewed by Cryer
[94]. Glucagon release which is reduced in early years of diabetes history [95] can-
not be improved in response to hypoglycemia with islet cell transplantation into liver
[96]. Thereafter, catecholamine secretion becomes the most important hypoglycemia
counterregulatory hormone [95, 97], until its secretion is impaired by hypoglycemia
episodes. However, hypoglycemia counterregulation is partly restored by prevention of
severe hypoglycemia and decreases in the incidences of mild hypoglycemia [98, 99].
Tight metabolic control is compatible with mostly intact hormonal hypoglycemia coun-
terregulation for up to 7 years provided there is a low incidence of hypoglycemia [100].
Hormonal counterregulation becomes progressively impaired; even meticulous preven-
tion of insulin-induced hypoglycemia cannot totally prevent this development in type 1
diabetic patients after a diabetes duration of more than 10 years [101].
b CELL FUNCTION
Diabetes is defined by a sole defect—the loss of b cell function below a level that is
adequate to maintain euglycemia. C-peptide is co-secreted with insulin in equimolar con-
centration by the b cell as a by-product of the enzymatic cleavage of proinsulin to insu-
lin. Measurement of C-peptide under standardized conditions provides a sensitive and
clinically valid assessment of b cell function (endogenous insulin secretion) [102]. The
diagnosis of type 1 diabetes can be enhanced with fasting C-peptide below 0.3 mmol/L
or glucagon-stimulated C-peptide under 0.6 nmol/L or high concentration of islet cell
antibodies, although with less sensitivity and specificity [102]. Continuing C-peptide
insulin secretion is important in avoiding hypoglycemia. Stimulated C-peptide levels
>0.2 pmol/mL at diagnosis is a level associated with improved control [47]. Glycemic
control strongly influences the decline in b cell function in type 1 diabetes. The DCCT
identified a “virtuous circle” whereby residual insulin secretion resulted in better glu-
cose control with less hypoglycemia and slower progression to vascular complications;
better glucose control, in turn, prolonged b cell function [47]. The natural course of b
cell destruction is heterogeneous in the decline of C-peptide. Some patients lose b cells
completely soon after the onset of diabetes whereas others retain minute residual b cells
over a long period [103]. In healthy subjects, C-peptide response increases with age
between 19 and 78 years [104, 105]. Age is a determinant of residual insulin production
at diagnosis [105, 106]. Older patients have much higher stimulated C-peptide levels
at the time of diagnosis of diabetes [107], whereas younger patients have a more rapid
decline in C-peptide. As shown in the DCCT and other studies [108], there is clear evi-
dence of clinical benefit from preserved b cell function in patients with type 1 diabetes:
less retinopathy, less neuropathy, and less hypoglycemia with intensive insulin therapy
[47, 48]. Potential direct effects of C-peptide include prevention and amelioration of
diabetic nephropathy, and neuropathy, decreasing microalbuminuria, improved survival
of renal allograft, activation of eNOS with microvasodilatory effect, and activation of
transcription factor [107, 109]. The reason that b cells should persist and enhance insulin
secretion is not clear.
WHOLE PANCREAS TRANSPLANTATION

Pancreas transplantation has a dramatic effect in curing the problems of hypogly-
cemia but with the risk of perioperative morbidity. Whole pancreas transplantation is
chosen principally for the patient with end-stage renal failure who had or plans to have
a kidney transplant. Procedures for whole pancreas transplantation include simultaneous
pancreas-kidney transplantation (SPK), pancreas after kidney transplantation (PAK), and
pancreas transplant alone (PTA). The procedures have been reviewed by Larsen [110]
and by Meloche [111]. The most commonly performed is SPK with enteric drainage and
systemic venous outflow. Among whole pancreas transplant procedures, patient survival
at 1 and 5 years is 95 and 85%, respectively. Graft survival for whole pancreas recipients
is 90, 70, and 45% at 1, 5, and 10 years after transplantation, respectively [112, 113].
Contraindications to transplantation of any type include active malignancy or infec-
tion, psychiatric disease which could decompensate after a large surgery, and subjects’
inability or unwillingness to take immunosuppressant medications regularly. In success-
ful pancreas transplantation, hypoglycemia-induced glucagon secretion and hepatic glu-
cose production are normalized [114]. Common complications and technical failures
include thrombosis, bleeding, leak (6.5%), auto-rejection (12%), and CMV infection
(10%) [112, 113].
EFFECT OF SPK TRANSPLANTATION ON DIABETIC RETINOPATHY

Advances in the technical aspects of SPK transplantation which have gradually
improved patient and graft survival have lead to investigations of the effect of pancreas
transplantation (with normalization or near-normalization of HbA1c) on secondary dia-
betic complications. The results of investigations of the effect of euglycemia on retin-
opathy following pancreas transplant can be broadly subdivided as follows:
1. No benefit [115–124]
2. Limited benefit [125–130]
3. Stable for 5 years [131]
4. Significant benefit in the latest publications [132, 133]
The control group has often been too small to be compared statistically with the
treatment group. Treatment groups have been controlled for immunosuppression (failed
pancreas graft, kidney transplant) or for functioning graft (nontransplanted exogenous
354 Begg et al.
insulin-treated patients with type 1 diabetes). There have been no reports of a beneficial
or adverse effect of immunosuppressives on retinal microvasculature. The inclusion of
a steroid in an immunosuppressive regimen increases the prevalence of cataracts. Stud-
ies on diabetic retinopathy have been difficult to interpret because of the predominance
of advanced proliferative retinopathy with high prevalence of scatter laser treatment.
Candidates for pancreas and kidney transplants are usually persons who are approach-
ing end-stage renal failure or are undergoing renal dialysis after about 22 years duration
of disease. Eyes that worsen develop vitreous hemorrhage, traction retinal detachment,
neovascular glaucoma, or have persistent neovascularization requiring more scatter
laser treatment. It may not be possible to separate the effects of normoglycemia from
those of scatter laser treatment. Normoglycemia has a beneficial effect on reducing the
risk of severe NPDR and early proliferative retinopathy [25, 33]. In a study of the influ-
ence of glycemic control on the initial response to scatter laser treatment in patients with
high-risk PDR, Kotoula et al. [134] reported that good metabolic control (HbA1c < 8%)
before, during, and after treatment was associated with greater regression of prolifera-
tive retinopathy following scatter laser treatment.
An early report from Ramsay et al. [124] evaluated retinopathy using seven-field
stereo fundus photography in 22 subjects (34 eyes) who had undergone successful pan-
creas transplantation and 16 subjects (28 eyes) with failed pancreas transplantation.
In the study group, 10 of 22 patients were blind in one eye, and the average grade of
retinopathy pretransplant was P6 (elevated neovascularization). Both groups had been
treated with scatter laser (44% eyes, study group; 78% eyes, control group). In the
study group, after a follow-up of mean 24 months, 19 eyes (56%) were unchanged
and 15 eyes (44%) progressed by two or more grades (5 were laser-treated) compared
with the control group in which 13 eyes (46%) were unchanged, 14 (56%) progressed,
and 1 (4%) improved. One 16-year-old subject with HbA1c ³ 16% progressed from
mild NPDR to PDR within 6 months of successful pancreas transplantation suggesting
accelerated retinopathy associated with profound reduction in HbA1c. Wang et al. [116]
compared the progress of diabetic retinopathy in 51 subjects with type 1 diabetes who
had undergone successful kidney and pancreas transplantation with 21 subjects who
had undergone successful renal transplant alone. In both groups, the prevalence of scat-
ter laser treatment was 72%. An evaluation was made on a side-by-side comparison and
grading of seven-field stereo fundus photographs taken weeks before transplantation
and again 1 year later. They reported that in the 1 year follow-up, near-normalization
of glycemia (mean HbA1c 6.4%) associated with successful transplantation did not
accelerate retinopathy nor has a beneficial effect on the progression of advanced retin-
opathy. Pearce et al. [131] found that more than 90% of 17 subjects (33 eyes) exam-
ined 5 years after successful SPK had stable retinopathy defined as absence of need
for laser treatment. In this series, 25 of 33 eyes had received scatter laser treatment
prior to transplantation. Marchetti et al. [127] reported a series of 28 PTA (without
controls) followed for 6–24 months with clinical and photographic documentation in
which diabetic retinopathy improved in 58.8%, stabilized in 35.3%, and worsened in
5.9%. Improvement was defined as regression to a lower retinopathy grade in the non-
proliferative group and a significant reduction of retinal lesions in the proliferative
and laser-treated group. Chow et al. [115] examined 46 patients after successful SPK
and 8 patients with failed SPK (functioning kidney). Sixty-eight of 82 eyes (83%) had
undergone scatter or focal laser treatment. Seventy-five percent of eyes in each group
remained stable. In the SPK group, 14% improved and 10% progressed from no dia-
betic retinopathy to NPDR (2 eyes), or progressed from NPDR to active proliferation
(4 eyes), or progressed from inactive to active proliferation (12 eyes). Six eyes devel-
oped macular edema. Koznarova et al. [125] compared 43 normoglycemic SPK patients
with 45 control patients, who either failed SPK or kidney transplants. On the basis of
examinations before and 1 year posttransplantation, the rates of improvement, stabi-
lization, and deterioration in the normoglycemic group were 21.3, 61.7, and 17.0%,
respectively and, in the control group, 6.1, 48.8, and 45.1%, respectively. Almost 80%
of eyes in each group had been treated with laser. Giannarelli et al. [132] followed 48
patients for median 17 months after successful SPK and a control group of 43 patients
with type 1 diabetes. In the NPDR SPK group (12 patients), 42% improved, 25% did
not change, and 33% progressed by one grade. In the laser-treated/proliferative retin-
opathy (LT/PDR) SPK group (36 patients), 97% did not change and one patient (3%)
worsened. In the LT/PDR group, the number of improved/stabilized patients was sig-
nificantly higher in the transplanted group than in the control group. Giannarelli et al.
[133] studied the course of retinopathy in 30 PTA recipients and in 35 nontransplanted
matched type 1 diabetic patients for 30 months. In both groups, the prevalence of laser
treatment and/or proliferative retinopathy was 67%. In the NPDR PTA group, 50%
of patients improved by one grade and 50% showed no change. In the LT/PDR PTA
group, stabilization was observed in 86% of cases, whereas worsening of retinopathy
occurred in 14% of patients. In the NPDR control group, retinopathy improved in 20%
of patients, remained unchanged in 10%, and worsened in 70%. In the LT/PDR control
group, retinopathy did not change in 43% and deteriorated in 57%. Macular edema in
four PTA patients at baseline resolved at follow-up. Despite a relatively short follow-
up, successful PTA positively affected the course of retinopathy. However, one PTA and
one control patient developed neovascular glaucoma. In both of Giannarelli’s studies
[130, 131], examinations were masked. Fundus photographs were graded using the
EURODIAB Study classification of severity of retinopathy.
Studies on the course of diabetic retinopathy following whole pancreas transplanta-
tion have not been designed to investigate the transient early worsening of retinopathy
that was found within 12 months of baseline in the DCCT and in the earlier studies [31].
Such occurrences might be expected in the presence of similar important risk factors
such as higher level of HbA1c before treatment and its greater reduction with treat-
ment during the first 6 months after transplantation (odds ratio 1.6 for each percent
point decrease). Longer duration of diabetes and more severe retinopathy are risk fac-
tors when worsening is measured by the development of soft exudates or IRMA, but not
when defined as progression of three or more steps on the retinopathy scale. One can
also question whether or not the time to recovery from worsening will follow the 50%
recovery rate within 6–12 months found in the DCCT and whether or not subsequent
progression will be found in 50% of the patients. Large decrease in HbA1c is a risk fac-
tor for the development of clinically important outcomes such as severe nonproliferative
retinopathy, proliferative retinopathy, and clinically significant macular edema. In the
DCCT, the long-term benefits greatly outweighed the risk of early worsening.
356 Begg et al.
ISLET CELL TRANSPLANTATION

Successful islet cell transplantation in experimental animals in 1972 [135] introduced
new concepts to avoid complications of whole pancreas graft related to exocrine pancreas
and vascular supply and to allow investigation of pretransplant procedures to reduce
immunogenicity. The technique of islet cell transplantation improved substantially in
2000 with the development of a glucocorticoid-free immunosuppressive protocol which
quickly resulted in exogenous insulin independence with no apparent diabetogenic or
toxic effects and improved graft survival [136]. This treatment became known as the
Edmonton Protocol. In the Edmonton series, insulin independence was achieved with a
transplanted islet cell mass of >9,000 IE/kg of recipient body weight delivered in two
or three infusions from 2 to 4 donors [112, 137]. Markmann et al. [138] confirmed the
efficacy of the Edmonton immunosuppressive protocol in a series of nine transplanted
patients of whom seven achieved insulin independence following either one infusion
(five patients) or two infusions (two patients). An international multicenter trial con-
firmed previous experience with the Edmonton Protocol at single centers [139]. Graft
dysfunction requiring renewal of insulin therapy has been observed with longer follow-
up. Persistent islet function even without insulin independence provides both protection
from severe hypoglycemia and improved levels of glycated hemoglobin [139]. Glucagon
secretion in response to hypoglycemia does not improve with islet cell transplantation as
described with whole pancreas transplantation [96]. Islet cell transplantation is a minor
and safe procedure, performed with local anesthesia via radiologic control of percutane-
ous cannulation of a portal vein. Islet cell transplantation (predominantly allotransplan-
tation) has an initial graft survival (insulin-free) rate of 44% and C-peptide-producing
(but not insulin-free) rate of 80%. Complications include portal vein thrombosis (5%),
bleeding (14%), emergency exploratory laparotomy (8%), liver steatosis (23%), and
mouth ulcers (77%). Patient survival ³5 years after transplant is 90% [112, 113].
ADVERSE EFFECTS OF CHRONIC IMMUNOSUPPRESSION

Islet cell transplantation requires long-term, calcineurin-based immunosuppressives
with the risk of developing nephrotoxicity, infection, and malignancy. New risks intro-
duced by immunosuppression were reviewed by Larsen [110]. The majority of islet
transplant programs use a combination of Sirolimus and Tacrolimus (Edmonton Pro-
tocol) and Mycophenolate Mofetil maintenance immunosuppressives. Usually one or
more induction immunosuppressive agents are used at the time of the first islet infusion
antibody induction therapy [111].
EFFECT OF ISLET CELL TRANSPLANTATION ON RETINOPATHY

As yet, it is unclear what clinical effect an islet transplant will have on secondary
diabetic complications. Lee et al. [140], who clinically examined eight patients at
least 1 year following islet cell transplantation (>5,000 IE/kg recipient body weight),
observed improvement in one patient and no clinical progression of retinopathy in the
others. Ryan et al. [141], who presented results of a 5-year follow-up of clinical islet
cell transplantation, briefly reported that of 47 completed patients, four required laser
treatment or vitrectomy within 5 months of transplantation. A comparison of the efficacy

of intensive medical therapy (intensive insulin therapy, and when indicated angiotensin
blockade, control of lipids and blood pressure to recommended level) with islet cell
transplantation on the progression of microvascular disease, conducted as a prospective
nonrandomized crossover cohort study, showed significant differences on the outcomes
of metabolic control and retinopathy [142, 143]. Progression was defined as the need
for laser treatment or one step or more worsening on the International Disease Sever-
ity Scale [144]. Seven-field stereo fundus photography was performed at baseline and
annual examinations. Multiple (1–4) islet infusions (total 10,000 IE/kg recipient body
weight) were required to induce and sustain insulin independence. Islets were isolated
from pancreas of adult heart-beating cadaver organ donors in the Ike Barber Human Islet
cell transplantation Laboratory at Vancouver Hospital [145]. Sixty-four percent (16 of
25 patients) remain insulin-independent at mean 36 months follow-up. Glucose control
assessed by 3 monthly HbA1c measurements over follow-up 34 ± 17 months (range 6–67
months) improved significantly from mean 8.1 ± 1.2% at entry to mean 7.5 ± 0.9% dur-
ing medical therapy, and significantly from mean 7.0 ± 0.7% at the time of the first islet
cell transplant to mean 6.7 ± 0.7% posttransplant. At baseline, there were 44 eyes with
nonproliferative retinopathy and 41 eyes with proliferative retinopathy of which 39 eyes
had been treated with laser. The follow-up interval was sufficiently long to assess the
outcome of progression of retinopathy. Progression occurred significantly more often in
all subjects in the medical group (10/82 eyes, 12.2%) than after islet cell transplantation
(0/51 eyes, 0%). Considering only subjects who had received transplants, progression
occurred in 6/51 eyes while on medical treatment and 0/51 eyes posttransplant. End-
point determination was not masked, but the decision to treat subjects with laser was
made by retina specialists independently of the study team. This is the first pancreas or
islet transplant study to include a medical control group treated to current standards.
Pancreas islet cell transplantation is an evolving minor procedure for the physiologic
delivery of insulin with the aim of normalization or near-normalization of HbA1c. It
achieves quality of life benefits which accrue for reasons of insulin independence and
the promise of a lower prevalence of complications at a later date, as well as a longer
lifespan.
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Index
A AZ. See Azurocidin

Activating protein-1 (AP-1) Azurocidin (AZ)
MAPK activity, 218 and aprotinin, 110
and NF-κB, 221 BRB permeability, 114, 115
transcription factors, 222 description, 110
Adrenomedullin (AM), 318 inhibition
Advanced glycation end products (AGEs) vascular leakage, 117
and CTGF, PCDR and VEGF, role, 117
diabetic rats, treatment, 269 injection, 114–115
ECM components, 269–270 β2-integrins expression, 109
pericytes, 270 role, VEGF-induced leakage
diabetic complications, role, 201 downstream effector, 116
Age-related macular degeneration (AMD) downstream mediator, 115
choroidal neovascularization, 290 intravitreal injection, 115–116
pegaptanib, 297
ranibizumab, 293
AGEs. See Advanced glycation end products B
A-kinase anchor protein 12 (APKAP12), 331 Basal lamina (BL) thickening
AM. See Adrenomedullin knockout mice
AMD. See Age-related macular degeneration CTGF protein expression, 272
Angio-fibrotic switch, PDR retinal capillaries, 272, 273
angiogenesis, 275–276 PCDR, 268–270
degree of fibrosis, 273–274 TGF-β, 271–272
endothelial cells, 273 VEGF role, 270–271
inhibition, 277 Basement membrane, 264
intravitreal inhibitors, 276 BDNF. See Brain-derived neurotrophic factor
mean levels, 275 Bevacizumab
neovascularization, 274–275 chronic, diffuse edema, 298
PVR patients, 274 Diabetic Retinopathy Clinical Research Network
Angiogenesis (DRCR), 297
description, 157–158 endophthalmitis, 297–298
development and progression, DR, 211–212 focal laser treatment, 298
growth factor alterations, 220 Food and Drug Administration (FDA), 297
IGFBP-3, 238 randomized trial, 298
NFs reduction in central retinal thickness, 297
FGF and EPO, 252 Blindness
PEDF treatments, 250 developed and developing nations, 18
VEGF, 252–253 partial sight, 18
VEGF, 234 sensitivity analysis, 21–22
Angiotensin II 10-year incidence, 18
activation, receptors, 312 Blood–retinal barrier (BRB)
neuroprotection, 312–313 alteration
RAS blockade, 312 acquisition, 60
AP-1. See Activating protein-1 macula, 59
APKAP12. See A-kinase anchor protein 12 retinal leakage mapping, 59
Astrocyte end feet, 106–107 vitreous fluorometry, 59

Edited by: J. Tombran-Tink et al. (eds.), DOI 10.1007/978-1-60761-150-9
367
368 Index
Blood–retinal barrier (BRB) (cont.) CNTF. See Ciliary neurotrophic factor

breakdown mechanisms (see BRB breakdown Color vision dysfunction
mechanisms) blue-yellow and blue-green, 71–72
functional unit, glial and endothelial cells, 327 FM 100 Hue Test, 73
physiological and diabetic conditions, 333, 335 hypotheses, 71
retinal vascular barrier Combination treatment, laser
astrocytes and Müller cells, 124 BCVA, 301
quadrants, 124 DRCR protocol, 302
SSECKS, 124 ranibizumab and triamcinolone, 301
vascular systems, 123 Complications, diabetic
BL thickening. See Basal lamina thickening HATs and HDACs, 222
Brain-derived neurotrophic factor (BDNF) MAPK pathway, 218
dopaminergic amacrine cells, 251 microvascular, polymorphisms, 217
expression, 317 O-linked glycosylation, 217
BRB. See Blood–retinal barrier Connective tissue growth factor (CTGF)
BRB breakdown mechanisms BL thickening
anti-VEGF properties, natriuretic peptides knockout mice, 272–273
(NP), 113–116 PCDR, 268–270
inner and outer TGF-β, 271–272
acute and chronic inflammation, 108 VEGF role, 270–271
age-related diseases, 108 ECM remodeling, PCDR, 262–264
apolipoprotein E (apoE), 108 mRNA levels, 268
aprotinin, 110 ocular angiogenesis, 267
AZ, 110 ocular fibrosis, 267
β2-integrins, 109 PDR, 273–277
components, 106 structure and function
leukocyte accumulation, 108–109 biological functions, 266
leukocyte adhesion, 109 exons, 265–266
neurovascular barrier, 106, 107 interactions, 266
properties, 106–107 wound healing, PDR, 264–265
protein and fluid extravasation, 107 Contrast sensitivity (CS)
protein leakage assays, 108 neurodegenerative changes, 200
selectins, 109 neuroretinal damage, 310
streptozotocin (STZ), 107 psychophysics (see Visual psychophysics, DR)
protective barriers Corneal confocal microscopy (CCM)
description, 105–106 corneal sub-basal nerve plexus (CSNP), 46–48
structure, 105, 106 diagnostic test, 46
structural compromise fiber tortuosity (FT), 46, 48
neovascularization, 111 focal plane, 46
VEGF, 112–113 nerve beadings, reduction, 46, 47
VAP-1, 111 nerve fiber length (NFL), 46, 47
vascular leakage, 105 noncontact procedure, 46
number of beadings (NBe), 46, 47
number of branching (NBr), 46, 47
C number of fibers (NF), 46, 47
Caspases Z-ring device, 46
“executioner enzymes”, 191 Corneal diabetic neuropathy
immunoreactivity, 191–192 CCM (see Corneal confocal microscopy)
CCM. See Corneal confocal microscopy chronic disability, 45
Cellular signaling electrophysiological tests, 45
CNTF’s functions, 250 long-term effects, 45
mechanisms (see Glucose-induced cellular nerves
signaling mechanisms) and diabetes, 48–50
Ciliary neurotrophic factor (CNTF) subbasal corneal nerve plexus, 46
cytokines, 249 Corneal nerves and diabetes
description, 317–318 abnormalities, 48
functions, 250 CSNP parameters, 49
retinal degeneration model, 250 hyperglycemia, 50
Index 369
nerve bundles, 48 morbidity, 340

neurons, 50 pancreas transplantation, 353
neurotrophic stimuli, 49 prevalence and incidence, PDR, 349–350
pathological changes, 49 reductions, HbA1c, 344–345
sensation, 48–49 risk factors, hypoglycemia, 345
stromal nerve trunks, 48 SPK transplantation, 353–355
tortuosity stage, nerve plexus, 49 treatment and HbA1c levels, 347–348
Corneal sub-basal nerve plexus (CSNP) weight gain, 346
antioxidant therapy, 50 Diabetes Quality of Life Measure (DQOL), 348
CCM, 47 Diabetic ketoacidosis (DKA), 345, 348, 351
five parameters, 46 Diabetic macular edema (DME)
mitochondria and glycogen, 48 bevacizumab, 297–299
CSNP. See Corneal sub-basal nerve plexus clinical practice, 71
combination treatment, laser, 301–302
CS function, 76
D 2-DE-based proteomics, 181
Dark adaptation duration and functional outcome, 97
rainstorms, 8 efforts, 289–290
shift, light to dark, 7 inhibition, VEGF, 175
DCCT. See Diabetes Control and Complications Trial management
1-DE. See 1-Dimensional electrophoresis antiangiogenic isoforms, 301
2-DE. See 2-Dimensional electrophoresis cytokine level, 301
DHA. See Docosahexaenoic acid focal/grid laser, 300
Diabetes Control and Complications Trial (DCCT) improvement, 300
β cell function interleukin-6 (IL-6), 301
clinical benefit, 353 leukocyte-mediated vascular
measurement, C-peptide, 352 permeability, 300
“virtuous circle”, 352 microperimetry, 90
benefits and risks, blood glucose Mollon–Reffin “Minimalist” test, 72
factors and blockers, 342 pathogenesis
HbA1c, 343 cataract surgery, 293
insulin regimen, 342–343 ETDRS, 292
photographic evidence, 343 fluorescein angiography, 290, 291
cardiovascular disease, 348 hyperglycemia, 290
connecting peptide (C-peptide) hypoxia, 290
β cell function, 346 intravitreal triamcinolone, 293
responders, 346 laser, 292
DKA, 345 optical coherence tomography (OCT), 290
DQOL, 348 PKC412, 292
DR progression, 19–20 placebo injection, 292
epidemiology, 340–341 plasma leaks, 290
glycemia and macular edema pegaptanib
data, WESDR, 341 neovascular AMD, 297
risk factor relationships, 341 VEGF medication, 296
treatment, 342 presentation and type, 70–71
glycemic control regimen quality of life
HbA1c level, 351, 352 clinical trial data, 302
hypoglycemia and weight gain, 350 intensive treatments, 302
insulin analogues, 351 low-vision specialist, 303
intensive therapy, 350 NEI-VFQ-25, 302
limitations and glucose monitoring devices, 351 proliferative diabetic retinopathy
treatment, 351 (PDR), 302
hypoglycemia counterregulation, 352 VTDR, 302
intensive insulin therapy ranibizumab, 293–296
beneficial effect, 343 VEGF Trap-Eye, 299–300
risk reduction, prevention cohort, 344 vision loss, 173, 289
ISLET cell transplantation, 356–357 visual acuity, 83–84
metabolic memory, 348–349 vitreous hemorrhage, 289
370 Index
Diabetic retina nonproliferative diabetic retinopathy

eye management problem (NPDR), 54
diabetes epidemic, 32 pericyte damage, 54–55
treatment focus, 32 prominent feature, 54
vasculopathy and neuropathy, 32–33 retinal changes, 54
multifocal electroretinogram (mfERG), 34–39 retinal circulation, 55
nonproliferative diabetic retinopathy hyperglycemia, 308
(NPDR), 31–32 IGFBP-3 (see IGF-binding protein-3
patient care (IGFBP-3))
assessment tools, 39–40 incidence, 19
conventional perimetry, 40 laser
“neuropathy”, 39 photocoagulation, 308
optometrists, 40 treatment, 20
systemic markers, 40 medical achievements, 14
visual acuity and foveal function microvascular circulation, 245, 246
“blue-cone” perimetry, 33 multimodal macula mapping, 61
clinical and research tools, 34 neurodegeneration
mfERG, 33–34 diabetic donors, 308
neural dysfunction measures, 34 neuroretinal damage, 310
neural latency abnormalities, 34 STZ, 309–311
predictive models, 34 neuronal and glial cell changes
“two-color threshold” technique, 33 cytotoxic edema, 60
Diabetic retinopathy (DR) optical coherence tomography (OCT), 61
BRB vascular endothelial damage, 60
alteration, 59–60 WESDR data, 60
complication, 246 neurotoxic factors, neuropeptides, 311–318
capillary degeneration neurotrophic drugs, 318–319
description, 143 NF (see Neurotrophic factors)
genetic modifications, 146, 148 patient experience
interval, 147–148 altered vision, 7
metabolic control, molecular mechanisms, 146 blur, eyesight, 4
metabolic memory, 148 complications, 6–7
molecular mechanisms, 146 driving, 8
nonuniform, 146 laser treatment, 5, 8
pharmacologic inhibition, 146, 147 oxygen levels and blood vessels, 5
retinal histopathology, 143, 144 physician qualities, 6
retinal vasculature and neuronal retina transitions, light, 7
structure, 148–149 phenotypes, 61–64
vascular nonperfusion, mechanisms, 144–146 photos, meaning
VEGF, 143–144 hydrant, 12, 13
changes, neurons and glia, 246 unnatural, 12
clinical trial design and management prevalence
drug, 64 reports, North America, 18
ETDRS, 64 worldwide reports, 18–19
intravenous fluorescein, 65 prevention, 19–20
MA turnover, 65 proteases (see Proteases, DR)
microthrombosis, 66 public health problem
moderate NPDR, 65 blindness and visual impairment, 18–19
significant visual loss, 64 prevalence, 18
slit-lamp examination, 65 qualitative study
description, 53 average age, 8
disease untreated, 21–22 fear, blindness, 11–12
formation and disappearance rates, MA, 55–59 insulin, 11
health-care professionals and public, 20–21 microaneurysm, 9, 10
history subhyaloid hemorrhage, 10
BRB, abnormality, 55 retinal capillary closure, 60
endothelial cells, 55 screening (see DR screening)
microaneurysms (MA), 54 symptomatic stage, 19
Index 371
treatments Endothelial cells

destructive photocoagulation, 66 dysfunction
glycemic control, 66 molecular and phenotypic changes, 213
pathways, 66 proliferative response, 213–214
predominant disease mechanisms, 67 working hypothesis, 212–213
type 1 and 2, 53 matrix interactions
vitreoretinal surgery, 308 collagen and fibronectin (FN), 215
vitreous proteomics (see Vitreous proteomics, neovascularization, 214–215
DR patients) vascular remodeling, 215
DiI. See 1,1’-Dioctadecyl-3,3,3,’3’-tetramethylindo- pericyte interactions
carbocyanine perchlorate biochemical mechanisms, 214
1-Dimensional electrophoresis (1-DE) physiological function, 214
analysis, proteins abundance, 182, 184 Endothelial-pericyte interactions, 214
angiotensinogen (AGT), 183 Endothelial progenitor cells (EPCs), 316
comparison, proteins abundance, 183, 185 EPCs. See Endothelial progenitor cells
kallikrein kinin system, 182, 183 EPO. See Erythropoietin
vitreous proteomes, comparisons, 182–183 Erythropoietin (EPO)
2-Dimensional electrophoresis (2-DE) advantages, 316–317
fluorescence-based labeling EPCs, 315–316
differences, 181 intravitreal injection, 252
identification, 181 intravitreal levels, 315–316
silver-stained proteins, 181 red blood cell production, 252
vitreous proteomes, comparisons, 181–182 ETDRS. See Early Treatment Diabetic
1,1’-Dioctadecyl-3,3,3,’3’-tetramethylindocarbocya- Retinopathy Study
nine perchlorate (DiI), 194 Extracellular matrices (ECMs)
DKA. See Diabetic ketoacidosis activation and dysfunction, 213
DME. See Diabetic macular edema AGEs, 269
Docosahexaenoic acid (DHA), 317 angiogenesis, 265
DQOL. See Diabetes Quality of Life Measure AP-1 transcription factors, 222
DR. See Diabetic retinopathy basement membrane (BM)
DR screening proteins, 213–214
definition, 17 fibroblasts, 265
lack of progress growth factors, 220
Canada, 24 MAPK, 218
European countries, 23 neovascularization, 214–215
St. Vincent declaration, 22 proteases
systematic screening, 22–23 angiogenesis process, 160
principles, 17–18 components, 158
degradation, uPA/uPAR, 158, 159
description, 158
E remodeling, BL thickening
Early Treatment Diabetic Retinopathy basement membrane, 264
Study (ETDRS) canine model, 263–264
chart, 70 galactose-fed rats, 264
FM 100 Hue Test, 72 growth factors, 264
investigation microvascular complications, 262–263
microperimetry, 92 TGF-β, 272
perimetry, 85 VEGF, 270–271
laser treatment, 20, 292 Extracellular proteases
macular laser photocoagulation, 71 ECM, 158
photographic lesions, 19 MMPs (see Matrix metalloproteinases
SWAP, 84 (MMPs))
vitrectomy, 20 uPA/uPAR system
ECMs. See Extracellular matrices activation, 158–159
Edmonton protocol, 356 ECM degradation, 158, 159
Electrophoresis interaction, 159
1-dimensional (1-DE), 182–185 Ly-6 and uPAR (LU) domain, 159
2-dimensional (2-DE), 181–182 molecular forms, 158
372 Index
F hexosamine pathway, 217

Farnsworth–Munsell 100-Hue Test (FM 100 Hue Test) increased oxidative stress, 219–220
color vision investigation, 73–75 MAPK, 218
description, 72 PKB and SGK-1, 218–219
insulin-dependent diabetes mellitus (IDDM), 72 PKC pathway, 218
FGF. See Fibroblast growth factor polyol pathway, 216–217
Fibroblast growth factor (FGF) protein glycation, 220
angiogenesis, 252 transcription factors, 221–222
retinal levels, βFGF, 252 transcription regulators, 222–223
Floaters Glucose-induced cellular signaling mechanisms
cause, 7 growth factors, aberrant expression, 220
timing, appearance, 7–8 hexosamine pathway, 217
FM 100 Hue Test. See Farnsworth–Munsell MAPK, 218
100-Hue Test oxidative stress
hyperglycemia-induced, 219
lipoxygenase enzyme (LOX), 220
G NADPH oxidase enzyme, 219–220
GDNF. See Glial cell-derived neurotrophic factor PARP, 220
GH. See Growth hormone PKB and SGK-1
Glial cell–derived cytokines and vascular integrity, DR inhibition, 218–219
BRB functional unit, 327 isoforms role, 218
composition, BRB, 325–326 PKC pathway, 218
cytokines polyol pathway
APKAP12, 331 aldose reductase (AR) inhibitor, 217
GDNF, 330–331 description, 216
IL-6, 331 enzymatic reactions, 216
IL-1β, 330 metabolic/biochemical changes, 216, 217
TNF-α, 329–330 protein glycation, 220
VEGF, 330 transcription factors
pathological progression, 326–327 AP-1, 222
retinoic acid (RA) description, 221
description, 331 NF-κB, 221–222
GDNF expression, 331–332 transcription regulators
promoter activity, GDNF, 332 acetylation and methylation, 222
RARα-mediated phenotypic transformation, 332 histone and NF-κB response, 222–223
recombinant GDNF and RARα stimulants, 332 phosphorylation, 222
structural model, TJ, 325, 326 vasoactive factors
TJ NO synthases, 216
claudins, 329 vasoconstriction and vasodilatory
description, 327–328 responses, 215–216
peripheral membrane proteins, 328 Glucose-induced oxidative stress, 219–220, 312
ZO-1 and 2, 329 Glutamate
Glial cell-derived neurotrophic factor (GDNF) elevated levels, 312, 318
BRB-forming capillary endothelial cells, 330–331 excitotoxicity, 311–312
characterisation, 249 Glutamate excitotoxicity
description, 317 description, 311–312
signals, 317 neurodegeneration, 201
Glucose-induced cellular signaling, DR Growth factors, 220
cellular targets Growth hormone (GH)
EC dysfunction, 212–214 and IGF pathway (see Growth hormone (GH)/
endothelial-matrix interactions, 214–215 insulin-like growth factor (IGF) pathway)
endothelial-pericyte interactions, 214 inhibition, 313
pathogenetic mechanisms, 212 Growth hormone (GH)/insulin-like growth factor
description, 211–212 (IGF) pathway
development and progression, events, 211, 212 animal models
mechanisms normoglycemic/normoinsulinemic transgenic
altered vasoactive factors, 215–216 mice, 236–237
growth factors, aberrant expression, 220 OIR, 236
Index 373
pro-angiogenic role, 236 intravitreal levels, 175–176

IGFBP-3, as regulator pathway, and GH (see Growth hormone (GH)/
divergent cellular functions, 238 insulin-like growth factor (IGF) pathway)
EPC recruitment, 238 β2-Integrin
inhibitory functions, 237 leukocyte adhesion, 109
interventions and bioavailability, 237 ligation, endothelium, 110, 114, 115
retinal expression, 237–238 neutrophils and monocytes, interaction, 109
vitreal levels, 237 Intensive insulin therapy
PDR beneficial effect, 343
identification, factors, 234 cardiovascular disease, 348
IGFBPs role, 234–235 hypoglycemia
ROP counterregulation, 352
detrimental role, 235 risk factors, 345
severity, determination, 235 micro-and macrovascular disease, 347
risk reduction, prevention cohort, 344
Interleukin-6 (IL-6), 331
H Interleukin-1β (IL-1β), 330
HATs. See Histone acetyltransferases Intracellular adhesion molecule 1 (ICAM-1)
HDACs. See Histone deacetylases AZ, 110
Hexosamine pathway, 217 leukocyte, 109
Histone acetyltransferases (HATs), 222 leukocyte-induced BRB permeability, 114, 115
Histone deacetylases (HDACs), 222 VEGF, 113
Islet cell transplantation, type 1 diabetes
Edmonton protocol, 356
I effects
ICAM-1. See Intracellular adhesion molecule 1 chronic immunosuppression, 356
IGF. See Insulin-like growth factor pancreas, 357
IGF-binding protein-3 (IGFBP-3) progression, 357
GH/IGF pathway
animal models, 236–237
PDR, 234–235 J
as regulator, 237–238 JAMs. See Junctional adhesion molecules
ROP, 235 Junctional adhesion molecules
inhibition, 239–240 (JAMs), 127–128
laser treatments, 233–234
therapeutic interventions
bolus injections, 238 K
correlation, serum and vitreal levels, 239 Kallikrein kinin system, 182, 183
“early worsening”, 239
oxygen-induced vessel, 238–239
VEGF, 234 L
IGFBP-3. See IGF-binding protein-3 Laser treatment
IL-6. See Interleukin-6 and driving, 8
IL-1β. See Interleukin-1β fear, 13–14
Immunohistochemical analysis, 130–131 peripheral vision, 8
Inflammatory cytokines Leukocyte adhesion, 109
APKAP12, 331 Liquefaction, vitreous, 174–175
GDNF, 330–331 Logarithm of the minimal angle of resolution
IL-6, 331 (LogMAR), 70
IL-1β, 330 LogMAR. See Logarithm of the minimal angle of
TNF-α, 329–330 resolution
VEGF, 330
Insulin-dependent diabetes
DCCT, 347 M
FM 100 Hue Test, 72 MA. See Microaneurysm
patient experience, 3–8 Macular edema
Insulin-like growth factor (IGF) features, diabetic retinopathy, 53
factor 1 (IGF-1), 252 OCT, 61
374 Index
Macular recovery function N

description, 77 Natriuretic peptides (NP), anti-VEGF properties
laser photocoagulation, 77, 83 atrial natriuretic peptide (ANP), 114
retinal mechanism, 83 AZ role, 115–116
MAPK. See Mitogen-activated protein kinase inhibition, 113
Mass spectrometry permeability, leukocyte-induced, 114–115
occludin phosphorylation, 131 pigment epithelium-derived factor (PEDF), 114
vitreous proteomics Neovascularization
description, 179 IGF-1
spectral analysis, 179 oxygen-induced retinal vessel, 238–239
workflow steps, 176, 177 receptor antagonist, 236
Matrix metalloproteinases (MMPs) ROP phase, 235
angiogenesis, 160 proteases, 163–164
cellular function, 160, 161 tissue inhibitor, MMPs, 164–166
domain structure, 160, 161 VEGF, 290
groups, 160 Nerve fiber layer (NFL), 196
significance, 162 Nerve growth factor (NGF), 249
synthesis, 160, 162 Neurodegeneration, DR
Metabolic memory, DCCT apoptosis, RGCs, 194
AGE formation, 349 biochemical evidence
hyperglycemia, 349 immunohistochemical analysis, 196–197
mitochondrial proteins, 349 measurements, PSD95, 197
mfERG. See Multifocal electroretinogram nNOS level, 197
Microaneurysm (MA) synaptic proteins level, 197, 198
bleeding, 9, 10 centrifugal axon abnormalities, 195–196
bursting, 9 contrast sensitivity, 200
formation and disappearance rates description, 189–190
CSME and non-CSME eyes, 58 diabetic donors, 308
cumulative number, 56 downregulation, SST, 315
fluorescein angiography, 55, 57 electrophysiological evidence
formation rate, 56 electroretinogram (ERG), 197–198
foveal avascular zone (FAZ), 56 oscillatory potentials (OPs), 198–199
fundus-digitized images, 55 STR, 199
noninvasive color, 59 wave amplitude, 199
patients, metabolic control, 57 excitotoxicity, glutamate, 311–312
thrombotic phenomena, 57 fundus examination, 203
laser, 292 histological evidence, apoptosis
plasma leakage, 290 “executioner enzymes”, caspases-3
turnover, 64 and-7, 191–192
Mitogen-activated protein kinase (MAPK), 217 TUNEL, 190–191
MMPs. See Matrix metalloproteinases neuroretinal damage, 310
Mollon–Reffin “Minimalist” test, 72, 74 NFL thickness, 196
Multifocal electroretinogram (mfERG) optic nerve retrograde transport, 199
adolescents and adult diabetes, 39 pathological changes, 190
bipolar contact lens electrode, 35 postmortem retinas, 200
logistic regression, 37 potential mechanisms
neural signals, 35 AGEs role, 201
noninvasive technique, 34 blood-retinal barrier, 200–201
predictive power, 35, 37 calcium concentration, 202, 203
prophylactic therapeutics, 38–39 glutamate excitotoxicity, 201
receiver operating characteristic (ROC), 37, 38 growth factor signaling, 201, 203
retinal area, zones, 38 psychophysical testing, 200
scaled hexagons, 35, 36 retina, morphological changes
sensitivity and specificity, 35, 37 inner plexiform (IPL) and nuclear layers
type 1 vs. type 2, retinal function, 39 (INL), 192, 193
Multimodal macula mapping layer thickness, reductions, 192–193
developing methods, 61 RGCs morphology, abnormalities
diagnostic tools, 61 axon swelling and beading, 194–195
nonproliferative retinopathy, 62 cell enlargement, 194
Index 375
description, 194, 195 MAPK activity, 218

DiI use, 194 PARP, 220
STZ, 309–311 p65 expression, 222–223
surviving amacrine cells, reductions transcription factors, 221
neurotransmitters, 193–194 Nyctometry, 77, 83
tyrosine hydroxylase immunoreactivity, 193
Neuronal nitric oxide synthase (nNOS)
labeling, 193 O
neurons and vascular blood flow, 197 OCT. See Optical coherence tomography
Neuropathy OIR. See Oxygen-induced retinopathy
neurosensory retina, 32 Optical coherence tomography (OCT)
retinal complications, 39 fluid accumulation image, 290, 291
Neuropeptides measurements, 296, 300
angiotensin II, 312–313 Oxygen-induced retinopathy (OIR), 236
BDNF, 317
CNTF and AM, 317–318
DHA and NPD1, 317 P
elevated levels, glutamate, 312, 318 PAI. See Plasminogen activator inhibitors
Epo, 315–317 Pancreas transplantation, 353, 354, 356
excitotoxicity, glutamate, 311–312 PARP. See Poly (ADP-ribose) polymerase
GDNF, 317 Pathogenesis, 148
PEDF, 313 PCDR. See Preclinical diabetic retinopathy
SST, 313–315 PDGF. See Platelet-derived growth factor
Neuroprotectin D1 (NPD1), 311, 317, 318 PDR. See Proliferative diabetic retinopathy
Neurotrophic factors (NFs) PEDF. See Pigment epithelium-derived factor
BDNF, 251 Pericytes
CNTF, 249–250 Akt activation, 133
diseases, 249 barrier formation, 124
features, 249 interactions, endothelial
FGF, 251–252 (see Endothelial-pericyte interactions)
IGF-1 and EPO, 252 PKC activity, 132
neuropeptides (see Neuropeptides) Perimetry
NGF and GDNF, 249 description, 83
PEDF, 250 investigation, 84–88
receptors, 247, 248 kinetic and static automated, 83
SERPINA3K, 251 SWAP and WWP, 84
VEGF, 252–253 visual acuity, 83–84
NF-κB. See Nuclear factor-κB visual field testing, 83
NFL. See Nerve fiber layer Peripheral diabetic neuropathy, 45, 46
NFs. See Neurotrophic factors Phenotypes, DR
NGF. See Nerve growth factor diabetes mellitus, 64
nNOS. See Neuronal nitric oxide synthase genetic factors, 64
Non-enzymatic glycation, 220 HbA1C values, 62
Nonperfusion hyperglycemia, 63, 64
cellular target, 212 patients observations, 62, 63
sensitivity loss, 84 retinal thickness, 62
vascular risk factors, 61
degeneration, 144 RLA-leaking, 62
hemodynamics, 145 visual acuity, 62
lumen invasion, 145 Pigment epithelium-derived
occlusions, 144 factor (PEDF)
platelets, vasoocclusion, 145 angiogenic inhibitor, 250
VEGF, intravitreal administration, 146 DR treatment, 313
white blood cells, vasoocclusion, 144–145 inhibitors, angiogenesis, 313
Nonproliferative diabetic retinopathy (NPDR), 31 intraperitoneal administration, 250
NPD1. See Neuroprotectin D1 phyla, 313
NPDR. See Nonproliferative diabetic retinopathy VEGF, 250
Nuclear factor-κB (NF-κB) PKA. See Protein kinase A
and AP-1, 222 PKB. See Protein kinase B
376 Index
PKC. See Protein kinase C isoforms role, 132

Plasminogen activator inhibitors (PAI), 163 isozymes, BRB, 133, 134
Platelet-derived growth factor (PDGF), 175 membrane translocation and activation, 132
Polyol pathway, 216–217 pathway, 218
Poly (ADP-ribose) polymerase (PARP), 220 Proteomics
Preclinical diabetic retinopathy (PCDR) vascular permeability, DR, 129
BL thickening, CTGF vitreous (see Vitreous proteomics, DR patients)
AGEs, 269–270
expression, 268–269
description, 261–262 Q
rodent models, DR, 261–262 Quality of life
Proliferative diabetic retinopathy (PDR) and DME, 302–303
CTGF and VEGF DQOL, 348
angiogenesis, 275–276 functional vision, 70
degree of fibrosis, 273–274 improvement, 6, 14
endothelial cells, 273
inhibition, 277
intravitreal inhibitors, 276 R
mean levels, 275 RA. See Retinoic acid
neovascularization, 274–275 Ranibizumab
PVR patients, 274 AMD, 293, 295
1-DE-based proteomics, 182–184 anti-VEGF murine mono-clonal antibody, 293, 294
2-DE-based proteomics, 181–182 clinical trial, 293
GH/IGF pathway, 234–235 foveal thickening, 293–294
Lamoureux use, 302 MARINA and ANCHOR, 293
PDGF, 175 monoclonal antibody, 293
protein concentration, 176–177 multicenter trial, 295
VEGF, 175 optimal dosing regimen, 296
vision loss, 173 reduction in macular edema, 296
Proteases, DR RISE and RIDE phase III trials, 296
diabetic macular edema systemic side effects, 294
inhibition, BRB prevention, 167–168 visual acuity, READ-2, 295, 296
MMP-2 and MMP-9, 166–167 RARα. See RA receptor-α
VE-cadherin staining, 167 RA receptor-α (RARα)
retinal neovascularization phenotypic transformation, glial cells, 332, 334
angiogenesis and matrix degradation, 164 stimulants, 332
angiogenesis inhibition, 165–166 trans-acting coactivator, 332
hyperglycemic condition, 164 RAS. See Renin-angiotensin system
MMP activation, 163–164 Renin-angiotensin system (RAS)
TIMP-2 mRNA and protein levels, 164 angiotensin II, 312–313
tissue inhibitor, MMPs, 164–166 blockade, 312
transcription factor, 164 Retina
uPAR expression, 164, 165 hemorrhages, 182, 183
retinal vasculature proteins diffusion, 174
angiogenesis, 157–158 rhegmatogenous retinal detachment (RRD), 174
endogenous inhibitors, 163 transferrin role, 175
extracellular proteases, 158–162 vascular permeability (RVP), VEGF, 175
PAI, 163 vitreous fluid, 176
vasculogenesis, 157 Retinal ganglion cells (RGCs)
urokinase inhibitor, A6, 168 abnormalities, 194
Protein glycation, 220 axon swelling and beading, 194–195
Protein kinase A (PKA), 218, 329 cell enlargement, 194
Protein kinase B (PKB), 218–219 description, 194, 195
Protein kinase C (PKC) DiI use, 194
atypical (aPKC) isoforms, 133 loss, 194
classes, 132 NFL thickness, 196
classical isoforms and isozymes, 133 STR, 194, 195
de novo synthesis, 132 Retinal leakage analyzer (RLA), 59, 61
Index 377
Retinal neovascularization, proteases worsening, retinopathy, 355

angiogenesis and matrix degradation, 164 SLO. See Scanning laser ophthalmoscope
angiogenesis inhibition Snellen chart, 70
MMP inhibitors, 165–166 Somatostatin (SST)
uPA/uPAR system, 166 downregulation, 315
hyperglycemic condition, 164 functions, retinal homeostasis, 315
MMP activation, 163–164 inhibitory actions, 313–314
TIMP-2 mRNA and protein levels, 164 neuroretina, 314–315
transcription factor, 164 SPK transplantation. See Simultaneous
uPAR expression, 164, 165 pancreas-kidney transplantation
Retinal pigment epithelium (RPE) Src-suppressed C kinase substrate (SSECKS), 124
claudins expression, 126 SSECKS. See Src-suppressed C kinase substrate
controls, 123 SST. See Somatostatin
tight junctions complex, 125 STR. See Scotopic threshold response
Retinal vascular endothelium, 54 Streptozotocin (STZ)
Retinal vasculature comparison, neurodegenerative features, 310–311
AGE formation, 269 neurotoxic effect, 310, 318
integrity, 290 RGCs, 310
and neuronal retina structure, 148–149 St. Vincent declaration, 22
proliferation, 246–247 STZ. See Streptozotocin
proteases (see Proteases, DR) SWAP. See Short-wavelength sensitive pathway
Retinoic acid (RA)
description, 331
GDNF expression, 331–332 T
promoter activity, GDNF, 332 Terminal dUTP nick end labeling (TUNEL)
RARα-mediated phenotypic transformation, 332 description, 190
recombinant GDNF and RARα stimulants, 332 “executioner enzymes”, caspases-3 and-7, 191–192
Retinoic X receptor (RXR), 331, 332 immunoreactivity, caspase-3, 192
Retinopathy of prematurity (ROP), 235 photoreceptors, 191
Retinopathy progression trypsin-digest approach, 190, 191
blood pressure, 66 Tight junctions (TJ)
fluorescein leakage, 56, 65 claudins, 329
MA counting, 55 barrier formation, model, 126
RGCs. See Retinal ganglion cells description, 126
ROP. See Retinopathy of prematurity expression, 126–127
RPE. See Retinal pigment epithelium interactions, 126, 127
composition, 125
description, 327–328
S formation, 125
Scanning laser ophthalmoscope (SLO) JAMs
description, 89 division, 127–128
microperimetry investigation, 89, 91–94 role, 128
vs. MP-1 microperimeter, 89 occludin
Scotopic threshold response (STR), 199 and claudin-5, localization, 128, 129
Screening. See DR screening role, 128
Selectins, 109 sequence and structure, 128
Serum-and glucocorticoid-regulated kinase peripheral membrane proteins, 328
(SGK-1), 218–219 tricellulin, 128
SGK-1. See Serum-and glucocorticoid-regulated ZO, 125
kinase ZO-1 and 2, 329
Short-wavelength sensitive pathway (SWAP) TIMPs. See Tissue inhibitors of metalloproteinases
description, 84 Tissue inhibitors of metalloproteinases (TIMPs), 163
investigation, perimetry, 85–88 TJ. See Tight junctions
vs. WWP, 84 TNF-α. See Tumor necrosis factor-α
Simultaneous pancreas-kidney (SPK) transplantation Tractional retinal detachment, 289
immunosuppression, 353–354 Transforming growth factor-beta (TGF-β)
NPDR PTA group, 355 and CTGF, BL thickening
scatter laser treatment, 354–355 downstream effects, 271–272
378 Index
Transforming growth factor-beta (cont.) intravitreal injection, 300

drugs, 271 PKC412, 290
pericytes, 272 ranibizumab, 296
GDNF, 317 recombinant fusion protein, 299
mRNA levels, 272 vascular permeability, 290
Tumor necrosis factor-α (TNF-α), 329–330 Vascular leakage
TUNEL. See Terminal dUTP nick end labeling AZ inhibition, 117
AZ role, 115
description, 105
U downstream effector, VEGF, 116
Ubiquitination, 131–132 leukocyte mediators, 110
UKPDS. See United Kingdom Prospective Diabetes protein leakage assays, use, 108
Study Vascular permeability, DR
United Kingdom Prospective Diabetes Study activation, kallikrein, 130
(UKPDS), 19, 20 changes, blood vessel and macular edema, 130
uPA. See Urokinase plasminogen activator kallikrein/bradykinin system, 134
Urokinase plasminogen activator (uPA) occludin phosphorylation
angiogenesis and matrix degradation, 164 gene deletion and knockdown, 131
inhibition, retinal angiogenesis, 166 Ser490, 131
proteolytic activity, PAI, 163 ubiquitination, 131–132
secretion and activation, MMP, 163 PKC
uPA/uPAR system (see Extracellular proteases) aPKC isoforms, 133
classes, 132
classical isoforms and isozymes, 133
V de novo synthesis, 132
VA. See Visual acuity isoforms role, 132
VAP-1. See Vascular adhesion protein 1 isozymes, BRB, 133, 134
Vascular adhesion protein 1 (VAP-1), 111 membrane translocation and activation, 132
Vascular endothelial growth factor (VEGF) VEGF-induced regulation, 130–131
capillary nonperfusion, 143–144 Vasculogenesis, 157
concanavalin A, 130–131 Vasoocclusion
CTGF platelets, 145
ECM remodeling, 270–271 white blood cells, 144–145
gene expression and protein levels, 270 VEGF. See Vascular endothelial growth factor
ocular angiogenesis, 267 Vision Contrast Test System, 77
PDR, 274–277 Visual acuity (VA)
cytokine, 113 description, 70
description, 112 ETDRS chart, 70–71
IGFBP-3 addition, 237 logMAR, 70
isoforms, 252–253 Snellen chart, 70
leukocyte-mediated breakdown, role, 330 Visual impairment
levels, 175, 176 macular degeneration, 18
low levels, secretion, 253 national health and nutrition examination
“master switch”, angiogenesis, 234 survey, 19
members, 112 taking insulin, 18
occludin, immunohistochemical analysis, 130 working age group, 18
PDR and DME, mediator, 175 Visual psychophysics, DR
proliferation and migration, lymphatic acuity (VA), 70–71
endothelium, 112–113 color vision
proliferative neovascular vessels, 236–237 abnormalities, 71–72
retinal neovascularization, role, 113 FM 100 Hue Test, 72
retinal vessel growth, 235 hypotheses, 71
therapies, 253 investigation, 72–75
Trap-Eye macular function, 71
antiangiogenic isoforms, 301 Mollon–Reffin “Minimalist” test, 72
bevacizumab, 297 CS
DME pathogenesis, 290 acuity testing, 76
expression, 290 assessment procedure, 76
Index 379
description, 72 2-DE, 181–182

investigation, 77–82 description, 176
reductions, 76–77 direct functional analyses, 185
spatial resolution defects, 76 mass spectrometry, 179
Vision Contrast Test System, 77 molecule approach
description, 69–70 IGF-I and IGF-binding proteins, 175–176
macular recovery function (nyctometry) PDGF, 175
description, 77 PDR and DME, 173
laser photocoagulation, 77, 83 protein approach
retinal mechanism, 83 transferrin, 175
microperimetry VEGF, 175
description, 84 sample pre-fractionation, 178–179
duration and functional outcome, DME, 97 spectral analysis
fixation characteristics, 84 label-free measurements, 180
fixation pattern, 97 parameters and thresholds, use, 179–180
investigation, 90–97 Sequest and X!Tandem analyses, 179
macular disorders, 89 workflow, steps, 176, 177
map, color fundus, 90, 97
MP-1 microperimeter, 89
retinal sensitivity, correlation, 90 W
SLO, 89 WESDR. See Wisconsin Epidemiologic Study of
perimetry, 83–84 Diabetic Retinopathy
psychophysical test, 69 White-on-white perimetry (WWP)
Vitreous description, 84
antiangiogenic activity, 313 investigation, 84–88
EPO, 315 vs. SWAP, 84
fluorometry, 59 Wisconsin Epidemiologic Study of Diabetic
growth factors, 220 Retinopathy (WESDR)
level blindness and visual impairment, 18
CTGF, 273 intensive insulin therapy, 340–341
IGF-1, 239 retinal edema, 60
MMPs, 166–167 type 1 diabetes, 341
VEGF secretion, 253 25-year progression, 18
proteomics (see Vitreous proteomics, Wound healing, PDR
DR patients) ECM production, 265
Vitreous proteomics, DR patients growth factors, 265
acquisition neovascularization and fibrosis, 265
biological processes, 177–178 VEGF, 264–265
factors, 176 WWP. See White-on-white perimetry
fluid, 176
protein concentration, 176–177
anatomy X
collagen isoforms, concentrations, 174 X!Tandem, 177, 179
gel-like composition, 174
liquefaction process, 174–175
characterization, 173–174 Z
data analysis, 180 Zonula occludens (ZO) proteins, 125
1-DE, 182–184 ZO proteins. See Zonula occludens proteins

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Visual Dysfunction in Diabetes

For further volumes

Joyce Tombran-Tink, PhD

Colin J. Barnstable, DPhil

ISBN 978-1-60761-149-3 e-ISBN 978-1-60761-150-9

Library of Congress Control Number: 2011941439

© Springer Science+Business Media, LLC 2012

Printed on acid-free paper

Humana Press is part of Springer Science+Business Media (www.springer.com)

HOW IS DIABETIC RETINOPATHY DETECTED?

HOW DOES DIABETES AFFECT THE EYE?

HOW CAN VISION LOSS BE LIMITED: EXPERIMENTAL THERAPIES

Part I Living with Diabetic Retinopathy

Part II How Is Diabetic Retinopathy Detected?

Part III How Does Diabetes Affect the Eye?

13 Glucose-Induced Cellular Signaling in Diabetic Retinopathy.......... 211

Part IV How Can Vision Loss Be Limited: Experimental Therapies

17 Ranibizumab and Other VEGF Antagonists for Diabetic

E.J. Kuiper • Department of Ophthalmology, Ocular Angiogenesis Group,

R.J. van Geest • Department of Ophthalmology, Ocular Angiogenesis Group,

Keywords Dark adaptation • Floaters • Insulin-dependent diabetes • Laser treatment • Micro

From: Ophthalmology Research: Visual Dysfunction in Diabetes

Fig. 1. Left eye microaneurysm.

Fig. 2. Left eye subhyaloid

PHOTOS OF THE MEANING OF DIABETES

Keywords Screening • Diabetic retinopathy • Visual Impairment • Blindness • Diabetes control

DEFINITIONS OF SCREENING FOR DIABETIC RETINOPATHY

From: Ophthalmology Research: Visual Dysfunction in Diabetes

Is There Evidence That Sight-Threatening Diabetic Retinopathy

Reports on Blindness and Visual Impairment

Is There Evidence That the Incidence of Sight-Threatening Diabetic

Is There Evidence That Sight-Threatening Diabetic Retinopathy Has a

Is There Evidence That Treatment for Sight-Threatening Diabetic

The Evidence that Laser Treatment Is Effective

The Evidence That Vitrectomy for More Advanced Disease Is Effective

Is a Suitable and Reliable Screening Test Available, Acceptable

Are the Costs of Screening and Effective Treatment of Sight-Threatening

PROGRESS OF LACK OF PROGRESS IN SCREENING FOR DIABETIC

9. Hesse L, Grusser M, Hoffstadt K, Jorgens V, Hartmann P, Kroll P. Population-based study of

46. Yorston D, Wickham L, Benson S, Bunce C, Sheard R, Charteris D. Predictive clinical

Anthony J. Adams and Marcus A. Bearse Jr.

Keywords Multifocal electroretinogram • Non proliferative diabetic retinopathy • Neuropathy

From: Ophthalmology Research: Visual Dysfunction in Diabetes

DIABETES AND AN UNRESOLVED DIABETIC

Current Treatment Focus

Vasculopathy and Neuropathy of the Retina

THE NEED TO GO BEYOND VISUAL ACUITY

Predictive Models of Visible Retinopathy Onset at Specific Locations

HOW IS THE MFERG MEASURED AND WHAT IS IT MEASURING?

Where Are These Neural Signals Generated in the Retina?

Some Key Results

Fig. 1. Stimulus array of 103

Adolescents and Adult Diabetes

Type 1 vs. Type 2: Differences in Retinal Function

THE HORIZON FOR PATIENT CARE OF DIABETES

6. Wolter JR. Diabetic retinopathy. Am J Ophthalmol. 1961;51:1123–41.

From: Ophthalmology Research: Visual Dysfunction in Diabetes

CORNEAL CONFOCAL MICROSCOPY

Fig. 3. Normal nerve tortuosity in the corneal subbasal nerve layer.