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Becker S, L'Ecuyer Z, Jones BW, Zouache MA, McDonnell FS, Vinberg F. Modeling complex age-related eye disease. Prog Retin Eye Res 2024; 100:101247. [PMID: 38365085 PMCID: PMC11268458 DOI: 10.1016/j.preteyeres.2024.101247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 01/31/2024] [Accepted: 02/02/2024] [Indexed: 02/18/2024]
Abstract
Modeling complex eye diseases like age-related macular degeneration (AMD) and glaucoma poses significant challenges, since these conditions depend highly on age-related changes that occur over several decades, with many contributing factors remaining unknown. Although both diseases exhibit a relatively high heritability of >50%, a large proportion of individuals carrying AMD- or glaucoma-associated genetic risk variants will never develop these diseases. Furthermore, several environmental and lifestyle factors contribute to and modulate the pathogenesis and progression of AMD and glaucoma. Several strategies replicate the impact of genetic risk variants, pathobiological pathways and environmental and lifestyle factors in AMD and glaucoma in mice and other species. In this review we will primarily discuss the most commonly available mouse models, which have and will likely continue to improve our understanding of the pathobiology of age-related eye diseases. Uncertainties persist whether small animal models can truly recapitulate disease progression and vision loss in patients, raising doubts regarding their usefulness when testing novel gene or drug therapies. We will elaborate on concerns that relate to shorter lifespan, body size and allometries, lack of macula and a true lamina cribrosa, as well as absence and sequence disparities of certain genes and differences in their chromosomal location in mice. Since biological, rather than chronological, age likely predisposes an organism for both glaucoma and AMD, more rapidly aging organisms like small rodents may open up possibilities that will make research of these diseases more timely and financially feasible. On the other hand, due to the above-mentioned anatomical and physiological features, as well as pharmacokinetic and -dynamic differences small animal models are not ideal to study the natural progression of vision loss or the efficacy and safety of novel therapies. In this context, we will also discuss the advantages and pitfalls of alternative models that include larger species, such as non-human primates and rabbits, patient-derived retinal organoids, and human organ donor eyes.
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Affiliation(s)
- Silke Becker
- John A. Moran Eye Center, University of Utah, Salt Lake City, UT, USA
| | - Zia L'Ecuyer
- John A. Moran Eye Center, University of Utah, Salt Lake City, UT, USA
| | - Bryan W Jones
- John A. Moran Eye Center, University of Utah, Salt Lake City, UT, USA
| | - Moussa A Zouache
- John A. Moran Eye Center, University of Utah, Salt Lake City, UT, USA
| | - Fiona S McDonnell
- John A. Moran Eye Center, University of Utah, Salt Lake City, UT, USA; Biomedical Engineering, University of Utah, Salt Lake City, UT, USA
| | - Frans Vinberg
- John A. Moran Eye Center, University of Utah, Salt Lake City, UT, USA; Biomedical Engineering, University of Utah, Salt Lake City, UT, USA.
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2
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Fraenkl SA, Simon Q, Yucel Y, Gupta N, Wittwer VV, Frueh BE, Tschanz SA. Impact of cerebral hypoperfusion-reperfusion on optic nerve integrity and visual function in the DBA/2J mouse model of glaucoma. BMJ Open Ophthalmol 2022; 7:bmjophth-2022-001078. [PMID: 36161839 PMCID: PMC9476133 DOI: 10.1136/bmjophth-2022-001078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 08/30/2022] [Indexed: 11/28/2022] Open
Abstract
Objective One of the most important risk factors for developing a glaucomatous optic neuropathy is elevated intraocular pressure. Moreover, mechanisms such as altered perfusion have been postulated to injure the optical path. In a mouse model, we compare first negative effects of cerebral perfusion/reperfusion on the optic nerve structure versus alterations by elevated intraocular pressure. Second, we compare the alterations by isolated hypoperfusion-reperfusion and isolated intraocular pressure to the combination of both. Methods and analysis Mice were divided in four groups: (1) controls; (2) perfusion altered mice that underwent transient bi-common carotid artery occlusion (BCCAO) for 40 min; (3) glaucoma group (DBA/2J mice); (4) combined glaucoma and altered perfusion (DBA/2J mice with transient BCCAO). Optic nerve sections were stereologically examined 10–12 weeks after intervention. Results All experimental groups showed a decreased total axon number per optic nerve compared with controls. In DBA/2J and combined DBA/2J & BCCAO mice the significant decrease was roughly 50%, while BCCAO leaded to a 23% reduction of axon number, however reaching significance only in the direct t-test. The difference in axon number between BCCAO and both DBA/2J mice was almost 30%, lacking statistical significance due to a remarkably high variation in both DBA/2J groups. Conclusion Elevated intraocular pressure in the DBA/2J mouse model of glaucoma leads to a much more pronounced optic nerve atrophy compared with transient forebrain hypoperfusion and reperfusion by BCCAO. A supposed worsening effect of an altered perfusion added to the pressure-related damage could not be detected.
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Affiliation(s)
| | - Quentin Simon
- Institute of Anatomy, University of Bern, Bern, Switzerland
| | - Yeni Yucel
- Keenan Research Centre, St Michael's Hospital Li Ka Shing Knowledge Institute, Toronto, Ontario, Canada.,Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ontario, Canada
| | - Neeru Gupta
- Keenan Research Centre, St Michael's Hospital Li Ka Shing Knowledge Institute, Toronto, Ontario, Canada.,Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ontario, Canada
| | - Valéry V Wittwer
- Department of Ophthalmology, Inselspital, University of Bern, Bern, Switzerland.,Ophthalmologic Network Organization (ONO), Geneva, Switzerland
| | - Beatrice E Frueh
- Department of Ophthalmology, Inselspital, University of Bern, Bern, Switzerland
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3
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Bierlein ER, Smith JC, Van Hook MJ. Mechanism for altered dark-adapted electroretinogram responses in DBA/2J mice includes pupil dilation deficits. Curr Eye Res 2022; 47:897-907. [PMID: 35179406 DOI: 10.1080/02713683.2022.2044055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
PURPOSE The DBA/2J (D2) mouse is an established model of pigmentary glaucoma, a type of primary open angle glaucoma. Prior studies have documented defects in flash electroretinogram (ERG) responses in D2 mice, but the origin of those defects is not clear. The purpose of this study was to understand the origin of these A-wave and B-wave changes in D2 ERGs.Materials & Methods: To accomplish this, we analyzed the differences between 9-month-old DBA/2J-Gpnmb+ (D2-control) and D2 mouse eyes in relation to ERG responses, intraocular pressure (IOP), outer nuclear layer thickness, and pupil area. RESULTS D2 scotopic ERGs showed lower A-wave amplitude and longer implicit time as well as a significant rightward shift in the intensity-response curve. D2 IOP increased at approximately seven months of age and had a weak correlation with the ERG A-wave sensitivity. Outer nuclear layer thickness was not significantly different in D2s compared to D2-control retinas. D2 mouse pupils also showed abnormal pupillary shape and no dilation following treatment with tropicamide eye drops. The pupil size moderately correlated with the A-wave sensitivity and this was pharmacologically replicated in C57Bl/6J mice following administration of pilocarpine to constrict the pupils. However, pilocarpine treatment did not affect ERG amplitudes. CONCLUSIONS These data suggest that the smaller pupil sizes prevented light from reaching the photoreceptors and thus contributed to reduced ERG sensitivity in D2 mice. The reduced ERG A-wave amplitude in D2 mice likely results from dysfunctional photoreceptor responses.
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Affiliation(s)
- Elizabeth R Bierlein
- Truhlsen Eye Institute, Department of Ophthalmology & Visual Sciences, University of Nebraska Medical Center, Omaha, NE, USA.,Department of Pharmacology & Experimental Neuroscience, University of Nebraska Medical Center, Omaha, NE, USA
| | - Jennie C Smith
- Truhlsen Eye Institute, Department of Ophthalmology & Visual Sciences, University of Nebraska Medical Center, Omaha, NE, USA
| | - Matthew J Van Hook
- Truhlsen Eye Institute, Department of Ophthalmology & Visual Sciences, University of Nebraska Medical Center, Omaha, NE, USA.,Department of Cellular & Integrative Physiology, University of Nebraska Medical Center, Omaha, NE, USA
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4
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Calvo E, Milla-Navarro S, Ortuño-Lizarán I, Gómez-Vicente V, Cuenca N, De la Villa P, Germain F. Deleterious Effect of NMDA Plus Kainate on the Inner Retinal Cells and Ganglion Cell Projection of the Mouse. Int J Mol Sci 2020; 21:ijms21051570. [PMID: 32106602 PMCID: PMC7084685 DOI: 10.3390/ijms21051570] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Revised: 02/21/2020] [Accepted: 02/22/2020] [Indexed: 12/24/2022] Open
Abstract
Combined administration of N-Methyl-D-Aspartate (NMDA) and kainic acid (KA) on the inner retina was studied as a model of excitotoxicity. The right eye of C57BL6J mice was injected with 1 µL of PBS containing NMDA 30 mM and KA 10 mM. Only PBS was injected in the left eye. One week after intraocular injection, electroretinogram recordings and immunohistochemistry were performed on both eyes. Retinal ganglion cell (RGC) projections were studied by fluorescent-cholerotoxin anterograde labeling. A clear decrease of the retinal "b" wave amplitude, both in scotopic and photopic conditions, was observed in the eyes injected with NMDA/KA. No significant effect on the "a" wave amplitude was observed, indicating the preservation of photoreceptors. Immunocytochemical labeling showed no effects on the outer nuclear layer, but a significant thinning on the inner retinal layers, thus indicating that NMDA and KA induce a deleterious effect on bipolar, amacrine and ganglion cells. Anterograde tracing of the visual pathway after NMDA and KA injection showed the absence of RGC projections to the contralateral superior colliculus and lateral geniculate nucleus. We conclude that glutamate receptor agonists, NMDA and KA, induce a deleterious effect of the inner retina when injected together into the vitreous chamber.
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Affiliation(s)
- Estrella Calvo
- Department of Systems Biology, University of Alcalá, 28871 Madrid, Spain (P.D.l.V.)
| | | | - Isabel Ortuño-Lizarán
- Department of Physiology, Genetics and Microbiology, University of Alicante, 03690 Alicante, Spain
| | - Violeta Gómez-Vicente
- Department of Optics, Pharmacology and Anatomy, University of Alicante, 03690 Alicante, Spain;
| | - Nicolás Cuenca
- Department of Physiology, Genetics and Microbiology, University of Alicante, 03690 Alicante, Spain
| | - Pedro De la Villa
- Department of Systems Biology, University of Alcalá, 28871 Madrid, Spain (P.D.l.V.)
- Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), 28034 Madrid, Spain
| | - Francisco Germain
- Department of Systems Biology, University of Alcalá, 28871 Madrid, Spain (P.D.l.V.)
- Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), 28034 Madrid, Spain
- Correspondence:
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Yan X, Atorf J, Ramos D, Thiele F, Weber S, Dalke C, Sun M, Puk O, Michel D, Fuchs H, Klaften M, Przemeck GKH, Sabrautzki S, Favor J, Ruberte J, Kremers J, de Angelis MH, Graw J. Mutation in Bmpr1b Leads to Optic Disc Coloboma and Ventral Retinal Gliosis in Mice. Invest Ophthalmol Vis Sci 2020; 61:44. [PMID: 32106289 PMCID: PMC7329948 DOI: 10.1167/iovs.61.2.44] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Accepted: 11/10/2019] [Indexed: 12/14/2022] Open
Abstract
Purpose The clinical phenotype of retinal gliosis occurs in different forms; here, we characterize one novel genetic feature, (i.e., signaling via BMP-receptor 1b). Methods Mouse mutants were generated within a recessive ENU mutagenesis screen; the underlying mutation was identified by linkage analysis and Sanger sequencing. The eye phenotype was characterized by fundoscopy, optical coherence tomography, optokinetic drum, electroretinography, and visual evoked potentials, by histology, immunohistology, and electron-microscopy. Results The mutation affects intron 10 of the Bmpr1b gene, which is causative for skipping of exon 10. The expression levels of pSMAD1/5/8 were reduced in the mutant retina. The loss of BMPR1B-mediated signaling leads to optic nerve coloboma, gliosis in the optic nerve head and ventral retina, defective optic nerve axons, and irregular retinal vessels. The ventral retinal gliosis is proliferative and hypertrophic, which is concomitant with neuronal delamination and the reduction of retinal ganglion cells (RGCs); it is dominated by activated astrocytes overexpressing PAX2 and SOX2 but not PAX6, indicating that they may retain properties of gliogenic precursor cells. The expression pattern of PAX2 in the optic nerve head and ventral retina is altered during embryonic development. These events finally result in reduced electrical transmission of the retina and optic nerve and significantly reduced visual acuity. Conclusions Our study demonstrates that BMPR1B is necessary for the development of the optic nerve and ventral retina. This study could also indicate a new mechanism in the formation of retinal gliosis; it opens new routes for its treatment eventually preventing scar formation in the retina.
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Affiliation(s)
- Xiaohe Yan
- Shenzhen Key Laboratory of Ophthalmology, Shenzhen Eye Hospital, Jinan University, Shenzhen, China
- School of Optometry, Shenzhen University, Shenzhen, China
| | - Jenny Atorf
- Department of Ophthalmology, University Hospital Erlangen, Erlangen, Germany
| | - David Ramos
- Department of Animal Health and Anatomy, Center of Animal Biotechnology and Gene Therapy, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Frank Thiele
- Institute of Experimental Genetics, Helmholtz Zentrum München, Neuherberg, Germany
| | - Susanne Weber
- Institute of Developmental Genetics, Helmholtz Zentrum München, Neuherberg, Germany
| | - Claudia Dalke
- Institute of Developmental Genetics, Helmholtz Zentrum München, Neuherberg, Germany
- The German Mouse Clinic, Helmholtz Zentrum München, Neuherberg, Germany
| | - Minxuan Sun
- Institute of Developmental Genetics, Helmholtz Zentrum München, Neuherberg, Germany
- The German Mouse Clinic, Helmholtz Zentrum München, Neuherberg, Germany
| | - Oliver Puk
- Institute of Developmental Genetics, Helmholtz Zentrum München, Neuherberg, Germany
- The German Mouse Clinic, Helmholtz Zentrum München, Neuherberg, Germany
| | - Dian Michel
- Institute of Experimental Genetics, Helmholtz Zentrum München, Neuherberg, Germany
| | - Helmut Fuchs
- Institute of Experimental Genetics, Helmholtz Zentrum München, Neuherberg, Germany
- The German Mouse Clinic, Helmholtz Zentrum München, Neuherberg, Germany
| | - Matthias Klaften
- Institute of Experimental Genetics, Helmholtz Zentrum München, Neuherberg, Germany
| | | | - Sibylle Sabrautzki
- Institute of Experimental Genetics, Helmholtz Zentrum München, Neuherberg, Germany
| | - Jack Favor
- The German Mouse Clinic, Helmholtz Zentrum München, Neuherberg, Germany
- Institute of Human Genetics, Helmholtz Zentrum München, Neuherberg, Germany
| | - Jesús Ruberte
- Department of Animal Health and Anatomy, Center of Animal Biotechnology and Gene Therapy, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Jan Kremers
- Department of Ophthalmology, University Hospital Erlangen, Erlangen, Germany
| | - Martin Hrabě de Angelis
- Institute of Experimental Genetics, Helmholtz Zentrum München, Neuherberg, Germany
- The German Mouse Clinic, Helmholtz Zentrum München, Neuherberg, Germany
- Chair of Experimental Genetics, Faculty of Life and Food Sciences Weihenstephan, Technische Universität München, Freising-Weihenstephan, Germany
- German Center for Diabetes Research (DZD), Neuherberg, Germany
| | - Jochen Graw
- Institute of Developmental Genetics, Helmholtz Zentrum München, Neuherberg, Germany
- The German Mouse Clinic, Helmholtz Zentrum München, Neuherberg, Germany
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Therapeutic Strategies for Attenuation of Retinal Ganglion Cell Injury in Optic Neuropathies: Concepts in Translational Research and Therapeutic Implications. BIOMED RESEARCH INTERNATIONAL 2019; 2019:8397521. [PMID: 31828134 PMCID: PMC6885158 DOI: 10.1155/2019/8397521] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Revised: 10/07/2019] [Accepted: 10/28/2019] [Indexed: 12/19/2022]
Abstract
Retinal ganglion cell (RGC) death is the central and irreversible endpoint of optic neuropathies. Current management of optic neuropathies and glaucoma focuses on intraocular pressure-lowering treatment which is insufficient. As such, patients are effectively condemned to irreversible visual impairment. This review summarizes experimental treatments targeting RGCs over the last decade. In particular, we examine the various treatment modalities and determine their viability and limitations in translation to clinical practice. Experimental RGC treatment can be divided into (1) cell replacement therapy, (2) neuroprotection, and (3) gene therapy. For cell replacement therapy, difficulties remain in successfully integrating transplanted RGCs from various sources into the complex neural network of the human retina. However, there is significant potential for achieving full visual restoration with this technique. Neuroprotective strategies, in the form of pharmacological agents, nutritional supplementation, and neurotrophic factors, are viable strategies with encouraging results from preliminary noncomparative interventional case series. It is important to note, however, that most published studies are focused on glaucoma, with few treating optic neuropathies of other etiologies. Gene therapy, through the use of viral vectors, has shown promising results in clinical trials, particularly for diseases with specific genetic mutations like Leber's hereditary optic neuropathy. This treatment technique can be further extended to nonhereditary diseases, through transfer of genes promoting cell survival and neuroprotection. Crucially though, for gene therapy, teratogenicity remains a significant issue in translation to clinical practice.
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Quantification of Changes in Visual Function During Disease Development in a Mouse Model of Pigmentary Glaucoma. J Glaucoma 2019; 27:828-841. [PMID: 30001268 DOI: 10.1097/ijg.0000000000001024] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
PURPOSE We investigated the relationship between visual parameters that are commonly affected during glaucomatous disease progression with functional measures of retina physiology using electroretinography and behavioral measures of visual function in a mouse model of glaucoma. Electroretinogram components measuring retinal ganglion cell (RGC) responses were determined using the non-invasive Ganzfeld flash electroretinography (fERG) to assess RGC loss in a mouse model of glaucoma. METHODS Intraocular pressure (IOP), behaviorally assessed measures of visual function, namely visual acuity and contrast sensitivity as well as fERG responses were recorded in 4- and 11-month-old male DBA/2 mice. Scotopic threshold response (STR) and photopic negative response components as well as oscillatory potentials (OPs) were isolated from fERG responses and correlated with IOP, optomotor reflex measurements, and RGC counts. RESULTS The 11-month-old DBA/2 mice had significantly elevated IOP, reduced visual performance, as assessed behaviorally, significant RGC loss, deficits in standardized fERG responses, reduced STRs, and differences in OP amplitudes and latencies, when compared with 4-month-old mice of the same strain. STRs and OPs correlated with some visual and physiological parameters. In addition, elevated IOP and RGC loss correlated positively with measures of visual function, specifically with surrogate measures of RGC function derived from fERG. CONCLUSIONS Our data suggest that RGC function as well as interactions of RGCs with other retinal cell types is impaired during glaucoma. In addition, a later OP wavelet denoted as OP4 in this study was identified as a very reproducible indicator of loss of visual function in the glaucoma mouse model.
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Shah M, Cabrera-Ghayouri S, Christie LA, Held KS, Viswanath V. Translational Preclinical Pharmacologic Disease Models for Ophthalmic Drug Development. Pharm Res 2019; 36:58. [PMID: 30805711 PMCID: PMC6394514 DOI: 10.1007/s11095-019-2588-5] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Accepted: 02/08/2019] [Indexed: 12/14/2022]
Abstract
Preclinical models of human diseases are critical to our understanding of disease etiology, pathology, and progression and enable the development of effective treatments. An ideal model of human disease should capture anatomical features and pathophysiological mechanisms, mimic the progression pattern, and should be amenable to evaluating translational endpoints and treatment approaches. Preclinical animal models have been developed for a variety of human ophthalmological diseases to mirror disease mechanisms, location of the affected region in the eye and severity. These models offer clues to aid in our fundamental understanding of disease pathogenesis and enable progression of new therapies to clinical development by providing an opportunity to gain proof of concept (POC). Here, we review preclinical animal models associated with development of new therapies for diseases of the ocular surface, glaucoma, presbyopia, and retinal diseases, including diabetic retinopathy and age-related macular degeneration (AMD). We have focused on summarizing the models critical to new drug development and described the translational features of the models that contributed to our understanding of disease pathogenesis and establishment of preclinical POC.
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Affiliation(s)
- Mihir Shah
- Biological Research, Allergan plc, 2525 Dupont Drive, Irvine, California, 92612, USA
| | - Sara Cabrera-Ghayouri
- Biological Research, Allergan plc, 2525 Dupont Drive, Irvine, California, 92612, USA
| | - Lori-Ann Christie
- Biological Research, Allergan plc, 2525 Dupont Drive, Irvine, California, 92612, USA
| | - Katherine S Held
- Biological Research, Allergan plc, 2525 Dupont Drive, Irvine, California, 92612, USA
| | - Veena Viswanath
- Biological Research, Allergan plc, 2525 Dupont Drive, Irvine, California, 92612, USA.
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9
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Harada C, Kimura A, Guo X, Namekata K, Harada T. Recent advances in genetically modified animal models of glaucoma and their roles in drug repositioning. Br J Ophthalmol 2018; 103:161-166. [PMID: 30366949 PMCID: PMC6362806 DOI: 10.1136/bjophthalmol-2018-312724] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 08/21/2018] [Accepted: 08/25/2018] [Indexed: 12/18/2022]
Abstract
Glaucoma is one of the leading causes of vision loss in the world. Currently, pharmacological intervention for glaucoma therapy is limited to eye drops that reduce intraocular pressure (IOP). Recent studies have shown that various factors as well as IOP are involved in the pathogenesis of glaucoma, especially in the subtype of normal tension glaucoma. To date, various animal models of glaucoma have been established, including glutamate/aspartate transporter knockout (KO) mice, excitatory amino acid carrier 1 KO mice, optineurin E50K knock-in mice, DBA/2J mice and experimentally induced models. These animal models are very useful for elucidating the pathogenesis of glaucoma and for identifying potential therapeutic targets. However, each model represents only some aspects of glaucoma, never the whole disease. This review will summarise the benefits and limitations of using disease models of glaucoma and recent basic research in retinal protection using existing drugs.
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Affiliation(s)
- Chikako Harada
- Visual Research Project, Tokyo Metropolitan Institute of Medical Science, Tokyo 156-8506, Japan
| | - Atsuko Kimura
- Visual Research Project, Tokyo Metropolitan Institute of Medical Science, Tokyo 156-8506, Japan
| | - Xiaoli Guo
- Visual Research Project, Tokyo Metropolitan Institute of Medical Science, Tokyo 156-8506, Japan
| | - Kazuhiko Namekata
- Visual Research Project, Tokyo Metropolitan Institute of Medical Science, Tokyo 156-8506, Japan
| | - Takayuki Harada
- Visual Research Project, Tokyo Metropolitan Institute of Medical Science, Tokyo 156-8506, Japan
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Abstract
Electroretinography is a crucial assay for studying the function and the functional integrity of the retina. The mouse is an important animal model for studying the retinal neurons and circuitries. In addition, it is often used as animal model for human retinal disorders. Therefore, a good understanding of the procedures in animal handling, of the methods for data analysis and of the requirements for stimulators and for the data acquisition equipment is of importance. Here, the currently most common methods and materials for in vivo electroretinography in the mouse are discussed.
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Affiliation(s)
- Jan Kremers
- Department of Ophthalmology, University Hospital Erlangen, Erlangen, Germany.
| | - Naoyuki Tanimoto
- Department of Ophthalmology, University Hospital Schleswig-Holstein, Kiel, Germany
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11
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Norrin protects optic nerve axons from degeneration in a mouse model of glaucoma. Sci Rep 2017; 7:14274. [PMID: 29079753 PMCID: PMC5660254 DOI: 10.1038/s41598-017-14423-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Accepted: 10/10/2017] [Indexed: 11/25/2022] Open
Abstract
Norrin is a secreted signaling molecule activating the Wnt/β-catenin pathway. Since Norrin protects retinal neurons from experimental acute injury, we were interested to learn if Norrin attenuates chronic damage of retinal ganglion cells (RGC) and their axons in a mouse model of glaucoma. Transgenic mice overexpressing Norrin in the retina (Pax6-Norrin) were generated and crossed with DBA/2J mice with hereditary glaucoma and optic nerve axonal degeneration. One-year old DBA/2J/Pax6-Norrin animals had significantly more surviving optic nerve axons than their DBA/2J littermates. The protective effect correlated with an increase in insulin-like growth factor (IGF)-1 mRNA and an enhanced Akt phosphorylation in DBA/2J/Pax6-Norrin mice. Both mouse strains developed an increase in intraocular pressure during the second half of the first year and marked degenerative changes in chamber angle, ciliary body and iris structure. The degenerations were slightly attenuated in the chamber angle of DBA/2J/Pax6-Norrin mice, which showed a β-catenin increase in the trabecular meshwork. We conclude that high levels of Norrin and the subsequent constitutive activation of Wnt/β-catenin signaling in RGC protect from glaucomatous axonal damage via IGF-1 causing increased activity of PI3K-Akt signaling. Our results identify components of a protective signaling network preventing degeneration of optic nerve axons in glaucoma.
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12
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Moustafa MT, Ramirez C, Schneider K, Atilano SR, Limb GA, Kuppermann BD, Kenney MC. Protective Effects of Memantine on Hydroquinone-Treated Human Retinal Pigment Epithelium Cells and Human Retinal Müller Cells. J Ocul Pharmacol Ther 2017; 33:610-619. [PMID: 28961056 DOI: 10.1089/jop.2016.0129] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
PURPOSE Memantine (MEM) acts on the glutamatergic system by blocking N-methyl-d-aspartate (NMDA) glutamate receptors. The role that MEM plays in protecting retinal cells is unknown. Hydroquinone (HQ) is one of the cytotoxic components in cigarette smoke. In the present study, we tested whether pretreatment with MEM could protect against the cytotoxic effects of HQ on human retinal pigment epithelium cells (ARPE-19) and human retinal Müller cells (MIO-M1) in vitro. METHODS Cells were plated, pretreated for 6 h with 30 μM of MEM, and then exposed for 24 h to 200, 100, 50, and 25 μM of HQ while MEM was still present. Cell viability (CV), reactive oxygen species (ROS), mitochondrial membrane potential (ΔΨm), and lactate dehydrogenase (LDH) release assays were performed. RESULTS HQ-treated cells showed a dose-dependent decrease in CV and ΔΨm, but an increase in ROS production and LDH levels in both cell lines. MEM pretreatment reversed the CV in 50, 100, and 200 μM doses in ARPE-19 cells and at all HQ concentrations in MIO-M1 cells compared to HQ-treated cultures. ROS production was reversed in all HQ concentrations in both cell lines. ΔΨm was significantly increased after MEM pretreatment only in 50 μM HQ concentration for both cell lines. LDH levels were decreased at 50 and 25 μM HQ in ARPE-19 and MIO-M1 cells, respectively. CONCLUSION HQ-induced toxicity is concentration dependent in ARPE-19 and MIO-M1 cultures. MEM exerts protective effects against HQ-induced toxicity on human retinal pigment epithelial and Müller cells in vitro.
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Affiliation(s)
- Mohamed Tarek Moustafa
- 1 Gavin Herbert Eye Institute, University of California, Irvine , Irvine, California
- 2 Ophthalmology Department, Minia University , Minia, Egypt
| | - Claudio Ramirez
- 1 Gavin Herbert Eye Institute, University of California, Irvine , Irvine, California
| | - Kevin Schneider
- 1 Gavin Herbert Eye Institute, University of California, Irvine , Irvine, California
| | - Shari R Atilano
- 1 Gavin Herbert Eye Institute, University of California, Irvine , Irvine, California
| | - Gloria Astrid Limb
- 3 Division of Ocular Biology and Therapeutics, UCL Institute of Ophthalmology , London, United Kingdom
| | - Baruch D Kuppermann
- 1 Gavin Herbert Eye Institute, University of California, Irvine , Irvine, California
| | - Maria Cristina Kenney
- 1 Gavin Herbert Eye Institute, University of California, Irvine , Irvine, California
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Kurtenbach S, Gießl A, Strömberg S, Kremers J, Atorf J, Rasche S, Neuhaus EM, Hervé D, Brandstätter JH, Asan E, Hatt H, Kilimann MW. The BEACH Protein LRBA Promotes the Localization of the Heterotrimeric G-protein G olf to Olfactory Cilia. Sci Rep 2017; 7:8409. [PMID: 28814779 PMCID: PMC5559528 DOI: 10.1038/s41598-017-08543-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Accepted: 07/10/2017] [Indexed: 02/07/2023] Open
Abstract
BEACH domain proteins are involved in membrane protein traffic and human diseases, but their molecular mechanisms are not understood. The BEACH protein LRBA has been implicated in immune response and cell proliferation, and human LRBA mutations cause severe immune deficiency. Here, we report a first functional and molecular phenotype outside the immune system of LRBA-knockout mice: compromised olfaction, manifesting in reduced electro-olfactogram response amplitude, impaired food-finding efficiency, and smaller olfactory bulbs. LRBA is prominently expressed in olfactory and vomeronasal chemosensory neurons of wild-type mice. Olfactory impairment in the LRBA-KO is explained by markedly reduced concentrations (20–40% of wild-type levels) of all three subunits αolf, β1 and γ13 of the olfactory heterotrimeric G-protein, Golf, in the sensory cilia of olfactory neurons. In contrast, cilia morphology and the concentrations of many other proteins of olfactory cilia are not or only slightly affected. LRBA is also highly expressed in photoreceptor cells, another cell type with a specialized sensory cilium and heterotrimeric G-protein-based signalling; however, visual function appeared unimpaired by the LRBA-KO. To our knowledge, this is the first observation that a BEACH protein is required for the efficient subcellular localization of a lipid-anchored protein, and of a ciliary protein.
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Affiliation(s)
- Stefan Kurtenbach
- Department of Cell Physiology, Ruhr University Bochum, D-44780, Bochum, Germany
| | - Andreas Gießl
- Department of Biology, Animal Physiology, University of Erlangen-Nürnberg, D-91058, Erlangen, Germany
| | - Siv Strömberg
- Department of Neuroscience, Uppsala University, S-75124, Uppsala, Sweden
| | - Jan Kremers
- Department of Ophthalmology, University Hospital Erlangen, D-91054, Erlangen, Germany.,Department of Anatomy II, Friedrich-Alexander University Erlangen-Nürnberg, D-91054, Erlangen, Germany
| | - Jenny Atorf
- Department of Ophthalmology, University Hospital Erlangen, D-91054, Erlangen, Germany
| | - Sebastian Rasche
- Department of Cell Physiology, Ruhr University Bochum, D-44780, Bochum, Germany
| | - Eva M Neuhaus
- Department of Pharmacology and Toxikology, University Hospital Jena, D-07747, Jena, Germany
| | - Denis Hervé
- Inserm UMR-S839, Institut du Fer a Moulin, Universite Pierre et Marie Curie, F-75005, Paris, France
| | | | - Esther Asan
- Institute of Anatomy and Cell Biology, University of Würzburg, D-97070, Würzburg, Germany
| | - Hanns Hatt
- Department of Cell Physiology, Ruhr University Bochum, D-44780, Bochum, Germany
| | - Manfred W Kilimann
- Department of Neuroscience, Uppsala University, S-75124, Uppsala, Sweden. .,Department of Molecular Neurobiology, Max Planck Institute for Experimental Medicine, D-37075, Göttingen, Germany.
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Tsai TI, Atorf J, Neitz M, Neitz J, Kremers J. Rod- and cone-driven responses in mice expressing human L-cone pigment. J Neurophysiol 2015; 114:2230-41. [PMID: 26245314 DOI: 10.1152/jn.00188.2015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Accepted: 08/03/2015] [Indexed: 12/31/2022] Open
Abstract
The mouse is commonly used for studying retinal processing, primarily because it is amenable to genetic manipulation. To accurately study photoreceptor driven signals in the healthy and diseased retina, it is of great importance to isolate the responses of single photoreceptor types. This is not easily achieved in mice because of the strong overlap of rod and M-cone absorption spectra (i.e., maxima at 498 and 508 nm, respectively). With a newly developed mouse model (Opn1lw(LIAIS)) expressing a variant of the human L-cone pigment (561 nm) instead of the mouse M-opsin, the absorption spectra are substantially separated, allowing retinal physiology to be studied using silent substitution stimuli. Unlike conventional chromatic isolation methods, this spectral compensation approach can isolate single photoreceptor subtypes without changing the retinal adaptation. We measured flicker electroretinograms in these mutants under ketamine-xylazine sedation with double silent substitution (silent S-cone and either rod or M/L-cones) and obtained robust responses for both rods and (L-)cones. Small signals were yielded in wild-type mice, whereas heterozygotes exhibited responses that were generally intermediate to both. Fundamental response amplitudes and phase behaviors (as a function of temporal frequency) in all genotypes were largely similar. Surprisingly, isolated (L-)cone and rod response properties in the mutant strain were alike. Thus the LIAIS mouse warrants a more comprehensive in vivo assessment of photoreceptor subtype-specific physiology, because it overcomes the hindrance of overlapping spectral sensitivities present in the normal mouse.
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Affiliation(s)
- Tina I Tsai
- Department of Ophthalmology, University Hospital Erlangen, Erlangen, Germany; Department of Biology, Division of Animal Physiology, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany
| | - Jenny Atorf
- Department of Ophthalmology, University Hospital Erlangen, Erlangen, Germany; Department of Biology, Division of Animal Physiology, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany
| | - Maureen Neitz
- Vision Sciences, University of Washington, Seattle, Washington
| | - Jay Neitz
- Vision Sciences, University of Washington, Seattle, Washington
| | - Jan Kremers
- Department of Ophthalmology, University Hospital Erlangen, Erlangen, Germany; Department of Anatomy II, University of Erlangen-Nürnberg, Germany; and School of Optometry and Vision Science, University of Bradford, Bradford, United Kingdom
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Domenici L, Origlia N, Falsini B, Cerri E, Barloscio D, Fabiani C, Sansò M, Giovannini L. Rescue of retinal function by BDNF in a mouse model of glaucoma. PLoS One 2014; 9:e115579. [PMID: 25536045 PMCID: PMC4275209 DOI: 10.1371/journal.pone.0115579] [Citation(s) in RCA: 88] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2014] [Accepted: 11/29/2014] [Indexed: 12/21/2022] Open
Abstract
Vision loss in glaucoma is caused by progressive dysfunction of retinal ganglion cells (RGCs) and optic nerve atrophy. Here, we investigated the effectiveness of BDNF treatment to preserve vision in a glaucoma experimental model. As an established experimental model, we used the DBA/2J mouse, which develops chronic intraocular pressure (IOP) elevation that mimics primary open-angle glaucoma (POAG). IOP was measured at different ages in DBA/2J mice. Visual function was monitored using the steady-state Pattern Electroretinogram (P-ERG) and visual cortical evoked potentials (VEP). RGC alterations were assessed using Brn3 immunolabeling, and confocal microscope analysis. Human recombinant BDNF was dissolved in physiological solution (0.9% NaCl); the effects of repeated intravitreal injections and topical eye BDNF applications were independently evaluated in DBA/2J mice with ocular hypertension. BDNF level was measured in retinal homogenate by ELISA and western blot. We found a progressive decline of P-ERG and VEP responses in DBA/2J mice between 4 and 7 months of age, in relationship with the development of ocular hypertension and the reduction of Brn3 immunopositive RGCs. Conversely, repeated intravitreal injections (BDNF concentration = 2 µg/µl, volume = 1 µl, for each injection; 1 injection every four days, three injections over two weeks) and topical eye application of BDNF eye-drops (12 µg/µl, 5 µl eye-drop every 48 h for two weeks) were able to rescue visual responses in 7 month DBA/2J mice. In particular, BDNF topical eye treatment recovered P-ERG and VEP impairment increasing the number of Brn3 immunopositive RGCs. We showed that BDNF effects were independent of IOP reduction. Thus, topical eye treatment with BDNF represents a promisingly safe and feasible strategy to preserve visual function and diminish RGC vulnerability to ocular hypertension.
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Affiliation(s)
- Luciano Domenici
- Neuroscience Institute of the National Council of Research (CNR), Pisa, Italy; Department of Applied Clinical Sciences and Biotechnology (DISCAB), University of L'Aquila, L'Aquila, Italy
| | - Nicola Origlia
- Neuroscience Institute of the National Council of Research (CNR), Pisa, Italy
| | - Benedetto Falsini
- Institute of Ophthalmology, Policlinico Gemelli, Catholic University, Rome, Italy
| | - Elisa Cerri
- Neuroscience Institute of the National Council of Research (CNR), Pisa, Italy
| | - Davide Barloscio
- Neuroscience Institute of the National Council of Research (CNR), Pisa, Italy
| | - Carlotta Fabiani
- Neuroscience Institute of the National Council of Research (CNR), Pisa, Italy
| | - Marco Sansò
- Department of Translational Research on New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Luca Giovannini
- Department of Translational Research on New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
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Namekata K, Kimura A, Kawamura K, Harada C, Harada T. Dock GEFs and their therapeutic potential: neuroprotection and axon regeneration. Prog Retin Eye Res 2014; 43:1-16. [PMID: 25016980 DOI: 10.1016/j.preteyeres.2014.06.005] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Revised: 06/26/2014] [Accepted: 06/30/2014] [Indexed: 12/17/2022]
Abstract
The dedicator of cytokinesis (Dock) family is composed of atypical guanine exchange factors (GEFs) that activate the Rho GTPases Rac1 and Cdc42. Rho GTPases are best documented for their roles in actin polymerization and they regulate important cellular functions, including morphogenesis, migration, neuronal development, and cell division and adhesion. To date, 11 Dock family members have been identified and their roles have been reported in diverse contexts. There has been increasing interest in elucidating the roles of Dock proteins in recent years and studies have revealed that they are potential therapeutic targets for various diseases, including glaucoma, Alzheimer's disease, cancer, attention deficit hyperactivity disorder and combined immunodeficiency. Among the Dock proteins, Dock3 is predominantly expressed in the central nervous system and recent studies have revealed that Dock3 plays a role in protecting retinal ganglion cells from neurotoxicity and oxidative stress as well as in promoting optic nerve regeneration. In this review, we discuss the current understanding of the 11 Dock GEFs and their therapeutic potential, with a particular focus on Dock3 as a novel target for the treatment of glaucoma and other neurodegenerative diseases.
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Affiliation(s)
- Kazuhiko Namekata
- Visual Research Project, Tokyo Metropolitan Institute of Medical Science, 2-1-6 Kamikitazawa, Setagaya-ku, Tokyo 156-8506, Japan
| | - Atsuko Kimura
- Visual Research Project, Tokyo Metropolitan Institute of Medical Science, 2-1-6 Kamikitazawa, Setagaya-ku, Tokyo 156-8506, Japan
| | - Kazuto Kawamura
- Visual Research Project, Tokyo Metropolitan Institute of Medical Science, 2-1-6 Kamikitazawa, Setagaya-ku, Tokyo 156-8506, Japan
| | - Chikako Harada
- Visual Research Project, Tokyo Metropolitan Institute of Medical Science, 2-1-6 Kamikitazawa, Setagaya-ku, Tokyo 156-8506, Japan
| | - Takayuki Harada
- Visual Research Project, Tokyo Metropolitan Institute of Medical Science, 2-1-6 Kamikitazawa, Setagaya-ku, Tokyo 156-8506, Japan.
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Pérez de Lara MJ, Santano C, Guzmán-Aránguez A, Valiente-Soriano FJ, Avilés-Trigueros M, Vidal-Sanz M, de la Villa P, Pintor J. Assessment of inner retina dysfunction and progressive ganglion cell loss in a mouse model of glaucoma. Exp Eye Res 2014; 122:40-9. [PMID: 24631335 DOI: 10.1016/j.exer.2014.02.022] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2013] [Revised: 02/13/2014] [Accepted: 02/25/2014] [Indexed: 12/11/2022]
Abstract
The DBA/2J mouse is a model of ocular hypertension and retinal ganglion cell (RGC) degeneration, the main features of which are iris pigment dispersion (IPD) and iris stromal atrophy (ISA). These animals also experience glaucomatous changes, including an increase in intraocular pressure (IOP) beginning at about 9-12 months of age and sectorial RGC death in the retina. The aim of this study was to determine the onset of functional changes exhibited by DBA/2J mice in the inner retina. This was performed by means of electroretinographic recordings (scotopic threshold response, STR) and their correlation with morphological changes (loss of RGCs). To this end, we recorded the scotopic threshold response in control C57BL/6J and in DBA/2J mice at different ages. The RGCs, in both DBA/2J and C57BL/6J animals, were identified at 15 months of age by retrograde tracing with an analogue of fluorogold, hydroxystilbamidine methanesulfonate (OHSt), applied on the superior colliculi. Whole mount retinas were processed to quantify the population of RGCs identified by fluorogold tracing and Brn3a immunodetection, and were counted using image analysis software; an isodensity contour plot was generated for each retina. DBA/2J mice showed a significant reduction in the positive STR (pSTR) amplitudes at 12 months of age, as compared to control C57BL/6J mice of the same age. The pSTR mean amplitude decreased to approximately 27.82% of the values recorded in control mice (p = 0.0058). STR responses decreased in both strains as a result of the natural process of aging, but the decrease was more pronounced in DBA/2J mice. Furthermore, quantification of the total number of RGCs identified by OHSt and Brn3a expression showed a reduced population of RGCs in DBA/2J mice as compared to control mice. Regression analysis revealed significant correlations between the decrease in pSTR and a non-homogeneous reduction in the number of RGCs throughout the retina. Our results indicate the existence of a correlation between retinal function impairment and RGC loss. This functional and morphological analysis allows a reliable assessment of the progression of the disease.
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Affiliation(s)
- María J Pérez de Lara
- Department of Biochemistry and Molecular Biology IV, Faculty of Optics and Optometry, Complutense University of Madrid, c/Arcos de Jalón 118, E-28037 Madrid, Spain; Red Española Temática de Investigación Cooperativa en Patología Ocular Prevalente y Crónica, Instituto de Salud Carlos III, Madrid, PC, Spain
| | - Concepción Santano
- Department of Biochemistry and Molecular Biology IV, Faculty of Optics and Optometry, Complutense University of Madrid, c/Arcos de Jalón 118, E-28037 Madrid, Spain
| | - Ana Guzmán-Aránguez
- Department of Biochemistry and Molecular Biology IV, Faculty of Optics and Optometry, Complutense University of Madrid, c/Arcos de Jalón 118, E-28037 Madrid, Spain; Red Española Temática de Investigación Cooperativa en Patología Ocular Prevalente y Crónica, Instituto de Salud Carlos III, Madrid, PC, Spain
| | - F Javier Valiente-Soriano
- Experimental Ophthalmology Laboratory, Dept. of Ophthalmology, College of Medicine, University of Murcia, Regional Campus of International Excellence "Campus Mare Nostrum", Murcia Institute of Bio-Health Research (IMIB), E-30100 Murcia, Spain; Red Española Temática de Investigación Cooperativa en Patología Ocular Prevalente y Crónica, Instituto de Salud Carlos III, Madrid, PC, Spain
| | - Marcelino Avilés-Trigueros
- Experimental Ophthalmology Laboratory, Dept. of Ophthalmology, College of Medicine, University of Murcia, Regional Campus of International Excellence "Campus Mare Nostrum", Murcia Institute of Bio-Health Research (IMIB), E-30100 Murcia, Spain; Red Española Temática de Investigación Cooperativa en Patología Ocular Prevalente y Crónica, Instituto de Salud Carlos III, Madrid, PC, Spain
| | - Manuel Vidal-Sanz
- Experimental Ophthalmology Laboratory, Dept. of Ophthalmology, College of Medicine, University of Murcia, Regional Campus of International Excellence "Campus Mare Nostrum", Murcia Institute of Bio-Health Research (IMIB), E-30100 Murcia, Spain; Red Española Temática de Investigación Cooperativa en Patología Ocular Prevalente y Crónica, Instituto de Salud Carlos III, Madrid, PC, Spain
| | - Pedro de la Villa
- Department of Systems Biology, University of Alcalá, 28871 Alcalá de Henares, Spain; Red Española Temática de Investigación Cooperativa en Patología Ocular Prevalente y Crónica, Instituto de Salud Carlos III, Madrid, PC, Spain
| | - Jesús Pintor
- Department of Biochemistry and Molecular Biology IV, Faculty of Optics and Optometry, Complutense University of Madrid, c/Arcos de Jalón 118, E-28037 Madrid, Spain; Red Española Temática de Investigación Cooperativa en Patología Ocular Prevalente y Crónica, Instituto de Salud Carlos III, Madrid, PC, Spain.
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