John S. Penn

Vascular endothelial growth factor in eye disease

Collectively, angiogenic ocular conditions represent the leading cause of irreversible vision loss in developed countries. In the US, for example, retinopathy of prematurity, diabetic retinopathy and age-related macular degeneration are the principal causes of blindness in the infant, working age and elderly populations, respectively. Evidence suggests that vascular endothelial growth factor (VEGF), a 40kDa dimeric glycoprotein, promotes angiogenesis in each of these conditions, making it a highly significant therapeutic target. However, VEGF is pleiotropic, affecting a broad spectrum of endothelial, neuronal and glial behaviors, and confounding the validity of anti-VEGF strategies, particularly under chronic disease conditions. In fact, among other functions VEGF can influence cell proliferation, cell migration, proteolysis, cell survival and vessel permeability in a wide variety of biological contexts. This article will describe the roles played by VEGF in the pathogenesis of retinopathy of prematurity, diabetic retinopathy and age-related macular degeneration. The potential disadvantages of inhibiting VEGF will be discussed, as will the rationales for targeting other VEGF-related modulators of angiogenesis.

Exposure to Alternating Hypoxia and Hyperoxia Causes Severe Proliferative Retinopathy in the Newborn Rat

ABSTRACT: Exposure to variable hyperoxia has recently been shown to be much more effective at producing proliferative retinopathy in the newborn rat than exposure to constant hyperoxia. To incorporate a more clinically relevant oxygen- exposure paradigm in our studies, we have now used a cycle between 50 and 10% oxygen and have compared its effects with those found using new exposures to the previously used 80/40% cycle. Starting at birth and continuing for 14 d, rats were exposed to environments that cycled between 50 and 10% oxygen or 80 and 40% oxygen every 24 h. After exposure, some rats were killed for assessment of retinal vascular development. Others were removed to room air for 4 d before killing and evaluation for the presence of abnormal neovascularization—a clinical consequence believed to be promoted by termination of oxygen therapy. The 50/10% cycle resulted in greater retardation of retinal blood vessel development during oxygen than that found in the 80/40% exposure group. After 4 d postexposure in room air, the incidence of preretinal neovascularization was 97% in the 50/10% rats and 72% in the 80/40% group. Clearly, the overall amount of oxygen the subject receives is less critical than other parameters of its administration in producing proliferative retinopathy. Also, the range of variation (40% in both cases) is not the controlling characteristic. Our results suggest that consistency of oxygen level and avoidance of hypoxic levels should be important concerns in neonatal oxygen therapy.

Mechanisms and Management of Retinopathy of Prematurity

This article reviews retinopathy of prematurity, particularly regarding oxygen use, and describes current and potential therapies based on mechanistic studies in models relevant to current oxygen stresses in preterm infants.

Effect of light history on retinal antioxidants and light damage susceptibility in the rat

Albino rats were born and raised to 12 weeks of age in 12L:12D light regimes of 5, 300 or 800 lx. Upon killing, the activities of the following glutathione enzymes were measured in the neuroretina: (1) glutathione peroxidase; (2) glutathione-S-transferase; and (3) glutathione reductase. Also measured were vitamin E, ascorbic acid, and the levels of oxidized and reduced glutathione. Animals raised in 800-lx cyclic light have a significant increase in the retinal activities of the three glutathione enzymes over activities measured in animals raised in the two dimmer regimes. The retinal level of vitamin E, measured per nmol of lipid phosphorus, is directly and significantly correlated with rearing illuminance (P less than 0.05). The same is true of retinal ascorbic acid, which shows a 30% increase in the 800-lx-reared rats over the level of those raised in the intermediate light regime (300 lx). Some of the animals from each group were exposed to 2000 lx for 24 hr to determine if correlations existed between the levels of retinal antioxidants listed above and susceptibility to light damage. Animals raised in 5-lx cyclic light lost almost all of their photoreceptors as a result of the exposure. Rats raised in 300-lx cyclic light lost a small but significant number (ca. 20%), while those raised in 800 lx sustained no light damage. Electroretinographic evaluation supports these morphometrical findings.

Inactivating Variants in ANGPTL4 and Risk of Coronary Artery Disease

BACKGROUND Higher-than-normal levels of circulating triglycerides are a risk factor for ischemic cardiovascular disease. Activation of lipoprotein lipase, an enzyme that is inhibited by angiopoietin-like 4 (ANGPTL4), has been shown to reduce levels of circulating triglycerides. METHODS We sequenced the exons of ANGPTL4 in samples obtain from 42,930 participants of predominantly European ancestry in the DiscovEHR human genetics study. We performed tests of association between lipid levels and the missense E40K variant (which has been associated with reduced plasma triglyceride levels) and other inactivating mutations. We then tested for associations between coronary artery disease and the E40K variant and other inactivating mutations in 10,552 participants with coronary artery disease and 29,223 controls. We also tested the effect of a human monoclonal antibody against ANGPTL4 on lipid levels in mice and monkeys. RESULTS We identified 1661 heterozygotes and 17 homozygotes for the E40K variant and 75 participants who had 13 other monoallelic inactivating mutations in ANGPTL4. The levels of triglycerides were 13% lower and the levels of high-density lipoprotein (HDL) cholesterol were 7% higher among carriers of the E40K variant than among noncarriers. Carriers of the E40K variant were also significantly less likely than noncarriers to have coronary artery disease (odds ratio, 0.81; 95% confidence interval, 0.70 to 0.92; P=0.002). K40 homozygotes had markedly lower levels of triglycerides and higher levels of HDL cholesterol than did heterozygotes. Carriers of other inactivating mutations also had lower triglyceride levels and higher HDL cholesterol levels and were less likely to have coronary artery disease than were noncarriers. Monoclonal antibody inhibition of Angptl4 in mice and monkeys reduced triglyceride levels. CONCLUSIONS Carriers of E40K and other inactivating mutations in ANGPTL4 had lower levels of triglycerides and a lower risk of coronary artery disease than did noncarriers. The inhibition of Angptl4 in mice and monkeys also resulted in corresponding reductions in these values. (Funded by Regeneron Pharmaceuticals.).

Arterial oxygen fluctuation and retinopathy of prematurity in very-low-birth-weight infants

OBJECTIVE: To determine the influence of arterial oxygen fluctuation on development of threshold ROP.STUDY DESIGN: Retrospective study of 231 infants, ≤1500 g birth weight, who were admitted to Arkansas Childrens Hospital NICU from January 1993 to June 1995. Fluctuation in partial pressure of dissolved arterial oxygen (PaO2) was expressed as coefficient of variation (CoV) for each infant. We investigated the relationship between CoV at three intervals and the risk of developing threshold ROP.RESULTS: The odds ratio (OR) of developing threshold ROP versus prethreshold ROP or less associated with a 10% increase in the CoV during the first 5 days of oxygen therapy was 1.44, and during the first 10 days was 1.51. When analysis was restricted to infants receiving 30 days of therapy, the OR during the first 5 days of therapy was 1.67, during the first 10 days was 1.82, and during days 11–30 was 1.68.CONCLUSIONS: Very-low-birth-weight infants experiencing fluctuating PaO2 are at higher risk of threshold ROP.

Therapeutic Effect of Liposomal Superoxide Dismutase in an Animal Model of Retinopathy of Prematurity

A newborn rat model of retinopathy of prematurity was used to test the hypothesis that a lack of superoxide dismutase contributes to the retinal vaso-attenuation seen during exposure of the animals to hyperoxic conditions. To determine the endogenous superoxide dismutase activity of the retina under hyperoxic conditions, litters of albino rats were placed in either constant 80% ambient oxygen (constant hyperoxia), or placed in 21% oxygen (room air) immediately after birth. Every other day, for 14 days, several rat pups were sacrificed and their retinas removed for the determination of total superoxide dismutase (SOD) activity and manganese-associated SOD activity. An attempt was made to increase retinal SOD activity by intraperitoneal administration of exogenous SOD encapsulated in polyethylene glycol-modified liposomes. Additional litters were exposed to the same oxygen treatments and supplemented twice daily with either liposome-encapsulated superoxide dismutase in saline or liposomes containing saline without SOD. Animals were sacrificed at various time points for the determination of total superoxide dismutase activity and computer-assisted analysis of vessel density and avascular area. Animals raised in an atmosphere of constant 80% oxygen had significantly reduced levels of retinal superoxide dismutase activity through 6 days of life when compared to their room air-raised littermates. At 6 days of age, daily supplementation with liposome-encapsulated SOD had significantly increased retinal superoxide dismutase activity and reduced oxygen-induced vaso-attenuation as evidenced by increased vessel density and decreased avascular area, when compared to littermates exposed to constant hyperoxia that received control liposomes. Superoxide dismutase had no adverse effects on any of the animals regardless of treatment. Tracing experiments demonstrated that liposomes entered the retina and were found in cells morphologically resembling mi-croglia. Delivery of SOD to the retina via long-circulating liposomes proved beneficial, suggesting that restoration and/or supplementation of endogenous antioxidants in oxygen-damaged retinal tissue is a potentially valuable therapeutic strategy.

Genetic and Pharmacologic Inactivation of ANGPTL3 and Cardiovascular Disease

BACKGROUND Loss‐of‐function variants in the angiopoietin‐like 3 gene (ANGPTL3) have been associated with decreased plasma levels of triglycerides, low‐density lipoprotein (LDL) cholesterol, and high‐density lipoprotein (HDL) cholesterol. It is not known whether such variants or therapeutic antagonism of ANGPTL3 are associated with a reduced risk of atherosclerotic cardiovascular disease. METHODS We sequenced the exons of ANGPTL3 in 58,335 participants in the DiscovEHR human genetics study. We performed tests of association for loss‐of‐function variants in ANGPTL3 with lipid levels and with coronary artery disease in 13,102 case patients and 40,430 controls from the DiscovEHR study, with follow‐up studies involving 23,317 case patients and 107,166 controls from four population studies. We also tested the effects of a human monoclonal antibody, evinacumab, against Angptl3 in dyslipidemic mice and against ANGPTL3 in healthy human volunteers with elevated levels of triglycerides or LDL cholesterol. RESULTS In the DiscovEHR study, participants with heterozygous loss‐of‐function variants in ANGPTL3 had significantly lower serum levels of triglycerides, HDL cholesterol, and LDL cholesterol than participants without these variants. Loss‐of‐function variants were found in 0.33% of case patients with coronary artery disease and in 0.45% of controls (adjusted odds ratio, 0.59; 95% confidence interval, 0.41 to 0.85; P=0.004). These results were confirmed in the follow‐up studies. In dyslipidemic mice, inhibition of Angptl3 with evinacumab resulted in a greater decrease in atherosclerotic lesion area and necrotic content than a control antibody. In humans, evinacumab caused a dose‐dependent placebo‐adjusted reduction in fasting triglyceride levels of up to 76% and LDL cholesterol levels of up to 23%. CONCLUSIONS Genetic and therapeutic antagonism of ANGPTL3 in humans and of Angptl3 in mice was associated with decreased levels of all three major lipid fractions and decreased odds of atherosclerotic cardiovascular disease. (Funded by Regeneron Pharmaceuticals and others; ClinicalTrials.gov number, NCT01749878.)

Effect of a Water-Soluble Vitamin E Analog, Trolox C, on Retinal Vascular Development in an Animal Model of Retinopathy of Prematurity

The debate over the efficacy of vitamin E as a therapy for retinopathy of prematurity (ROP) continues 45 years after it was first proposed. The discrepancies between one clinical study and another may be due to the difficulty of delivering a lipid-soluble molecule like vitamin E to the immature retina. Trolox C is a water-soluble analog of vitamin E with potent antioxidant activity. We have studied the effectiveness of intraperitoneal injection of Trolox C in an animal model of ROP. Albino rats were placed in 80% oxygen at birth where they remained for 14 d before sacrifice and assessment of retinal vasculature. Rats were administered 625 microg/kg Trolox C, or vehicle, by intraperitoneal injection on alternate days for the duration of the exposure. Other rats were simultaneously raised in room air, injected, and assessed as controls. Percent avascular retinal area, vascular leakage, and retinal capillary density were measured by computer-assisted image analysis. Trolox C-injected rats had significantly smaller avascular areas (14.6 +/- 4.8% vs. 25.4 +/- 6.3%), less leak area (0.04 +/- 0.07 mm2 vs. 0.16 +/- 0.14 mm2), and greater capillary density (24.3 +/- 2.6 pixel % vs. 18.9 +/- 3.1 pixel %) than vehicle-injected counterparts. These findings indicate that Trolox C facilitated the process of retinal vasculogenesis under hyperoxemic conditions. They also suggest that oxygen free radical-mediated damage plays a role in the pathologic effect of high oxygen rearing of newborn rats. Additional studies are warranted to determine precise site(s) and mechanism(s) of Trolox C activity in this and similar disease models in which peroxidation is believed to play a causal role.

Detection of Vascular Endothelial Growth Factor (VEGF) Protein in Vascular and Non-Vascular Cells of the Normal and Oxygen-Injured Rat Retina

Vascular endothelial growth factor (VEGF) is a potent and specific endothelial cell cytokine that can be up-regulated by hypoxia. There is evidence that VEGF is a significant mediator in retinal neovascular diseases and other disorders in which hypoxia is believed to influence the pathogenesis. Here we demonstrate the spatial relationships among areas of retinal non-perfusion, VEGF protein and vascular endothelial cells throughout the retina, and relate these results to cellular distribution of VEGF in cross section. Newborn albino rats were oxygen-injured by cycles of alternating 50% and 10% oxygen for 14 days and then placed in room air. On days 16, 21 and 26, oxygen-injured and control (raised in room air) rats were sacrificed, enucleated and retinas were dissected and fixed for whole mount immunostaining for VEGF or embedding in glycol methacrylate for VEGF immunohistochemistry. Intact eyes taken on days 16 and 20 were processed similarly. Vascular endothelial cells were demonstrated by staining whole-mounted retinas for adenosine diphosphatase (ADPase) activity. Preretinal neovascular growths (i.e., abnormal vessels extending from the retina into the vitreous) were VEGF-positive. There was also a pan-retinal distribution of non-endothelial cells that were VEGF-positive in both room air and oxygen-injured rats, with stronger immunostaining in day 16 oxygen-injured retinas. In cross-section, VEGF staining was confirmed in preretinal growths, normal retinal vessels, cells in the inner nuclear layer (primarily Müller cells) and ganglion cells. Retinas which had been incubated with nonimmune IgG or absorbed anti-VEGF antibody showed little or no staining. In conclusion, we have identified cells of the inner retina which express VEGF. The production of VEGF by these cells--in particular, Müller cells--may promote preretinal neovascularization in oxygen-injured eyes. We have found, moreover, that the combination of immunohistochemistry and ADPase staining of whole mount preparations is a unique and powerful tool for evaluating relationships between presumed areas of retinal ischemia, VEGF (and other cytokines) and retinal blood vessels, within an entire retina. This approach can be used to study any proliferative retinal disorders in which VEGF is a potential component of the pathogenesis.