Macular Degeneration: Grossniklaus HE

Singh SR, Grossniklaus HE, Kang SJ, Edelhauser HF, Ambati BK, Kompella UB. · Department of Pharmaceutical Sciences, University of Nebraska Medical Center, Omaha, NE, USA. · Gene Ther. · Pubmed #19194480 No free full text.

Abstract: Choroidal neovascularization (CNV) leads to loss of vision in age-related macular degeneration (AMD), the leading cause of blindness in adult population over 50 years old. In this study, we developed intravenously administered, nanoparticulate, targeted nonviral retinal gene delivery systems for the management of CNV. CNV was induced in Brown Norway rats using a 532 nm laser. We engineered transferrin, arginine-glycine-aspartic acid (RGD) peptide or dual-functionalized poly-(lactide-co-glycolide) nanoparticles to target delivery of anti-vascular endothelial growth factor (VEGF) intraceptor plasmid to CNV lesions. Anti-VEGF intraceptor is the only intracellularly acting VEGF inhibitory modality. The results of the study show that nanoparticles allow targeted delivery to the neovascular eye but not the control eye on intravenous administration. Functionalizing the nanoparticle surface with transferrin, a linear RGD peptide or both increased the retinal delivery of nanoparticles and subsequently the intraceptor gene expression in retinal vascular endothelial cells, photoreceptor outer segments and retinal pigment epithelial cells when compared to nonfunctionalized nanoparticles. Most significantly, the CNV areas were significantly smaller in rats treated with functionalized nanoparticles as compared to the ones treated with vehicle or nonfunctionalized nanoparticles. Thus, surface-functionalized nanoparticles allow targeted gene delivery to the neovascular eye on intravenous administration and inhibit the progression of laser-induced CNV in a rodent model.

Kang SJ, Schmack I, Benson HE, Grossniklaus HE. · LF Montgomery Ophthalmic Pathology Laboratory, Emory Eye Center, 1365-B Clifton Road NE, Atlanta, GA 30322, USA. · Br J Ophthalmol. · Pubmed #17567659 No free full text.

Abstract: BACKGROUND: To report the histopathological findings after photodynamic therapy (PDT) in eyes obtained postmortem with choroidal neovascularisation (CNV) secondary to age-related macular degeneration (AMD). METHODS: Two eyes were obtained postmortem from two patients with CNV secondary to AMD. Both of the patients had been treated with PDT. Serial sections through the posterior poles were obtained and stained with haematoxylin-eosin, periodic acid-Schiff, Masson trichrome or phosphotungstic acid haematoxylin (PTAH). Two-dimensional reconstructions were prepared and compared with fluorescein angiograms. RESULTS: The interval between PDT and death was 3 months and 17 months in each patient, respectively. Light-microscopic examination showed that CNV enveloped with retinal pigment epithelium (RPE) in both eyes. The average size of the CNV was 550 x 280 microm. One eye had combined (subRPE/subretinal) growth pattern CNV, and the other eye had both type I (subRPE) and combined growth pattern CNV. All specimens contained fibrous proliferation and patent vascular channels within the CNV, and there was no thrombus formation within the vascular channels. No apparent abnormalities in the choroid were observed by light microscopy. CONCLUSIONS: Although involution with fibrous tissue proliferation occurred, PDT did not result in permanent occlusion of the vascular channels in the CNV. Our findings indicate that PDT may accelerate involution of CNV, thus limiting its size and preserving photoreceptors.

Grossniklaus HE, Wilson DJ, Bressler SB, Bressler NM, Toth CA, Green WR, Miskala P. · Department of Ophthalmology, Emory University School of Medicine, 428 Emory Eye Center, 1365 Clifton Road, Atlanta, GA 30322, USA. · Am J Ophthalmol. · Pubmed #16386982 No free full text.

Abstract: PURPOSE: To compare the fundus photographic and fluorescein angiographic features with the histologic findings in eyes from patients enrolled in the Submacular Surgery Trials (SST). DESIGN: Clinical trials with clinicopathologic correlation. METHODS: Eyes that were obtained postmortem from patients who participated in the donor program were processed at the SST Pathology Center and examined histologically; the macular regions were reconstructed topographically with two-dimensional cartography. Fundus photographic and fluorescein angiographic features were correlated with the histopathologic and two-dimensional cartographic findings. RESULTS: The eyes from two patients each from the SST Group N and B Trials were studied. The study eye of one patient that had been assigned randomly to observation contained a subretinal fibrovascular scar that corresponded to a histologic growth pattern of a thick, collagenized subretinal component combined with a subretinal pigment epithelium (subRPE) fibrovascular component. The study eye of the other patient who was assigned randomly to observation showed angiographic occult without classic choroidal neovascularization (CNV) that corresponded to subRPE CNV. The study eye of one patient who was assigned randomly to surgery showed an angiographic surgical defect without CNV and histologic retinal pigment epithelium (RPE)/photoreceptor atrophy that was associated with a thin layer of subRPE CNV. The study eye of the other patient who was assigned randomly to surgery showed an angiographic surgical defect with classic CNV that corresponded to histologic RPE/photoreceptor atrophy that was associated with subRPE fibrovascular tissue and subretinal CNV. Both surgical eyes contained linear breaks in Bruch's membrane that included chevron-shaped breaks. CONCLUSION: Four SST study eyes that were examined postmortem contained CNV. The angiographic patterns and histologic features of the CNV support previous correlations of surgically excised CNV.

Grossniklaus HE, Miskala PH, Green WR, Bressler SB, Hawkins BS, Toth C, Wilson DJ, Bressler NM. · Montgomery Ophthalmic Pathology Labotratory, BT0428 Emory Eye Center, 1365 Clifton Road NE, Atlanta, GA 30322, USA. · Arch Ophthalmol. · Pubmed #16009831 No free full text.

Abstract: OBJECTIVES: To identify the histologic and ultrastructural features of surgically excised subfoveal choroidal neovascular lesions from patients enrolled in the Submacular Surgery Trials and to compare them with clinical data. METHODS: Surgically excised subfoveal choroidal neovascular lesions from patients enrolled in the Submacular Surgery Trials group N trial (lesion predominantly choroidal neovascularization [CNV] with evidence of classic CNV from age-related macular degeneration), group B trial (lesion predominantly hemorrhagic from age-related macular degeneration), and group H trial (idiopathic subfoveal CNV or subfoveal CNV from ocular histoplasmosis syndrome) between October 1, 1999, and September 1, 2001, were submitted to the pathology center. The lesion growth pattern (subretinal pigment epithelial [sub-RPE], subretinal, combined, or indeterminate) and the cellular and extracellular constituents were classified independently. Demographic, clinical, and fluorescein angiographic characteristics of patients, eyes, and lesions, respectively, were compared with the pathologic features. RESULTS: Of 269 patients assigned to surgery during the 24 months that pathologic specimens were collected, surgical specimens from study eyes of 199 were submitted to the pathology center. Of the 199 routine histologic specimens processed, 144 (72%) were classified as CNV, 51 (26%) as fibrocellular tissue, and 4 (2%) as hemorrhage. The median specimen size was smaller in group H (932 x 208 mum) than in groups N (1980 x 325 mum) and B (1800 x 395 mum). The CNV growth pattern was determined in 91 (46%) of 199 specimens. Of 159 group N and group B lesions, 76 (48%) had an indeterminate growth pattern, 28 (18%) had a sub-RPE growth pattern, and 33 (21%) had sub-RPE and subretinal growth patterns. Of 40 group H lesions, 32 (80%) had an indeterminate growth pattern, 7 (18%) had a subretinal growth pattern, and 1 (2%) had a combined sub-RPE and subretinal pattern. Based on electron microscopy, the most common cellular lesion components were RPE, macrophages, erythrocytes, fibrocytes, and vascular endothelium; the most common extracellular components were 24-nm collagen and fibrin. Basal laminar and linear deposits were found in 80% (40/50) and 16% (8/49) of group N specimens, 66% (43/65) and 5% (3/65) of group B specimens, and 8% (2/26) and 0% (0/26) of group H specimens, respectively. CONCLUSIONS: Most surgically excised subfoveal specimens had evidence of CNV or tissue associated with CNV. The constituents in CNV were consistent with granulation tissue proliferation. The presence of basal deposits in surgically excised specimens suggested a clinical diagnosis of age-related macular degeneration, even when blood was the predominant component of the lesion. Correlation of growth patterns above or below the RPE with fluorescein angiographic patterns of classic or occult CNV was limited because most specimens had insufficient material to determine these patterns.

Moshfeghi DM, Kaiser PK, Grossniklaus HE, Sternberg P, Sears JE, Johnson MW, Ratliff N, Branco A, Blumenkranz MS, Lewis H. · Cole Eye Institute, Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA. · Am J Ophthalmol. · Pubmed #12614752 No free full text.

Abstract: PURPOSE: To report the clinicopathologic findings after submacular removal of choroidal neovascular membranes (CNV) treated with verteporfin ocular photodynamic therapy. DESIGN: Interventional case series. METHODS: Retrospective review of eight eyes of eight patients who underwent submacular surgery for CNV after having previously received verteporfin ocular photodynamic therapy for presumed ocular histoplasmosis (one patient), age-related macular degeneration ([AMD] three patients) pathologic myopia (two patients), punctate inner choroiditis (one patient), and idiopathic CNV (one patient). All cases had undergone ocular photodynamic therapy with verteporfin using standard protocols. Six of eight patients suffered a submacular hemorrhage after ocular photodynamic therapy, and two of eight patients refused further ocular photodynamic therapy. All patients subsequently had submacular surgery with removal of the CNV. One membrane was routinely processed, sectioned, and stained with hematoxylin and eosin. Five membranes were stained with toluidine blue for light microscopic examination. Semithin (1.0 microm) sections were cut and stained with uranyl acetate-lead citrate for transmission electron microscopy. RESULTS: Choroidal neovascular membranes were removed at 3 days (presumed ocular histoplasmosis), 29 days (punctate inner choroiditis), 63 days (AMD, pathologic myopia), 66 days (AMD), 107 days (pathologic myopia), 116 days (AMD), and 152 days (idiopathic) after verteporfin ocular photodynamic therapy. Histopathologic and ultrastructural examination showed areas of vascular occlusion at 3 days that were not seen at later time points. All specimens had patent CNV. There were signs of vascular damage with extravasated erythrocytes and fibrin, pigment clumping in cells, and inflammatory cells in all but the 3-day specimen.CONCLUSIONS: This case series presents data only from patients who refused repeat treatment with ocular photodynamic therapy or who developed submacular hemorrhage after initial photodynamic therapy. Histopathologic evaluation of CNV 3 days after verteporfin ocular photodynamic therapy showed partial vascular occlusion that was not present in later specimens. These later specimens demonstrated evidence of vascular damage. Verteporfin ocular photodynamic therapy does not appear to lead to permanent and complete occlusion of the CNV. Thus, treatments that lead to permanent closure of CNV without damage to the retinal pigment epithelium and sensory retina are still needed.

Grossniklaus HE, Brooks HL, Sippy BD, Liu P. · L.F. Montgomery Ophthalmic Pathology Laboratory, Department of Ophthalmology, BT 428 Emory Eye Center, Emory University School of Medicine, 1365 Clifton Road NE, Atlanta, GA 30322, USA. · Retina. · Pubmed #12476118 No free full text.

This publication has no abstract.

Dithmar S, Sharara NA, Curcio CA, Le NA, Zhang Y, Brown S, Grossniklaus HE. · L. F. Montgomery Ophthalmic Pathology Laboratory, Emory Eye Center, 1365B Clifton Rd NE, Atlanta, GA 30322, USA. · Arch Ophthalmol. · Pubmed #11709015 No free full text.

Abstract: OBJECTIVE: To examine the histologic, histochemical, and ultrastructural changes in Bruch membrane in mice on a high-fat diet with and without laser photochemical injury. METHODS: Five groups of C57BL/6 mice were studied. Group 1 included 2-month-old mice on a normal diet; group 2 included 8-month-old mice on a normal diet; group 3 included 8-month-old mice on a high-fat diet; groups 4 and 5 included 8-month-old mice on a normal diet or high-fat diet, respectively, that underwent laser application of one eye with argon blue laser (488 nm). The mice were killed and plasma lipid levels were measured. The eyes were examined by standard electron microscopy, filipin histochemistry for unesterified cholesterol (UC) and esterified cholesterol (EC), and the osmium-tannic acid-phenylenediamine method for preserving extracellular lipid particles. RESULTS: The plasma cholesterol level was significantly higher in the mice on the high-fat diet than the controls (P<.001). Bruch membrane was thicker in group 2 than group 1 (P =.04) and group 3 had a thicker Bruch membrane than group 2 (P =.003). All eyes in group 3 exhibited accumulation of electron-lucent debris. There was no histochemical and ultrastructural evidence that this material represented accumulated UC or EC. Seven of 9 laser-injured eyes in group 5 accumulated basal laminar deposit (BlamD)-like material in Bruch membrane (P =.02). CONCLUSIONS: Electron-lucent debris accumulates in murine Bruch membrane, and the amount correlates with age and high-fat diet. This debris has some similarities with basal linear deposits, although the debris does not form a discrete layer external to the basement membrane of the retinal pigment epithelium as occurs in basal linear deposits. These deposits do not appear to be UC or EC. Laser photochemical injury of the retinal pigment epithelium may result in the appearance of BlamD-like deposits in eyes with electron-lucent debris. The BlamD-like deposits in this model are similar to the basal laminar deposits that occur in age-related macular degeneration. CLINICAL RELEVANCE: This is an animal model of ultrastructural BlamD-like material in Bruch membrane that is very similar to the deposits that occur in age-related macular degeneration.

Dithmar S, Curcio CA, Le NA, Brown S, Grossniklaus HE. · Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia, USA. · Invest Ophthalmol Vis Sci. · Pubmed #10892840 links to  free full text

Abstract: PURPOSE: To examine the histologic and ultrastructural changes in Bruch's membrane (BM) in apolipoprotein E deficient [ApoE(-)] mice in comparison with age-matched control animals. METHODS: Two-month-old (group 1) and 8-month-old (group 2) normal control C57BL/6 mice and 2-month-old (group 3) and 8-month-old (group 4) ApoE(-) mice were studied. All groups of mice were fed a standard rodent diet. The mice were killed, serum lipid levels were determined, and the eyes were ultrastructurally examined using standard techniques to measure the thickness of BM. The area fraction of electron-lucent (EL) particles in BM was quantified using point-counting stereology. RESULTS: The serum cholesterol levels of the ApoE(-) mice were significantly higher than those of the control mice (P = 0.0001). There was a significant thickening and EL particle accumulation in BM associated with age in the control animals. Group 2 had a thicker BM and more EL particle accumulation than group 1 (P = 0.0410 for thickness; P = 0.0042 for particle accumulation). Age-related changes were not seen in ApoE(-) mice; thickness and accumulation were similar in groups 3 and 4 (P = 0.50, thickness; P approximately/= 1.0, accumulation). Significant thickening and accumulation were seen in young ApoE(-) mice (group 3) versus young control animals (group 1; P = 0.008, thickening; P < 0.0001, EL particle accumulation). Group 4 ApoE(-) mice did not have a thicker BM or more EL particles than group 2 control animals (P = 0.2910, thickness; P = 0.35, EL particle accumulation). "Membrane-bounded" material (material between two membranes) was present significantly more frequently in ApoE(-) mice. CONCLUSIONS: ApoE(-) mice exhibit accumulation of EL particles at an earlier age and have more membrane-bounded material in BM than control mice. This material has ultrastructural similarities to basal linear deposit, which accumulates in age-related maculopathy.

Grossniklaus HE, Cingle KA, Yoon YD, Ketkar N, L'Hernault N, Brown S. · Department of Ophthalmology, Emory University School of Medicine, Atlanta, GA, USA. · Arch Ophthalmol. · Pubmed #10815153 No free full text.

Abstract: OBJECTIVE: To topographically localize vascular channels, macrophages, and retinal pigment epithelium and other components of choroidal neovascularization (CNV) associated with age-related maculopathy. METHODS: Two postmortem eyes with age-related maculopathy and CNV were evaluated. The formalin-fixed CNV complex was excised and processed for confocal scanning laser microscopy including immunostaining for factor VIII-related antigen and incubation with Ig fluorescein isothiocyanate. After confocal microscopy, the specimens were serial step sectioned, stained, and 2-dimensional topographic reconstructions were made. The confocal images were compared with the 2-dimensional reconstructions. RESULTS: Both specimens contained central disciform scars surrounded by areas of intact retinal pigment epithelium. The first specimen was more atrophic and contained fewer choroidal neovascular channels than the second specimen. The topographic arrangement of the CNV and retinal pigment epithelial changes in the confocal images corresponded with the 2-dimensional reconstructions. Macrophages were concentrated around areas of vascularization. CONCLUSION: Confocal scanning laser microscopy of excised CNV simulates fluorescein angiography and topographic localization of the components of CNV provides insight into the pathogenesis of CNV.

Spraul CW, Lang GE, Grossniklaus HE, Lang GK. · Department of Ophthalmology, Emory University School of Medicine, Atlanta, Georgia, USA. · Surv Ophthalmol. · Pubmed #10548114 No free full text.

Abstract: OBJECTIVE: Age-related macular degeneration (AMD) is the leading cause of irreversible blindness in industrialized countries. Different risk factors have been associated with AMD. We performed a histopathologic and morphometric study to compare eyes with different stages of AMD to age-matched eyes. This study aimed to investigate the correlation among morphometric characteristics of choroidal vessels, the retinal pigment epithelium, and Bruch's membrane, to study the association between these characteristics and the presence and type of AMD, and to identify morphologic risk factors for exudative AMD. Furthermore, we histologically analyzed surgically removed choroidal neovascular membranes secondary to underlying diseases other than AMD to discern whether the cellular and extracellular components of the membranes of eyes with AMD are similar to those with diseases other than AMD. METHODS: We analyzed 51 eye bank eyes (Georgia Eye Bank, Atlanta, GA) from 40 donors with different stages of AMD and compared them with 40 age-matched controls. The eyes were processed for light microscopy. The degree of calcification of Bruch's membrane, fragmentation of Bruch's membrane, number and types of drusen, basal laminar deposit, and seven morphometric variables of the choroid were assessed in the macular and extramacular regions. Surgically excised subfoveal membranes were processed and evaluated by light and transmission electron microscopy. RESULTS: There were no statistically significant differences observed between eyes with neovascular and non-neovascular AMD. The single most important difference between eyes with and without AMD was the amount of basal laminar deposit (P < 0.001). Eyes with AMD displayed fewer large choroidal vessels in the submacular choroid than eyes without AMD (mean density values of all choroidal vessels [arteries and veins] were 3.5 +/- 1.5 mm(-1) and 5.7 +/- 1.6 mm(-1), P < 0.001, respectively). The submacular choriocapillaris density was higher in eyes with AMD (mean density, 0.62 +/- 0.06) than in eyes without AMD (mean density, 0.51 +/- 0.08 [P < 0.001]). The diameter of the larger choroidal vessels in the peripheral choroid was higher in eyes with AMD (mean diameter, 30 +/- 8 microm) than in eyes without AMD (mean diameter, 21.4 +/- 6.2 microm [P < 0.001]). The peripheral choriocapillaris density displayed the same pattern as the macular region in eyes with and without AMD. There was a statistically significant difference observed in the degree of calcification and fragmentation of Bruch's membrane in eyes with exudative AMD (mean degree of calcification, 1.6; median number of breaks in Bruch's membrane, five) as compared with controls (mean degree of calcification, 0.8; median number of breaks in Bruch's membrane, zero). The difference for these two variables between eyes with nonexudative AMD (mean degree of calcification, 0.8; median number of breaks in Bruch's membrane, one) and controls (mean degree of calcification, 0.8; median number of breaks in Bruch's membrane, zero) failed to reach statistical significance. Eyes with AMD displayed significantly more soft, diffuse, and large drusen, as well as basal laminar deposit, in the macular area than controls. CONCLUSION: Combining our data with data from the literature, we conclude that AMD can be interpreted as a dynamic process with early proliferation and subsequent atrophy of capillaries of the choriocapillaris. Calcification and fragmentation of Bruch's membrane; soft, diffuse, and large drusen; and basal laminar deposit, but not hard drusen, strongly correlate with the histologic presence of AMD. The degree of calcification and fragmentation of Bruch's membrane is prominent in eyes with exudative AMD. The formation of choroidal neovascular membranes represents a stereotypic, nonspecific wound repair response independent of the underlying disease.

Spraul CW, Lang GE, Grossniklaus HE, Lang GK. · No affiliation provided · Ophthalmic Res. · Pubmed #10224509 No free full text.

This publication has no abstract.