Nathaniel Parker

The Visual System

Undergraduate Final Paper
Introduction
Glaucoma is a collection neurodegenerative optic pathologies common in humans that
can lead to irreversible blindness if undiagnosed and untreated.
1
Since it is the leading cause of
irreversible blindness worldwide it has a profound impact on patients, their families and friends,
as well as society as a whole.
1
While glaucoma is a common disease, our knowledge of its
etiology, pathogenesis, and treatment is significantly lacking. However, over the past couple of
decades, a better understanding of the disease has been developed. Glaucoma is prevalent at
higher rates in the elderly, African Americans, as well as individuals who suffer from diabetes,
hypertension, or myopia.
2
Since the prevalence of glaucoma sharply increases after the age 60
3
,
it is becoming a growing public health concern as the age structure of the United States begins to
change. Due to the heavy demands the disease places on the health care system as well as its
immense impact on individuals lives, it is vastly important to have a better understanding of the
degenerative process, since knowledge of early pathogenesis becomes paramount in providing
pathways for prevention and treatment.
Background
Glaucoma is not a single condition, but a collection of optic neuropathies characterized
by typical structural and functional defects (optic disc damage and visual eld loss).
4
Thus,
systems are in place to help classify the way different combinations of defects manifest into
different forms of glaucoma. The various types of glaucoma have been classically divided into
the categories of primary or secondary open-angle glaucoma and primary or secondary angle-
closure glaucoma. These divisions are based on the anatomical presentation of the disease effects
and whether or not the eye has pre-existing conditions. If the anterior chamber angle of the eye
(i.e. the angle where the iris meets the cornea) remains open, the diseases is classified as open
angle glaucoma.
2
However, if the anterior chamber angle is closed, the disease is termed angle-
closure or closed angle glaucoma.
2
If the patient has no pre-existing diseases in the eye in which
he is experiencing the defects, the glaucoma is qualified as primary.
2
On the other hand, if
disease is present in the eye prior to the presentation of defects due to glaucoma, the disease is
diagnosed as secondary glaucoma.
2

The characteristic combination of optic disc damage paired with visual eld loss is
representative of the demise of a considerable amount of retinal ganglion cells (RGCs)
concentrated in the inner retina.
4
Prior to the death of these RGC cell bodies, their axons in the
optic nerve, where these fibers pass out of the eye, begin to disappear which most often creates a
depression, or a cup, in the center of the optic disc. As more RGCs are effected by glaucoma, the
cup gets larger.
4
As the optic disc atrophies, it begins to lose function resulting in characteristic
mid-peripheral visual eld loss; in the end stages, this can progress to include degradation of
central visual acuity as well as the temporal visual field.
4
The ratio of size of the cup to the size
of the overall disc is used to determine the severity of structural change.
4
Both primary open-
angle (POAG) and primary angular-closure glaucoma (PACG) create similar defects in the optic
topography.
5
Patients with PACG, however, suffer more diffuse visual eld alteration.
5

Open Angle Glaucoma
The most common type of glaucoma, open-angle, segregates itself from other optic
neuropathies by its lengthy progression which can take months to years.
4
This extended
progression can often leave early stage patients without symptoms.
4
It is differentiated from
angle-closure glaucoma by the presence of an unrestricted anterior chamber angle.
2
This form of
glaucoma is most often presents itself in both eyes, but in an asymmetric manner. Generally, the
better eye has half the damage of the worse eye.
6

Primary open-angle glaucoma is unique in that it has no apparent precursory and/or
related ocular or systemic causes. POAG is thus a diagnosis of exclusion.
2
The diagnosis of
open-angle glaucoma requires an unrestrained anterior chamber angle (i.e. normal appearance of
the anterior chamber), optic disk cupping, and peripheral visual field loss resulting from the loss
of RGCs.
Angular-Closure Glaucoma
In contrast to open-angle glaucoma, patients suffering from primary angle-closure
glaucoma are traditionally thought experience intense symptoms that can lead to permanent
blindness rapidly if not treated properly.
2
This can be deceiving, however, because more than
75% of patients do not suffer the characteristic acute, painful attack.
4
Angle-closure glaucoma is distinguished from open-angle because the aqueous humor of
the eye is unable flow through the pupil into the anterior chamber due to a pupillary block.
4
This
increased resistance in this irislens channel puts pressure on the iris causing it to arch forward;
this in turn significantly limits access to the trabecular meshwork which is responsible for
draining aqueous humor.
2
If the aqueous humor outflow remains limited by the pupillary block
for days to weeks, the iris can permanently cling to the meshwork resulting in chronically
augmented intraocular pressure (IOP) and eventually progressing to glaucomatous neuropathy
similar to that seen in open-angle glaucoma.
4
A stimulus that causes the pupil to dilate or causes
the lens to move anteriorly may cause acute angle-closure glaucoma under such condidtions.
4
Pathology
Since IOP is currently the only treatable risk factor of glaucoma, IOP has traditionally
been etiologically associated with most cases of glaucoma.
7
It is important to remember that IOP
is only a part of the complex web of etiological associations. Clinical progression, similar to
patients that suffer from IOP, has been extensively observed in patients that never experience
IOP.
7
As is the case, it is important not think of these two similar outcomes are results of
separate pathways: An eye disease of ocular hypertension vs a CNS disease where patients
experience no ocular hypertension.
7
Research within the last decade has presented critical steps
towards a more complete knowledge of the mechanisms behind the neurodegeneration of
glaucoma. Accompanying this growing wealth of knowledge is a hope that this understanding
will reveal opportunities of intervention as well as new neuroprotective therapies. These
emerging assessments of the diseases have revealed that glaucoma is about an individuals
sensitivity to ocular hypertension not necessarily just about heightened IOP.
7
RGC vulnerability
The pathogenic mechanisms of neurodegeneration directly work against the function of
the RGC causing what is termed as primary degeneration.
7
Non-RGC cells can still be affected
indirectly as a secondary consequence to the deterioration of RGC cells and their axonal
projections. For example, multiple studies have demonstrated morphological indications of
photoreceptor pathology that likely results in loss of cells accompanying RGC degeneration.
8,9

These studies in no way indicate that non-RGC cells are primary targets independent of RGC
degeneration. They do, however, conclude that non-RGC retinal neurons eventually become
vulnerable as the pathogenesis progresses.
Since RGC remain the primary target of the pathogenic mechanisms, we must consider
what makes them primarily susceptible. Considering the architecture of the eye, the RGC is
unique in that its axon is only partially myelinated; when the axon exits the eye, it becomes
myelinated while piercing the laminar region of the nerve head before continuing to central brain
targets.
7
The site where the axon pass through the astrocyte rich optic nerve head has been
established as a site of vulnerability to IOP and age related stressors exhibits neurochemical
reactivity in glaucoma.
1
This distinctive construction requires an specific mitochondrial
distribution; since unmyelinated axons necessitate more energy to maintain conduction, there is
an profusion of mitochondria in the unmyelinated portion of the RGC axon.
7
This gradient of
mitochondria is regulated by physiological signals that control anterograde and retrograde
mitochondrial traffic.
10
Oxidative stress, increased cytochrome c, amplified mitochondrial
permeability, and accumulation of free radicals can result from decreased mitochondrial
motility.
10
Several models of glaucoma include these elements.
7
As the axons of the RGC
become damaged and retrograde transport of pro-survival factors becomes limited, the cell body
begins shrink and eventual rapid apoptosis occurs.
1,7
RGC axon terminals, do however, persist
for a short while after axonal transport is depleted.
1
Studies have shown that depletion of
anterograde transport are an earlier reporter of RGC pathogenesis than diminishing retrograde
transport.
7
This idea that depletion of RGCs axons lead to the destruction of cell bodies in
glaucoma is further justified when studies have shown that not only does ATP, a requirement for
transport, in the optic nerve decrease with age, but that this depletion is exacerbated by increased
IOP.
7
This progression from axon-to-cell body (can also be thought of as nerve-to-retina) has
been demonstrated in numerous animal studies.
7
Various animal studies have also revealed a dependency of axon loss on IOP levels. The
studies have generally shown that degree of axon loss is related to the extent of IOP
augmentation. Fig. 1 presents the data of various studies and presents relative axon
degenerations dependency on cumulative IOP exposure.

Fig 1.
7
IOP-Induced Loss of Axons. Graph depicts relative axon degeneration as a function of
relative cumulative IOP exposure. The two different methods of assessing axon degeneration
were the quantification of surviving RGC axons in the nerve or of RGC bodies in the retina via
Fluorogold labeling. Analysis obtained from Calkins (2012).

Fig 1. shows that the IOP dependency of RGC somatic loss is far less severe than that of
axonal loss. This underscores the idea that distal loss of axonal loss, which leads to actual vision
loss via apoptosis of RGC somas in the retina, is one of the earliest events in the pathology. This
temporal gap between axonal depletion and loss of the cell body leaves a possible window for
intervention.
The Calcium Hypothesis
Glaucoma is involved in the degradation of the CNS (i.e. the retina and optic nerve), and
thus shares epidemiological and mechanistic parallels with various other neurodegenerative
diseases such as Alzheimers, Parkinsons, and Huntingtons disease.
11
Despite the diverse
nature of these diseases etiologies, they share components involved in neurodegeneration that
may be used as potential therapeutic targets. Ca
2+
plays a key role general neural function and is
a target in the study of pathogeneses of these diseases, so it is important to look at the role it
plays in glaucoma too.
Neurodegeneration
Ca
2+
is used as an intracellular messenger in healthy neurons to trigger cascades which
control cellular functions such as exocytosis, gene transcription, intracellular respiration, and
trafficking of membrane matierals.
11
In most neurodegenerative diseases, axonopathy is resultant
of an increased influx of extracellular Ca
2+
.
11
This surge of intracellular Ca
2+
triggers enzymatic
activity that degrades the cytoskeleton. Excessive neuronal Ca
2+
levels have also been show to
stimulate processes that promote apoptosis in various neurodegenerative conditions.
11

The axonal degeneration that is characteristic of glaucoma patients shares striking several
similarities with other neurodegenerative diseases. Studies have shown similarities in the atypical
processing of amyloid precursor protein, dependence on target-derived trophic support, and
involvement in various Ca
2+
mediated cascades.
11
For example, calpains are a class of Ca
2+
-
dependent proteases that are present in glaucoma and various other neurodegenerative diseases.
Caplain, activated due to the Ca
2+
-dysregulation, can act directly on the synaptic components,
breaking down structural proteins and neurofilaments.
11
Finally, calpains can activate kinases
(cyclin-dependent kinase 5 (Cdk5), glycogen synthase kinase 2 (GSK3), and stress-activated
protein kinases (SAPK)) which phosphorylate neurofilaments and protein Tau resulting in the
inhibition of axonal transport.
11
The resulting cytoskeletal degradation manifests itself in the
form of transport failure, dendritic pruning, axonopathy, and eventually synapse loss.
Oxidative Stress
As the CNS ages, it becomes progressively more vulnerable to oxidative damage of DNA
and proteins.
11
Oxidative stress is presumed to play a role in glaucoma due to the apparent up-
regulation of specific anti-oxidants that are implicated in other neurodegenerative conditions. For
example, Ceruloplasim, which reduces the formation of reactive oxygen species (ROS) by
converting ferrous (Fe
2+
) iron into ferric (Fe
3+
) iron, is shown to be elevated in both animals and
humans with elevated IOP.
11
Additionally, glaucoma patients have shown the increase of several
anti-oxidants in the aqueous humor as well as the up-regulation of glial related oxidative stress
pathways in the retina and the optic nerve.
11

Ca
2+
again plays a role in this pathology. Ca
2+
-dysregulation can result in oxidative stress
through such mechanisms as increasing metabolic rate and activation of ROS-producing
enzymes.
11
Once formed, reactive oxygen species can damage proteins, lipids, and nucleic acids
directly. ROS also have an effect on mitochondrial functioning. Mitochondria decrease
respiration and depolarize their membrane in the presence of ROS, thus ROS causes a decrease
in mitochondrial ability to buffer Ca
2+
efficiently.
11
ROS also activate ryanodine (Ry) and
inositol triphosphate (IP3) receptors resulting in Ca
2+
release from internal stores.
11
Finally,
oxidative stress damages certain plasma membrane proteins that are responsible for maintaining
and restoring large Ca
2+
level differentials across the plasma membrane It is also important to
note that, that these three results of oxidative stress create a positive feedback loop with Ca
2+
-
dysregulation.
11

The possible mechanisms responsible for the maintenance of Ca
2+
-dysregulation in RGC
cells suffering from glaucoma are outline in Fig 2.

Fig. 2 Schematic of possible Ca
2+
-dependent mechanisms that could contribute to glaucoma. The
initial disruption of intracellular Ca
2+
-homeostasis of RGC cells could be cause by multiple
stressors relevant in glaucoma. This disruption immediately leads to immediate oxidative stress
and activation of calpains. Oxidative stress limits the Ca
2+
buffering capability of mitochondria,
activates (Ry) and inositol-triphosphate (IP3) receptors thereby releasing more Ca
2+
from
internal stores, and damages membrane proteins resulting in reduced clearance of intracellular
Ca
2+
. Activated calpains increase the activity of Cdk5, GSK3, and stress-activated protein SAPK
resulting in the phosphorylation cytoskeletal elements and decreased axonal transport. Calpains
also directly breaks down both the cytoskeleton and synapses. Grey boxes enclose targets not
directly established for glaucoma. Figure modified from Crish et al (2011).
Treatment
Currently, the only method of treatment used is pharmaceuticals barrage that aims to
lower a patients IOP. Generally, the management of glaucoma begins with using either a topical
-blocker or a topical prostaglandin analog.
2
IOP is decreased because beta-blockers reduce the
formation of aqueous humor in the eye.
2
Their relative lack of adverse ocular effects makes beta-
blockers a prime choice for an initial treatment option. On the other hand, IOP can be lowered in
a patient by increasing aqueous humor outflow in the eye via the use of prostaglandin analogs.
2
Like beta-blockers, these agents make strong options for first-line therapy because they have few
adverse effects, can be used once daily, and do not affect pupil size or accommodation.
2
Many
more options for treatment exist, but they all focus on lowering the IOP and yet they have more
adverse effects. The calcium hypothesis is strengthened by the fact that many drugs used to
lower IOP also secondarily modulate RGC intracellular calcium over time.
11

The research over the past decade that has suggested a pathology of glaucoma that
contains compartmentalized neurodegeneration and functional loss has many implications on
treatment options. First, it is much less of a feat to address axonal dystrophy than replace lost cell
bodies in the retina.
11
In fact, a new line of treatments supply exogenous ionic activity in the
hopes of supplementing loss of function.
11
Additionally, the temporal gap between the
degeneration of the axons and the cell bodies creates a window for treatment before irreversible
damage is done that has previously not been known.
11
Current research indicates that various
steps in the proposed Ca
2+
dysregulation hypothesis maybe be possible sites of intervention.
As the previous section indicates, oxidative stress can cause a decrease in mitochondrial
membrane potential as well as an increase in membrane permeability which have been associated
with the observed RGC apoptosis in glaucoma.
12,13
During glaucoma pathology, excess cytosolic
Ca
2+
buffered by mitochondria. This leads to an accumulation of Ca
2+
within mitochondria,
depolarization of the mitochondrial membrane, and the production of reactive oxygen species.
14

This combination of events has been shown to be correlated with the release of proteins which
induce apoptosis on localized RGCs.
15,16
The depolarization of the mitochondria has been
proposed as a site of intervention. Several chemical compounds have been suggested to enhance
the available energy within the cell and prevent mitochondrial depolarization.
14
Of these,
Ubiquinone shows the greatest potential for serving a neuroprotective role. Ubiquinone has
already been shown to serve as a neuroprotectant in various animal models of other
neurodegenerative diseases such as Parkinsons disease.
17
Its neuroprotective properties,
demonstrated in vivo and in vitro, have been shown to be multifaceted.
14
It is posited that
multidimensional effects of Ubiquinone are due to the compounds ability to help facilitate the
carrying of electrons in combination with its antioxidant properties, regulation of gene
properties, and its ability to control pores within the mitochondrial membrane.
18

Control of oxidative stress itself has also been considered as a non-IOP site of
intervention. The role of oxidative stress in the pathology of glaucoma has led to the
investigation of various antioxidants as possible therapies for slowing or stopping the apoptosis
of RGCs. The most noteworthy of those being investigated is Melatonin. Shown to be a possible
neuroprotectant, Melatonin is a naturally occurring antioxidant that plays a critical role in
aqueous humor circulation.
19
Melatonin has demonstrated its neuroprotective abilities in vivo
20

and in vitro in rabbit models.
21
Melatonins ability to protect RBCs from neurodegeneration is
thought to be mediated via various mechanisms including reducing strand breaks within DNA,
increasing phosphorylation of Protein Kinase B, reducing Nitric Oxide-prompted apoptosis, and
inhibiting mitochondrial transition pores and cytochrome c release.
14

Despite these beneficial discoveries, in order to effectively translate the results of these
mechanistic studies into a clinical setting, better technology is needed. Although it has been
helpful in unveiling what has been discovered thus far, current technology is not sensitive
enough to detect loss of function before the cell body is permanently injured. Thus, much more
work is needed before the burden glaucoma places on society begins to be alleviated.


Referenences

1
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2
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3
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4
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5
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6
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7
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8
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9
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10
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11
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12
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13
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14
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15
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16
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17
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18
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19
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20
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21
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