Atrophic Disease Research Articles

Inferring potential causative microbial factors of intestinal atrophic disease in the sea cucumber Apostichopus japonicus

The overexploitation of the wild populations of Apostichopus japonicus has caused a significant decline in their numbers, prompting the establishment of a sea cucumber aquaculture industry that has become a major player in East Asia. Recent research has focused on identifying the various factors that may affect sea cucumber aquaculture, including water quality, diet, and the microbiome associated with their hosts. Notably, studies on host-associated microbiomes have emerged as a prominent area of research, particularly in the context of investigating the relationship of the microbiome with diseases that have caused significant economic losses. Intestinal atrophy of A. japonicus larvae has been reported at a number of sea cucumber farms in Japan, but there have been no factor screenings, and there is currently no efficient mitigation. In this study, we applied metagenomic analyses for the first time to an intestinal atrophic case of the sea cucumber A. japonicus larvae, which occurred in an aquaculture facility in Hokkaido, Japan, elucidating potential causative microbial factors and comparing the diseased microbiome against the healthy pan-microbiome. Through our metagenome comparisons, we have found significant increases in Oceanicoccus, Ruegeria, Nioella, Labrenzia, Tenacibaculum, and Muricauda in the diseased larvae. Among those, Tenacibaculum was estimated to potentially be the most pathogenic bacterium in the development of intestinal atrophic disease due to previous outbreaks of sea urchin diseases in the same facility. Our metagenomic approach demonstrates the further need of microbial screening of such causative agents and identification of the pathogenesis of such diseases, which could contribute to establishing more sustainable aquaculture in the sea cucumber industry.

PCLE highlights distinctive vascular patterns in early gastric cancer and in gastric diseases with high risk of malignant complications

Endoscopy is widely used to detect and diagnose precancerous lesions and gastric cancer (GC). The probe-based Confocal Laser Endomicroscopy (pCLE) is an endoscopic technique suitable for subcellular resolution and for microvasculature analyses. The aim of this study was to use pCLE to identify specific vascular patterns in high-risk and early stage GC. Mucosal architecture, vessel tortuosity, enlargements and leakage were assessed in patients with autoimmune gastritis and early gastric cancer (EGC). We were able to stratify gastritis patients by identifying distinct vascular profiles: gastritis was usually associated with increased vascularization characterized by a high number of tortuous vessels, which were also found in atrophic autoimmune disease. Leaky and tortuous vessels, distributed in a spatially irregular network, characterized the atrophic metaplastic mucosa. The mucosal vasculature of EGC patients displayed tortuous vessels, but unlike what detected in atrophic gastritis, they appeared patchy, as is in neoplastic gastric tissue. Very importantly, we detected vascular changes even in areas without lesions, supporting the contention that vascular alterations may provide a favorable microenvironment for carcinogenesis. This report confirms that pCLE is a valid endoscopic approach to improve the definition of patients with malignant lesions or at increased risk for GC by assessing vascular changes.

Association of increased eomesodermin, BCL6, and granzyme B expression with major clinical manifestations of Hashimoto’s thyroiditis – an observational study

ABSTRACT Purpose Studies of cytotoxic T cells and their respective lineage master regulators have been limited in Hashimoto’s thyroiditis (HT). It is unclear whether their transcriptomes are changed in HT patients and how these changes are associated with the thyroid damage, major clinical manifestations, and disease progression. Methods We explored the gene expression patterns of selected transcription factors [eomesodermin (EOMES), BACH2, BCL6, TCF1] and cytolytic molecules [granzyme B (GZMB)] in peripheral blood (PB) T cells of 10 healthy controls and 30 HT patients of various subtypes (hypothyroid, untreated HT; L-thyroxine (T4)-treated HT, and spontaneously euthyroid HT) using real-time quantitative PCR. Results EOMES (Mann–Whitney P = 0.044), GZMB (P = 0.028), and BCL6 mRNA (P = 0.001) were overrepresented in PB T cells from HT and showed levels varying by age, thyroid volume and disease severity. BCL6 transcripts were predominantly enriched in severely affected, hypothyroid cases, both on and off LT4. Increased EOMES RNA expression was associated with advancing age, lower thyroid volumes and higher peak adjusted TSH levels over the course of the disease. The body mass-adjusted, steady-state maintenance dose of LT4 increased with GZMB and BCL6 levels in PB T cells of hypothyroid cases, mostly postmenopausal women having long-standing, non-goitrous and atrophic disease form. Conclusions Our exploratory results suggest a role for GZMB, EOMES, and BCL6 in the context of HT, thyroid injury, and aggressive/advanced disease forms. Functions enriched within differentially expressed transcripts could be an important new target in understanding the pathogenesis of HT.

P.02.19: Prevalence of H. Pylori Infection, Chronic Atrophic Gastritis and Reflux Disease in a Primary Care Population of North-East Italy with Serum Biomarker Panel (Gastropanel®)

P.02.19: Prevalence of H. Pylori Infection, Chronic Atrophic Gastritis and Reflux Disease in a Primary Care Population of North-East Italy with Serum Biomarker Panel (Gastropanel®)

Blood flow and oxygenation in atrophic diseases

SummaryThere is increasing evidence that alterations in retinal‐choroidal blood flow play a role in the pathogenesis of atrophic diseases. Studying the oxygen saturation of retinal vessels on patients affected by glaucoma and inherited diseases of the retina, suggest the oxygen metabolism to be altered. To which extend the role of the oxygen saturation contributes to the blood flow fluctuations and thus, to the progression of atrophic disease will be discussed in this presentation.

Xeroderma Pigmentosum – A Social Stigma Report in Two Siblings and Literature Review

Xeroderma pigmentosum is an autosomal recessive, rare pigmentary atrophic disease of childhood that progresses to early development of senile changes in sun-exposed skin. Xeroderma pigmentosum (XP) was first described in 1874 by Hebra and Kaposi. In 1882, Kaposi coined the term xeroderma pigmentosum for the condition, referring to its characteristic dry, pigmented skin. Xeroderma pigmentosum is also known as DeSanctis- Cacchione syndrome. DOI: http://dx.doi.org/10.3329/bjch.v38i1.20026 Bangladesh J Child Health 2014; VOL 38 (1) : 40-43

Extensive anogenital lichen sclerosus with vaginal stenosis: A case report

Lichen sclerosus (LS) is an acquired, chronic, inflammatory, fibrotic and atrophic disease, usually affecting skin, particularly genital region. It affects women, with a median age of 50years. No etiological factor is actually known. Here we have described a case of a woman affected by extensive anogenital lichen sclerosus complicated with vaginal stenosis.

Recent developments in the treatment of age-related macular degeneration.

Age-related macular degeneration (AMD) is a common cause of visual loss in the elderly, with increasing prevalence due to increasing life expectancy. While the introduction of anti-VEGF therapy has improved outcomes, there are still major unmet needs and gaps in the understanding of underlying biological processes. These include early, intermediate, and atrophic disease stages. Recent studies have assessed therapeutic approaches addressing various disease-associated pathways, including complement inhibitors. Drug-delivery aspects are also relevant, as many agents have to be administered repeatedly. Herein, relevant pathogenetic factors and underlying mechanisms as well as recent and potential therapeutic approaches are reviewed.

Salivary secretion: mechanism and neural regulation.

Maintenance of a film of saliva on oral surfaces is dependent upon nerve-mediated, reflex salivary gland secretion. Afferent signalling arises from taste, olfaction and mastication and is modified by signalling from other centres in the central nervous system before efferent signals are delivered to salivary glands in autonomic nerves. Salivary fluid secretion is largely dependent upon cholinergic signalling from parasympathetic nerves whilst the protein content of saliva is additionally dependent upon signalling by neuropeptides and, in the major (parotid, submandibular and sublingual) salivary glands, by sympathetic nerves and the release of noradrenaline. There have been significant recent advances in our understanding of the membrane transport proteins involved in intracellular calcium signalling in salivary acinar cells in response to nerve stimulation and of the ion transport proteins responsible for acinar cell secretion of saliva. Salivary glands retain an ability to regenerate following extreme atrophy, and autonomic nerves have an important role in both gland development and maintenance of long-term normal function. Continued advances in the understanding of the nerve-mediated regulation of salivary glands should help in the development of strategies for preventing chronic oral dryness resulting from drugs or atrophic disease associated with inflammation and irradiation.

Chronic helicobacter pylori infection induces SOCS1 expression but not CISH in a murine model of gastric infection

Background and Aims Helicobacter pylori infections continue to be a major challenge to the field of gastroenterology. Gastric H. pylori infections is a critical cause of chronic atrophic gastritis and peptic ulcer disease and is one of the leading carcinogens that leads to stomach cancer and MALT lymphoma. Helicobacter pylori infection has been demonstrated to modulate the local inflammatory response in the gastric mucosa. In this study, we examine the role of chronic in vivo H. pylori infection in the modulation of inflam-mation controlled by Supressors of Cytokine Signalling (SOCS), a family of anti-inflammatory regulators that act on various cytokine pathways. Methods C57Bl6 mice were infected at 5 weeks of age with the mouse-adapted H. pylori strain SS1 via oral gavage × 3 inoculations. The mice were culled 20 weeks post-infection and the stomach tissue harvested post-mortem and snap frozen. Total RNA was extracted from these tissues and cDNA produced from the mRNA by reverse transcription. A semi-quantitative real time PCR study was conducted examining Socs1 and Cish relative gene expression in infected ( n = 10) and uninfected controls ( n = 10). Results Mice infected with H. pylori had a significantly increased gene expression of Socs1 ( p Cish gene expression was not signifi-cantly altered upon infection. Conclusions Helicobacter pylori may supress localised inflam-mation via increased expression of SOCS1 in a murine model of chronic infection.

Letter: gastric atrophy as a precursor of gastric cancer – authors’ reply

The clinico-pathological assessment (and natural history) of autoimmune gastritis (AG) is a matter of debate.1 In their appreciated letter,2 Barbosa and Botelho de Carvalho suggest starting with the histological evidence of corpus-restricted gastritis as a reliable marker of autoimmunity targeting the oxyntic cell population. However, if we do, we should be aware that these ‘putative-AG’ patients include cases whose corpus inflammation/atrophy is part of a multifocal atrophic gastritis due to Helicobacter pylori infection. In our trial,3 we ‘cleansed’ our study population by requiring serology-confirmed gastric autoimmunity. Consistent with this choice, our study sample included 52 patients with antiparietal/anti-intrinsic factor antibodies, with corpus-predominant gastritis, but no histological evidence of corpus-restricted gastric atrophy. Among the patients with positive serology, 116 were followed up for longer than 24 months. At the end of the follow-up, 2 of the 6 cases enrolled as having non-atrophic gastritis featured stage II gastritis, supporting the hypothesis that the natural history of AG includes two subsequent phenotypes: initial non-atrophic and advanced atrophic disease.3 As for the OLGA staging, here again – and also in the autoimmune setting – OLGA staging consistently stratified patients by their different cancer risk.4-7 In fact, the stage of gastritis expresses ‘how advanced’ the disease is, irrespective of its aetiology. In our AG series, all incidental cancers coexisted with high-risk stages, basically confirming both that gastric atrophy is the field in which gastric cancer develops, and the clinical usefulness of staging in gastric cancer secondary prevention strategies.5 As for carcinoids, the related risk coincides with the histological score for corpus atrophy (more than with the OLGA stage): 17 of 19 (89.5%) carcinoids coexisted with score 3 corpus atrophy.3 In conclusion, in the presence of a compatible clinical syndrome, serology does identify autoimmune gastric disease, with a histology that includes both non-atrophic and atrophic phenotypes. Irrespective of the aetiology of gastritis, OLGA staging can convey clinically important information on the gastritis-associated cancer risk. The authors’ declarations of personal and financial interests are unchanged from those in the original article.3

Age-related Macular Degeneration – Review and Current Concepts

Age-related macular degeneration (ARMD) continues to be a significant public health concern, given its high prevalence and potential blinding prognosis in the elderly. Several risk factors have been identified in the development of ARMD, including age, race and family history. The pathogenesis of ARMD continues to be elucidated and recent research has focused on genetic factors. ARMD presents in either the atrophic or exudative form. Treatment for atrophic disease consists of antioxidants and zinc and close monitoring. Treatment for exudative disease is aimed at targeting choroidal neovascularisation. The development of anti-vascular endothelial growth factor (anti-VEGF) agents has revolutionised the treatment of exudative ARMD, providing a more favourable prognosis for previously blinding disease. A considerable amount of research is being carried out on new treatment modalities for both the atrophic and exudative forms of the disease.

Age-related Macular Degeneration—Review and Current Concepts

Age-related macular degeneration (ARMD) continues to be a significant public health concern, given its high prevalence and potential blinding prognosis in the elderly. Several risk factors have been identified in the development of ARMD, including age, race, and family history. The pathogenesis of ARMD continues to be elucidated, and recent research has focused on genetic factors. ARMD presents in either the atrophic or exudative form. Treatment for atrophic disease consists of antioxidants and zinc and close monitoring. Treatment for exudative disease is aimed at targeting choroidal neovascularization. The development of anti-vascular endothelial growth factor (anti-VEGF) agents has revolutionized the treatment of exudative ARMD, providing a more favorable prognosis for previously blinding disease. Considerable amount of research is being carried out on new treatment modalities for both the atrophic and exudative forms of the disease.

FUNDUS AUTOFLUORESCENCE, OPTICAL COHERENCE TOMOGRAPHY, AND ELECTRORETINOGRAM FINDINGS IN CHOROIDAL SCLEROSIS

The purpose of this study was to describe fundus autofluorescence (FAF), optical coherence tomography, and electroretinogram findings in choroidal sclerosis. This is a retrospective case series. Eight eyes of four patients with choroidal sclerosis were evaluated with FAF, optical coherence tomography, and electroretinogram testing. In all eight eyes, FAF imaging showed hypofluorescent placoid lesions corresponding to areas of chorioretinal atrophy seen on stereo biomicroscopy. Prominent hyperfluorescent linear markings underlying regions of atrophic disease were observed in all eyes, likely representative of normal choroidal vessel autofluorescence. In two eyes, FAF showed punctate hypofluorescent lesions in the fovea that were not visualized on biomicroscopy. In one eye, FAF identified a central island of preserved retinal pigment epithelium that was not realized on ophthalmoscopic examination. Optical coherence imaging was significant for loss of choroidal fine tubular structures, retinal pigment epithelium, and outer nuclear layer in regions of chorioretinal atrophy. Full-field electroretinogram testing showed generalized rod-cone dysfunction in all patients with a lower B- to A-wave ratio in two patients. Fundus autofluorescence and optical coherence tomography are nonin-vasive diagnostic adjuncts that can aid in the diagnosis of choroidal sclerosis. Fundus autofluorescence may be a more sensitive marker of disease extent and progression than clinical examination alone. Electroretinogram testing can result in an electronegative maximal response.

Lichen sclerosus et atrophicus in pediatric and adult male patients with congenital and acquired phimosis

Lichen sclerosus et atrophicus is a chronic inflammatory sclerotic and atrophic disease of unknown cause that predominantly affects male and female genital skin. This study was designed to evaluate histological characteristics of congenital and acquired phimoses among pediatric (n=60) and adult (n=60) male patients who were admitted for circumcision to the Clinics of Urology and Pediatric Surgery of Kaunas University of Medicine Hospital between 2000 and 2003 and to determine the rate of lichen sclerosus et atrophicus and other histological diagnoses among them. This study demonstrates that 45.1% of congenital and 62.3% of acquired phimoses show histological signs of lichen sclerosus et atrophicus. The rate of lichen sclerosus et atrophicus was statistically significantly higher among patients with acquired than congenital phimosis. Boys with acquired narrowing of prepuce were statistically significantly 3.9 times more likely to develop lichen sclerosus et atrophicus than those with congenital phimosis. There were no statistically significant differences between rates of lichen sclerosus et atrophicus and other dermatological diagnoses among pediatric and adult male patients if the type of phimosis (acquired or congenital) was considered. Histological features of lichen sclerosus et atrophicus and other histological diagnoses in boys and men with phimosis were detected with equal frequency irrespective the age of the subjects. The rate of lichen sclerosus et atrophicus was similar among all boys (56.7%) and men (53.3%) treated for phimosis. Only the type of phimosis had a statistically significant influence on the rate of lichen sclerosus et atrophicus and other histological diagnoses.

Chronic Progressive Nephropathy (CPN) in the Rat: Review of Pathology and Relationship to Renal Tumorigenesis

Chronic progressive nephropathy (CPN) is a rodent-specific, age-related renal disease, particularly of male rats, characterized by a spectrum of distinct histological changes which may begin early in the animal's life and progress to end-stage renal disease in certain rat strains. Although CPN-related pathology is well known to most toxicological pathologists other features of CPN such as pathogenesis, modulating factors, proliferative nature, response to chemical exposure and relationship to tumorigenesis are less clearly acknowledged. CPN is generally regarded as a degenerative to atrophic disease with compensatory regenerative hyperplasia. The proliferative nature of CPN often becomes problematic in advanced to end-stage renal disease. At this stage, a number of tubule profiles may be mistaken for atypical tubule hyperplasia, the reported precursor lesion of tubule adenoma. CPN associated proliferative tubule profiles must be carefully separated from atypical tubule hyperplasia particularly in studies where chemical exposure has exacerbated CPN. Over the past several years increasing evidence has supported the hypothesis that CPN may be regarded as a type of mode of action during renal carcinogenesis in rodent bioassay studies. Retrospective studies of control and treated animals have consistently shown a relationship between the increased severity of CPN and the presence of atypical tubule hyperplasia and small, incipient renal adenomas. Understanding CPN-related tumorigenesis is important for human risk assessment interpretation. Since CPN is a rodent specific disease with no apparent similar human kidney disease condition, evidence that renal tumors may arise from an interaction with CPN could assist regulatory agencies in interpreting data from studies with exacerbated CPN.

Autofluorescence Characteristics of Early, Atrophic, and High-Risk Fellow Eyes in Age-Related Macular Degeneration

To assess the relationships of drusen, pigment, and focally increased autofluorescence (FIAF) and the reticular pattern of hypoautofluorescence, to distinguish the combined photographic and AF characteristics of early, atrophic, and high-risk fellow eyes in AMD. In a retrospective interinstitutional clinical study, AF and color photograph pairs of 221 eyes were examined: 166 eyes of 83 patients with bilateral large, soft drusen, with and without geographic atrophy (GA), and 55 fellow eyes of 55 patients with unilateral choroidal neovascularization (CNV). Forty-two eyes (one eye from each of 42 patients with early or atrophic AMD) were divided into four groups: 14 with drusen only, 9 with drusen and pigment abnormalities, 11 fellow eyes of patients with unilateral GA, and 8 eyes of patients with bilateral GA (acronyms for the groups: D-D, D-Pig, D-GA and GA-GA, respectively). The 55 fellow eyes of patients with CNV were divided into three groups: 19 eyes with no FIAF (CNV-0), 16 with FIAF without reticular AF (CNV-1), and 20 eyes with reticular AF and/or pseudodrusen (CNV-R). Image pairs of eyes with FIAF were registered, and drusen, pigment, and FIAF were segmented using automated background leveling and thresholding. All 221 eyes were surveyed for reticular AF and reticular pseudodrusen. The main outcome measures were (1) the fraction and relative probability of FIAF colocalizing with drusen and pigment and (2) the presence or absence of reticular AF and reticular pseudodrusen. The mean fractions of FIAF that colocalized with large drusen were: D-D group, 0.46 +/- 0.21; D-Pig group, 0.42 +/- 0.29; D-GA group, 0.13 +/- 0.09; and GA-GA group, 0.11 +/- 0.12. Comparisons between groups showed significant differences when comparing either the D-D group or the D-Pig group with either the D-GA group or the GA-GA group (P between 0.0001 and 0.015), whereas other comparisons were nonsignificant (Mann-Whitney rank sum test). The mean probabilities of FIAF colocalizing with large drusen relative to chance (1.0) were: D-D group, 4.7 +/- 2.5; D-Pig group, 4.3 +/- 2.3; D-GA group, 1.4 +/- 0.8; and GA-GA group, 1.8 +/- 1.3, with similar significant differences as for the colocalization fractions. The mean probability of FIAF colocalizing with small to intermediate drusen in the D-D group was 1.5 +/- 1.3, which was not significantly different from chance. In the D-Pig group, the median probability of FIAF colocalizing with pigment abnormalities was 10.0 (range, 1.1-51.0). The AF patterns in 15 of 19 eyes in the CNV-0 group were normal; the remainder had nonreticular hypoautofluorescence only. In the CNV-1 group, the relations of FIAF with drusen and pigment were similar to those in the early AMD groups. CNV-R comprised 20 of 55 eyes in the CNV group, but reticular autofluorescence and/or pseudodrusen were found in only 14 of 166 eyes of the early and atrophic groups. Of the 34 total eyes with reticular AF or pseudodrusen, 28 had both, 4 had reticular AF only, and 2 had reticular pseudodrusen only. There are clear relationships between AF patterns and clinical AMD status. In early AMD, FIAF's colocalization with large, soft drusen and hyperpigmentation is several times greater than chance, suggesting linked disease processes. In advanced atrophic AMD, FIAF is found mostly adjacent to drusen and GA, suggesting that dispersal of drusen-associated lipofuscin is a marker of atrophic disease progression. In the neovascular case, a large group of fellow eyes have no FIAF abnormalities, suggesting that lipofuscin is not a major determinant of CNV. However, reticular hypoautofluorescence, consistent with widespread inflammatory damage to the RPE, appears to be a highly sensitive imaging marker for the disease that determines reticular pseudodrusen and is strongly associated with CNV.

Continuous intraperitoneal insulin infusion does not increase the risk of organ-specific autoimmune disease in type 1 diabetic patients: results of a multicentric, comparative study

The purpose of this national multicenter prospective study by the French EVADIAC group was to investigate the possibility that continuous intraperitoneal insulin infusion using an implanted pump (CIpii) increases the risk of autoimmune disease in type 1 diabetic patients as it increased anti-insulin immunogenicity. Prevalence of clinical (Hashimoto's disease, hyperthyroidism, gastric atrophic disease and vitiligo) and subclinical (presence of anti-thyroperoxidase antibodies, anti-intrinsic factor antibodies, abnormal TSH levels) autoimmune diseases was estimated by comparing two groups of patients already treated by either CIpii (n=154) or external pump (CSII) (n=121) for an average of 6 years. Incidence of autoimmune disease was determined by comparing the same measurements one year after inclusion. No significant difference was observed for the total prevalence of clinical and subclinical auto-immune thyroid and gastric di-seases (35.6% and 3.2% respectively in the CIpii group versus 40.4% and 2.6% in the CSII group). No significant difference for the incidence of clinical and subclinical auto-immune diseases was observed: 7.2% and 0% in CIpii and 7.3% and 1.7% in CSII. As previously shown AIA (anti-insulin antibodies) levels were higher in CIpii than in CSII (32.9% vs 20.2%, P<0.0001) but no correlation was observed with either clinical or subclinical autoimmune disease. This large-scale study eliminates the possibility that CIpii increases the risk of autoimmune disease.

Candidate gene analysis suggests a role for fatty acid biosynthesis and regulation of the complement system in the etiology of age-related maculopathy

Age-related maculopathy (ARM) is a leading cause of visual impairment in elderly Americans and is a complex genetic disorder. Hypothesized pathways for the etiology of ARM include cholesterol and lipoprotein metabolism and transport, extracellular matrix integrity, oxidative stress and inflammatory/immunologic processes. This study investigates 21 polymorphisms within 15 candidate genes whose products function within these pathways by performing family and case-control genetic association studies using clearly affected familial cases (n=338 families, 796 individuals), clearly affected, unrelated sporadic cases (n=196) and clearly unaffected, unrelated controls (n=120). Two genes demonstrated significant association with ARM status. A Met299Val variant in the elongation of very long chain fatty acids-like 4 (ELOVL4) gene was significantly associated with ARM in the case-control allele (P=0.001), case-control genotype (P=0.001) and case-control family (P<0.0001) tests. A Tyr402His variant in exon 9 in the complement factor H (CFH) gene was also significantly associated with ARM in the case-control allele (P<0.0001), case-control genotype (P<0.0001) and case-control family (P<0.0001) tests. All of these results remain significant after adjusting for false discovery rates to control for the impact of multiple testing. In addition, the CFH variant appears to play a role in exudative and atrophic disease, whereas the ELOVL4 variant may play a greater role in exudative disease in our population. These results support a potential role for multiple pathways in the etiology of ARM, including pathways involved with fatty acid biosynthesis and the complement system.

The epsilon2 and epsilon4 alleles of the apolipoprotein gene are associated with age-related macular degeneration.

To date, of all the genes studied in relation to age-related macular degeneration (AMD), the alleles of the apolipoprotein (apoE) gene have been the most consistently associated with disease. However, not all apoE studies have found an association, and among these the associations differ. The current study was conducted to investigate further the association of this gene in AMD. Three hundred twenty-two unrelated individuals with diagnosed AMD and 123 unrelated but ethnically matched control subjects were analyzed. All subjects completed a standard questionnaire and were given a fundus examination. A blood sample was collected for DNA extraction. The common allelic variants of apoE were screened through the use of polymerase chain reaction (PCR) and restriction enzyme digestion followed by statistical analysis. Individuals with the epsilon3 epsilon4 genotype of apoE had an approximate halving of disease risk for late (end-stage) AMD (odds ratio [OR] 0.58, 95% confidence interval [CI] 0.34-0.98) relative to the epsilon3 epsilon3 genotype at age of ascertainment. Stratification of late AMD into atrophic and neovascular disease revealed that the greatest protective effect for the epsilon3 epsilon4 genotype was in individuals with atrophic disease (OR 0.35, 95% CI 0.13-0.92). Men with the epsilon3 epsilon4 genotype also showed almost a threefold reduction in risk of disease in late AMD (OR 0.36, 95% CI 0.16-0.82). However, individuals with late AMD and the epsilon2 epsilon3 genotype had a significantly earlier mean age of diagnosis of disease (3.4 years, P = 0.015) compared with those with the epsilon3 epsilon3 genotype, and this was most evident in women (3.9 years, P = 0.011) and in individuals with neovascular disease (4.7 years, P = 0.003). The alleles of apoE appear to have a role in the etiology of AMD, with the epsilon4 allele being protective, or at the very least, delaying the age of diagnosis of disease, whereas the epsilon2 allele appears to have a modifier effect by bringing forward the mean age of disease diagnosis.