Retinal Pigment Epithelium Loss Research Articles

Repeatability of Microperimetry in areas of RPE and Photoreceptor loss in Geographic Atrophy supported by AI-based OCT biomarker quantification.

Growing interest in microperimetry (MP) or fundus-controlled perimetry (FCP) as targeted psychometric testing method in geographic atrophy (GA) is warranted due to the disease subclinical/extra-foveal appearance or preexisting foveal loss with visual acuity becoming unreliable. We provide comprehensive pointwise test-retest repeatability reference values on the most widely used MP devices and combine them with targeted testing in areas of retinal pigment epithelium (RPE) as well as photoreceptor (PR) integrity loss, guiding the interpretation of sensitivity loss during the long-term follow-up of GA patients. Prospective reliability study METHODS: Patients with GA underwent consecutive testing on CenterVue (iCare) MAIA and NIDEK MP3 devices. Obtained PWS measurements were spatially co-registered to an optical coherence tomography (OCT) volume scan acquired during the same visit. Areas with RPE and PR integrity loss, drusen and PR thickness as well as the volume of hyperreflective foci (HRF) where identified and quantified using a set of validated deep learning-based algorithms. Test-retest repeatability was assessed according to areas defined by biomarker-specific morphologic changes using Bland-Altmann coefficients of repeatability (CoR). Furthermore, the inter-device correlation, the repeatability of scotoma point detection as well as any potential effects on fixation stability were assessed. 900 stimuli per device from twenty subjects were included. Identical overall PWS test-retest variance could be detected for MAIA (±6.57) and MP3 (±6.59). PR integrity loss was associated with a higher test-retest variance on both devices (MAIA: p=0.002; MP3: p<0.001). Higher CoR for stimuli in areas presenting RPE loss (±10.99 vs ±5.34) or HRF (±9.21 vs ±6.25) could only be detected on MP3 examinations (p<0.001 and p=0.01, respectively). An excellent intra-device correlation (MAIA: 0.94[0.93-0.95] MP3: 0.94[0.94-0.95]) and a good mean inter-device correlation (0.84[0.53-0.92]) could be demonstrated. The chosen device, run order or absence of foveal sparing had no significant effect on fixation stability. Areas presenting automatically quantified PR integrity loss with and without underlying RPE loss are associated with higher test-retest variance for both MAIA and MP3. These findings are crucial for an accurate interpretation of GA progression during long-term follow-up and the planning of future trials with microperimetry testing as functional study endpoint.

Prominin-1 Knockdown Causes RPE Degeneration in a Mouse Model.

There are currently no effective treatments for retinal pigment epithelial (RPE) cell loss in atrophic AMD (aAMD). However, our research on Prominin-1 (Prom1), a known structural protein in photoreceptors (PRs), has revealed its distinct role in RPE and offers promising insights. While pathogenic Prom1 mutations have been linked to macular diseases with RPE atrophy, the broader physiological impact of dysfunctional Prom1 in RPE loss is unclear. We have shown that Prom1 plays a crucial role in regulating autophagy and cellular homeostasis in human and mouse RPE (mRPE) cells in vitro. Nevertheless, a comprehensive understanding of its in vivo expression and function in mRPE remains to be elucidated. To characterize Prom1 expression in RPE in situ, we used RNAscope assays and immunogold electron microscopy (EM). Our use of chromogenic and fluorescent RNAscope assays in albino and C57BL/6J mouse retinal sections has revealed Prom1 mRNA expression in perinuclear regions in mRPE in situ. Immunogold EM imaging showed Prom1 expression in RPE cytoplasm and mitochondria. To confirm Prom1 expression in RPE, we interrogated human RPE single-cell RNA-sequencing datasets using an online resource, Spectacle. Our analysis showed Prom1 expression in human RPE. To investigate Prom1's function in RPE homeostasis, we performed RPE-specific Prom1 knockdown (KD) using subretinal injections of AAV2/1.CMV.saCas9.U6.Prom1gRNA in male and female mice. Our data show that RPE-specific Prom1-KD in vivo resulted in abnormal RPE morphology, subretinal fluid accumulation, and secondary PR loss. These changes were associated with patchy RPE cell death and reduced a-wave amplitude, indicating retinal degeneration. Our findings underscore the central role of Prom1 in cell-autonomous mRPE homeostasis. The implications of Prom1-KD causing aAMD-like RPE defects and retinal degeneration in a mouse model are significant and could lead to novel treatments for aAMD.

IPSC-Derived LCHADD Retinal Pigment Epithelial Cells Are Susceptible to Lipid Peroxidation and Rescued by Transfection of a Wildtype AAV-HADHA Vector.

Progressive choroid and retinal pigment epithelial (RPE) degeneration causing vision loss is a unique characteristic of long-chain 3-hydroxyacyl-CoA dehydrogenase deficiency (LCHADD), a fatty acid oxidation disorder caused by a common c.1528G>C pathogenic variant in HADHA, the α subunit of the mitochondrial trifunctional protein (TFP). We established and characterized an induced pluripotent stem cell (iPSC)-derived RPE cell model from cultured skin fibroblasts of patients with LCHADD and tested whether addition of wildtype (WT) HAHDA could rescue the phenotypes identified in LCHADD-RPE. We constructed an rAAV expression vector containing 3' 3xFLAG-tagged human HADHA cDNA under the transcriptional control of the cytomegalovirus (CMV) enhancer-chicken beta actin (CAG) promoter (CAG-HADHA-3XFLAG). LCHADD-RPE were cultured, matured, and transduced with either AAV-GFP (control) or AAV-HADHA-3XFLAG. LCHADD-RPE express TFP subunits and accumulate 3-hydroxy-acylcarnitines, cannot oxidize palmitate, and release fewer ketones than WT-RPE. When LCHADD-RPE are exposed to docosahexaenoic acid (DHA), they have increased oxidative stress, lipid peroxidation, decreased viability, and are rescued by antioxidant agents potentially explaining the pathologic mechanism of RPE loss in LCHADD. Transduced LCHADD-RPE expressing a WT copy of TFPα incorporated TFPα-FLAG into the TFP complex in the mitochondria and accumulated significantly less 3-hydroxy-acylcarnitines, released more ketones in response to palmitate, and were more resistant to oxidative stress following DHA exposure than control. iPSC-derived LCHADD-RPE are susceptible to lipid peroxidation mediated cell death and are rescued by exogenous HADHA delivered with rAAV. These results are promising for AAV-HADHA gene addition therapy as a possible treatment for chorioretinopathy in patients with LCHADD.

Quantitative comparison of automated OCT and conventional FAF-based geographic atrophy measurements in the phase 3 OAKS/DERBY trials

With the approval of the first two substances for the treatment of geographic atrophy (GA) secondary to age-related macular degeneration (AMD), a standardized monitoring of patients treated with complement inhibitors in clinical practice is needed. Optical coherence tomography (OCT) provides high-resolution access to the retinal pigment epithelium (RPE) and neurosensory layers, such as the ellipsoid zone (EZ), which further enhances the understanding of disease progression and therapeutic effects in GA compared to conventional fundus autofluorescence (FAF). In addition, artificial intelligence-based methodology allows the identification and quantification of GA-related pathology on OCT in an objective and standardized manner. The purpose of this study was to comprehensively evaluate automated OCT monitoring for GA compared to reading center-based manual FAF measurements in the largest successful phase 3 clinical trial data of complement inhibitor therapy to date. Automated OCT analysis of RPE loss showed a high and consistent correlation to manual GA measurements on conventional FAF. EZ loss on OCT was generally larger than areas of RPE loss, supporting the hypothesis that EZ loss exceeds underlying RPE loss as a fundamental pathophysiology in GA progression. Automated OCT analysis is well suited to monitor disease progression in GA patients treated in clinical practice and clinical trials.

Selective nanosecond laser removal of retinal pigment epithelium for cell therapy

Retinal pigment epithelial (RPE) cells play a crucial role in the health of the retina, and their dysfunction is associated with various ocular diseases. The transplantation of RPE cells has been proposed as a potential treatment for numerous degenerative diseases, including geographic atrophy from macular degeneration. However, current models to induce RPE damage in animal models prior to transplantation involve mechanical scraping, chemical administration, or laser photocoagulation techniques, which can damage the overlying neurosensory retina. This study aims to investigate the feasibility and efficacy of nanosecond duration laser treatment to safely remove large areas of RPE cells without causing damage to the adjacent tissue or affecting the retinal architecture. Twelve pigmented rabbits were treated with a nanosecond laser on each eye at a laser energy ranging from 200 to 800 nJ with a treated area of 5 × 5 mm2. Human induced pluripotent stem cells-differentiated to RPE (hiPSC-RPE) cells labeled with indocyanine green (ICG), an FDA approved dye, were transplanted subretinally into the damaged RPE areas at day 14 post-laser treatment. The RPE atrophy and hiPSC-RPE cell survival was evaluated and monitored over a period of 14 days using color photography, fluorescein angiography (FA), photoacoustic microscopy (PAM), and optical coherence tomography (OCT) imaging. All treated eyes demonstrated focal RPE loss with a success rate of 100%. The injured RPE layers and the transplanted hiPSC-RPE cells were visualized in three dimensions using PAM and OCT. By performing PAM at an optical wavelength of 700 nm, the location of hiPSC-RPE cells were identified and distinguished from the surrounding RPE cells, and the induced PA signal increased up to 18 times. Immunohistochemistry results confirmed the grafted hiPSC-RPE replaced regions of RPE damage. This novel technique has the potential to serve as an animal model of RPE degeneration, to improve models of RPE transplantation, and may help accelerate translation of this therapeutic strategy for clinical use.

Disease Activity and Therapeutic Response to Pegcetacoplan for Geographic Atrophy Identified by Deep Learning-Based Analysis of OCT

PurposeTo quantify morphological changes of the photoreceptors (PR) and retinal pigment epithelium (RPE) layers under pegcetacoplan therapy in geographic atrophy (GA) using deep learning-based analysis of optical coherence tomography (OCT) images. DesignPost-hoc longitudinal image analysis SubjectsPatients with GA due to age-related macular degeneration from two prospective randomized phase III clinical trials (OAKS and DERBY) MethodsDeep learning-based segmentation of RPE loss and PR degeneration, defined as loss of the ellipsoid zone (EZ) layer on OCT, over 24 months on SD-OCT images Main outcome measuresChange in the mean area of RPE loss and EZ loss over time in the pooled sham arms and the monthly (PM)/every other month (PEOM) treatment arms Results897 eyes of 897 patients were included. There was a therapeutic reduction of RPE loss growth by 22%/20% in OAKS and 27%/21% in DERBY for PM/PEOM compared to sham, respectively, at 24 months. The reduction on the EZ level was significantly higher with 53%/46% in OAKS and 47%/46% in DERBY for PM/PEOM compared to sham at 24 months. The baseline EZ-RPE difference had an impact on disease activity and therapeutic response. The therapeutic benefit for RPE loss growth increased with larger EZ-RPE difference quartiles from 21.9%, 23.1%, 23.9% to 33.6% for PM vs. sham (all p<0.01) and from 13.6% (p=0.11), 23.8%, 23.8% to 20.0% for PEOM vs. sham (p<0.01) in quartiles 1,2,3 and 4, respectively, at 24 months. Regarding EZ layer maintenance, the therapeutic reduction of loss increased from 14.8% (p=0.09), 33.3%, 46.6% to 77.8% (p<0.0001) between PM and sham and from 15.9% (p=0.08), 33.8%, 52.0% to 64.9% (p<0.0001) between PEOM and sham for quartiles 1-4 at 24 months. ConclusionOCT-based AI analysis objectively identifies and quantifies PR and RPE degeneration in GA. Reductions in further PR degeneration consistent with EZ loss on OCT are even higher than the effect on RPE loss in phase 3 trials of pegcetacoplan treatment. The EZ-RPE difference has a strong impact on disease progression and therapeutic response. Identification of patients with higher EZ-RPE loss difference may become an important criterion for the management of GA secondary to AMD.

Chapter 15 - Gene and cell-based therapies for retinal and optic nerve disease

Leading causes of blindness worldwide include neurodegenerative diseases of the retina, which cause irreversible loss of retinal pigment epithelium (RPE) and photoreceptors, and optic neuropathies, which result in retinal ganglion cell (RGC) death. Because photoreceptor and RGCs do not spontaneously regenerate in mammals, including humans, vision loss from these conditions is, at present, permanent. Recent advances in gene and cell-based therapies have provided new hope to patients affected by these conditions. This chapter reviews the current state and future of these approaches to treating ocular neurodegenerative disease. Gene therapies for retinal degeneration and optic neuropathies primarily focus on correcting known pathogenic mutations that cause inherited conditions to halt progression. There are multiple retinal and optic neuropathy gene therapies in clinical trials, and one retinal gene therapy is approved in the United States, Canada, Europe, and Australia. Cell-based therapies are mutation agnostic and have the potential to repopulate neurons regardless of the underlying etiology of degeneration. While photoreceptor cell replacement is nearing a human clinical trial, RPE transplantation is currently in phase I/II clinical trials. RGC replacement faces numerous logistical challenges, but preclinical research has laid the foundation for functional repair of optic neuropathies to be feasible.

Clinical‐grade hPSC‐derived RPE grafts for the treatment of age‐related macular degeneration

Aims/Purpose: Age‐related Macular Degeneration (AMD), a prevalent global cause of vision loss in the elderly, necessitates the development of efficacious treatments. Existing therapies do not cure AMD due to its complexity and the irreversible loss of photoreceptors and Retinal Pigment Epithelium (RPE). Cell replacement therapies targeting faulty RPE cells offer potential for slowing AMD progression, but the immunocompatibility of such therapies is challenging. We aim to develop a cell therapy strategy to minimize immune rejection.Methods: Our strategy entailed establishing a Good Manufacturing Practice (GMP)‐compatible induced Pluripotent Stem Cell (iPSC) cell bank representing the most frequent homozygous human leukocyte antigen (HLA) haplotypes in the Andalusian population, facilitating derivation of immunocompatible RPE cells. We utilized and refined existing RPE differentiation protocols for generating clinically compliant RPE cells. Furthermore, we tested three bioscaffolds for RPE growth and maturation and compared the physical properties of the resulting RPE cell‐bioscaffold biopatch for transplantability.Results: We successfully established three GMP‐compatible iPSC lines featuring common homozygous HLA profiles. Through our refined differentiation protocols, these iPSCs were converted into functional, high‐purity and safe RPE cells. Comparative analysis of different bioscaffolds revealed variable capabilities for RPE growth, maturation and transplantability, thereby informing the final bioscaffold selection for RPE biopatch generation.Conclusions: Our study underscores the feasibility of generating clinical‐grade, immunocompatible iPSC‐derived RPE grafts using GMP‐compliant procedures for AMD treatment. This innovative approach addresses a critical unmet medical need and suggests potential for similar strategies in other cell replacement therapies. The selection of an optimal bioscaffold for RPE growth and maturation is critical for effective RPE biopatch development. Further pre‐clinical and clinical studies are required to evaluate the safety and efficacy of these RPE grafts in AMD treatment.

Extracellular vesicles from organoid-derived human retinal progenitor cells prevent lipid overload-induced retinal pigment epithelium injury by regulating fatty acid metabolism.

Retinal degeneration (RD), a group of diseases leading to irreversible vision loss, is characterised by retinal pigment epithelium (RPE) or retinal neuron damage and loss. With fewer risks of immune rejection and tumorigenesis, stem cell-secreted extracellular vesicles (EVs) offer a new cell-free therapeutic paradigm for RD, which remains to be investigated. Human retinal organoid-derived retinal progenitor cells (hERO-RPCs) are an easily accessible and advanced cell source for RD treatment. However, hERO-RPCs-derived EVs require further characterisation. Here, we compared the characteristics of EVs from hERO-RPCs (hRPC-EVs) with those of human embryonic stem cell (hESC)-derived EVs (hESC-EVs) as controls. Based on in-depth proteomic analysis, we revealed remarkable differences between hRPC-EVs and hESC-EVs. A comparison between EVs and their respective cells of origin demonstrated that the protein loading of hRPC-EVs was more selective than that of hESC-EVs. In particular, hESC-EVs were enriched with proteins related to angiogenesis and cell cycle, whereas hRPC-EVs were enriched with proteins associated with immune modulation and retinal development. More importantly, compared with that of hESC-EVs, hRPC-EVs exhibited a lower correlation with cell proliferation and a unique capacity to regulate lipid metabolism. It was further confirmed that hRPC-EVs potentially eliminated lipid deposits, inhibited lipotoxicity and oxidative stress, and enhanced phagocytosis and survival of oleic acid-treated ARPE-19 cells. Mechanistically, hRPC-EVs are integrated into the mitochondrial network of oleic acid-treated ARPE-19 cells, and increased the level of mitochondrial fatty acid β-oxidation-related proteins. Thus, organoid-derived hRPC-EVs represent a promising source of cell-free therapy for RD, especially for blinding diseases related to abnormal lipid metabolism in RPE cells.

Parapapillary βBM and γ Zones Played Different Roles in Axial Elongation Among Young Adolescents Using Optical Coherence Tomography.

To evaluate the influencing factors of parapapillary βBM and γ zones incidence in young adolescents and to explore their associations with axial length progression. In this prospective cohort study, 976 seventh-grade students from nine secondary schools in Beijing, China, were enrolled and followed up 1 year later. Parapapillary βBM zone was defined as retinal pigment epithelium loss while Bruch's membrane was present. Parapapillary γ zone was defined as the absence of retinal pigment epithelium and Bruch's membrane. Logistic regression model was used to analyze the influencing factors of βBM and γ zone incidence. A linear mixed model was used to analyze the associations between parapapillary zones and axial elongation. Of the 976 participants, 139 (14.2%) had only βBM zone, 398 (40.8%) had only γ zone, and 171 (17.5%) had both. At follow-up, the incidence of βBM zone was 11.5% (76/659), and the incidence of γ zone was 9.7% (39/404). Optic disc tilt, thinner subfoveal choroid, and longer axial length at baseline showed a higher risk of γ zone incidence. The absence of γ zone at baseline showed a faster axial length progression. When the baseline axial length was 25 mm or longer, the βBM zone was also related to the axial elongation. The γ zone was associated with axial length progression, and the βBM zone was also associated with the axial length progression when the axial length exceeded 25 mm, which was consistent with the notion that excessive axial length growth not only is the extension of the eyeball but also has its own pathologic changes.

Geographic atrophy: pathophysiology and current therapeutic strategies.

Geographic atrophy (GA) is an advanced stage of age-related macular degeneration (AMD) that leads to gradual and permanent vision loss. GA is characterized by the loss of photoreceptor cells and retinal pigment epithelium (RPE), leading to distinct atrophic patches in the macula, which tends to increase with time. Patients with geographic atrophy often experience a gradual and painless loss of central vision, resulting in difficulty reading, recognizing faces, or performing activities that require detailed vision. The primary risk factor for the development of geographic atrophy is advanced age; however, other risk factors, such as family history, smoking, and certain genetic variations, are also associated with AMD. Diagnosis is usually based on a comprehensive eye examination, including imaging tests such as fundus photography, optical coherence tomography (OCT), and fluorescein angiography. Numerous clinical trials are underway, targeting identified molecular pathways associated with GA that are promising. Recent approvals of Syfovre and Izervay by the FDA for the treatment of GA provide hope to affected patients. Administration of these drugs resulted in slowing the rate of progression of the disease. Though these products provide treatment benefits to the patients, they do not offer a cure for geographic atrophy and are limited in efficacy. Considering these safety concerns and limited treatment benefits, there is still a significant need for therapeutics with improved efficacy, safety profiles, and better patient compliance. This comprehensive review discusses pathophysiology, currently approved products, their limitations, and potential future treatment strategies for GA.

Micromolded honeycomb scaffold design to support the generation of a bilayered RPE and photoreceptor cell construct.

Age-related macular degeneration (AMD) causes blindness due to loss of retinal pigment epithelium (RPE) and photoreceptors (PRs), which comprise the two outermost layers of the retina. Given the small size of the macula and the importance of direct contact between RPE and PRs, the use of scaffolds for targeted reconstruction of the outer retina in later stage AMD and other macular dystrophies is particularly attractive. We developed microfabricated, honeycomb-patterned, biodegradable poly(glycerol sebacate) (PGS) scaffolds to deliver organized, adjacent layers of RPE and PRs to the subretinal space. Furthermore, an optimized process was developed to photocure PGS, shortening scaffold production time from days to minutes. The resulting scaffolds robustly supported the seeding of human pluripotent stem cell-derived RPE and PRs, either separately or as a dual cell-layered construct. These advanced, economical, and versatile scaffolds can accelerate retinal cell transplantation efforts and benefit patients with AMD and other retinal degenerative diseases.

Invited Session II: Retinal remodeling and regeneration: Insights into retinal cell replacement: Optimising photoreceptor and RPE transplantation.

Retinal degenerative diseases, such as age-related macular degeneration and inherited retinal degenerations, are characterized by the dysfunction and ultimately loss of photoreceptors and retinal pigment epithelium (RPE). Retinal cell replacement has emerged as a potential therapeutic strategy. This is enabled by the availability of desired donor cells differentiated in large numbers from human embryonic or induced pluripotent stem cells. With many differentiation protocols around, detailed comparison of donor cell and host characteristics allowing improved transplantations outcomes are however still sparse. Here, I will present our work on a more detailed assessment of photoreceptor and RPE single cell suspension transplantations. Human photoreceptors incorporate extensively into a cone-degeneration mouse host, interact with host Müller glia and bipolar cells and polarize to form inner and outer segments as well as synapses. Importantly, increased donor-host interactions correlate with improved graft polarization and maturation, with donor cell age greatly influencing this process. Similarly, RPE transplantations into an acute RPE depletion mouse model showed that monolayer formation strongly depends on RPE differentiation times, with further improvement by enrichment of an RPE subpopulation by cell surface markers. Overall, our work highlights the need for careful selection of appropriate donor cells for structural integration into recipient tissue after transplantation.

Functional Evaluation of Retinal Pigment Epithelium and Outer Retinal Atrophy by High-Density Targeted Microperimetry Testing

Complete retinal pigment epithelium (RPE) and outer retinal atrophy (cRORA) on OCT imaging has recently been proposed to describe end-stage atrophy in age-related macular degeneration (AMD) by international consensus and expected to be associated with a dense scotoma, but such functional evidence is lacking. This study sought to examine the visual sensitivity defects associated with cRORA and to determine OCT features associated with deep defects. Observational study. Sixty eyes from 53 participants, including 342 microperimetry tests over 171 study visits. Participants underwent targeted high-density threshold-based microperimetry testing of atrophic lesions (with at least incomplete RPE and outer retinal atrophy [iRORA]) with a 3.5° diameter grid. The maximum extent of signs of atrophy for all lesions was graded on OCT imaging. Number of deep visual sensitivity defects (threshold ≤ 10decibels [dB]). Presence of choroidal signal hypertransmission ≥ 500 μm, complete RPE loss ≥250 μm, and inner nuclear layer and outer plexiform layer subsidence, and hyporeflective wedge-shaped band (defined as nascent geographic atrophy [nGA]) ≥ 500 μm (P ≤ 0.020), but not RPE attenuation or disruption (P ≥ 0.192), were all independently associated with a significant increase in the number of deep visual sensitivity defects ≤ 10 dB. Only cRORA lesions with hypertransmission ≥ 500 μm or complete RPE loss ≥ 250 μm, or with both of these features (P < 0.001), but not lesions with only hypertransmission 250-499 μm (P = 0.303), had significantly more deep visual sensitivity defects ≤ 10 dB compared with iRORA lesions. Lesions with nGA ≥ 500 μm, irrespective of the presence of hypertransmission ≥ 500 μm and/or complete RPE loss ≥ 250 μm, also showed a higher number of deep visual sensitivity defects ≤ 10 dB compared with lesions without nGA ≥ 500 μm (P≤0.011). Not all cRORA lesions show a difference in the number of deep visual sensitivity defects compared with iRORA. Instead, hypertransmission ≥ 500 μm, complete RPE loss ≥ 250 μm, and nGA ≥ 500 μm are all OCT features independently associated with deep visual sensitivity detects that could help inform the definition of end-stage atrophy on OCT imaging. Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

MACULAR ATROPHY AND PHENOTYPIC VARIABILITY IN AUTOSOMAL DOMINANT STARGARDT-LIKE MACULAR DYSTROPHY DUE TO PROM1 MUTATION.

To describe the phenotypic variability and rates of progression of atrophy in patients with PROM1 -associated macular dystrophy. Patients in this retrospective, longitudinal case series from a tertiary center had clinical examination and multimodal imaging performed. Areas of retinal pigment epithelium and ellipsoid zone loss over time by optical coherence tomography were calculated by two independent graders. Fifteen patients from five kindreds with an Arg373Cys mutation in PROM1 were studied. The average age was 39 years, and 80% were women. The visual acuity was 20/40 at presentation and 20/57 at last follow-up (average 4.8 years). Three distinct macular phenotypes were observed: 1) central geographic atrophy (13%), 2) multifocal geographic atrophy (20%), and 3) bull's eye maculopathy (67%). The overall rate of atrophy progression was 0.36 mm 2 /year, but the average rate of atrophy progression varied by macular phenotype: 1.08 mm 2 /year for central geographic atrophy, 0.53 mm 2 /year for multifocal geographic atrophy, and 0.23 mm 2 /year for bull's eye maculopathy. Patients with PROM1 -associated macular dystrophy demonstrate distinct phenotypes, with bull's eye maculopathy being the most common. The average rate of atrophy progression may be similar to reported rates for ABCA4 -related Stargardt disease and less than age-related macular degeneration. These results provide important measures for following treatment response in future gene and stem cell-based therapies.

Progression Dynamics of Early versus Later Stage Atrophic Lesions in Nonneovascular Age-Related Macular Degeneration Using Quantitative OCT Biomarker Segmentation

To investigate the progression of geographic atrophy (GA) secondary to non-neovascular age-related macular degeneration (AMD) in early and later stage lesions using AI-based precision tools. Retrospective analysis of an observational cohort study. Seventy-four eyes of forty-nine patients with at least one complete retinal pigment epithelial and outer retinal atrophy (cRORA) lesion secondary to AMD were included. Patients were divided between recently developed cRORA and lesions with advanced disease status. Patients were prospectively imaged by spectral domain optical coherence tomography (SD-OCT) volume scans. The study period encompassed 18 months with scheduled visits every 6 months. Growth rates of recently to cRORA converted lesions were compared with lesions in an advanced disease status using mixed effect models. The progression of retinal pigment epithelial loss (RPEL) was considered the primary endpoint. Secondary endpoints consisted of external limiting membrane disruption (ELMD) and ellipsoid zone loss (EZL). These pathognomonic imaging biomarkers were quantified using validated deep learning algorithms. Further the EZ/RPE-Loss ratio was analysed in both study cohorts. Mean [95%CI] square root progression of recently converted lesions was 79.676[-77.140 - 236.493], 68.219[-101.210 - 237.648) and 84.825[-124.816 - 294.467] mm/half year for RPEL, ELML and EZL respectively. Mean square root progression of advanced lesions was 131.737[-22.574 - 286.047], 129.964[-36.666 - 296.594] and 116.837[-90.556 - 324.301] mm/half year for RPEL, ELML and EZL respectively. RPEL (p=0.038) and ELMD (p=0.026) progression showed significant differences between the two study cohorts. Further recent converters had significantly (p<0.001) higher EZ/RPE-Loss ratios in all time points compared to patients in an advanced disease status (1.716 [1.135 - 2.296] versus 1.153 [0.576 - 1.729]). Early cRORA lesions have a slower growth rate in comparison to atrophic lesions in advanced disease stages. Differences in growth dynamics may play a crucial role in understanding the pathophysiology of non-neovascular AMD and for the interpretation of clinical trials in GA. Individual disease monitoring using AI-based quantification paves the way towards optimized GA management.

Monitoring Lesion Area Progression in Stargardt Disease: A Comparison of En Face Optical Coherence Tomography and Fundus Autofluorescence.

To compare longitudinal changes in en face spectral domain-optical coherence tomography (SD-OCT) measurements of ellipsoid zone (EZ) and retinal pigment epithelium (RPE) loss to changes in the hypoautofluorescent and hyperautofluorescent (AF) areas detected with short-wavelength (SW)-AF in ABCA4-associated retinopathy. SD-OCT volume scans were obtained from 20 patients (20 eyes) over 2.6 ± 1.2 years (range 1-5 years). The EZ, and RPE/Bruch's membrane boundaries were segmented, and en face slab images generated. SubRPE and EZ slab images were used to measure areas of atrophic RPE and EZ loss. These were compared to longitudinal measurements of the hypo- and abnormal AF (hypoAF and surrounding hyperAF) areas. At baseline, the en face area of EZ loss was significantly larger than the subRPE atrophic area, and the abnormal AF area was significantly larger than the hypoAF area. The median rate of EZ loss was significantly greater than the rate of increase in the subRPE atrophic area (1.2 mm2/yr compared to 0.5 mm2/yr). The median rate of increase in the abnormal AF area was significantly greater than the increase in the hypoAF area (1.6 mm2/yr compared to 0.6 mm2/yr). En face SD-OCT can be used to quantify changes in RPE atrophy and photoreceptor integrity. It can be a complementary or alternative technique to SW-AF with the advantage of monitoring EZ loss. The SW-AF results emphasize the importance of measuring changes in the hypo- and abnormal AF areas. The findings are relevant to the selection of outcome measures for monitoring ABCA4-associated retinopathy.

Acute Syphilitic Posterior Placoid Chorioretinitis; a Case Report and Review

Background: Acute syphilitic posterior placoid chorioretinopathy (ASPPC) is a rare but defining characteristic of ocular syphilis. Clinical findings are subtle, geographic, yellowish, macular lesions, affecting the outer-retina and inner choroid, and often associated with subretinal fluid in the early phase. This case report will review the clinical signs of ASPPC to aid the practitioner in identification and recognition of its clinical importance as it relates to early diagnosis, treatment, and prognosis. Case Report: A 79-year-old African American male presented to clinic with a chief complaint of blur in the right eye for the prior two days. Spectral Domain Optical Coherence Tomography (SD-OCT) of the macula revealed a shallow retinal pigment epithelial detachment with subretinal fluid centrally with some loss of the retinal pigment epithelium (RPE) and photoreceptors nasally in the right eye. There was rapid progression over a week to full loss of RPE and photoreceptors with reduction of vision to hand motion in the right eye, suggesting an infectious etiology. Serologic testing was ordered, and an RPR and FTA-ABS were both reactive. A diagnosis of acute syphilitic posterior placoid chorioretinopathy was made. An infectious disease physician treated the patient with IV penicillin G. There was a complete resolution of ocular findings. Conclusion: Syphilis should be considered for any ocular inflammatory condition. ASPPC is highly suggestive of syphilis. All patients with ocular syphilis should be evaluated for neurosyphilis. Treatment is IV penicillin G for 10-14 days and considered successful when there is a four-fold reduction in titers. Full visual recovery typically occurs within 12 weeks of treatment if a diagnosis and treatment are initiated early in the course of ocular disease.

Deep-learning automated quantification of longitudinal OCT scans demonstrates reduced RPE loss rate, preservation of intact macular area and predictive value of isolated photoreceptor degeneration in geographic atrophy patients receiving C3 inhibition treatment

ObjectiveTo evaluate the role of automated optical coherence tomography (OCT) segmentation, using a validated deep-learning model, for assessing the effect of C3 inhibition on the area of geographic atrophy (GA);...

Role of Epithelial-to-Mesenchymal Transition of Retinal Pigment Epithelial Cells in Glaucoma Cupping

Optic nerve head (ONH) cupping is a clinical feature of glaucoma associated with extracellular matrix (ECM) remodelling and lamina cribrosa (LC) fibrosis. Peripapillary atrophy (PPA) occurs commonly in glaucoma, and is characterised by the loss of retinal pigment epithelium (RPE) adjacent to the ONH. Under pro-fibrotic conditions, epithelial cells throughout the body can differentiate into fibroblast-like cells through epithelial-to-mesenchymal transition (EMT) and contribute to ECM fibrosis. This is investigated here in the context of glaucoma and PPA. Human-donor ONH sections were assessed for the presence of the RPE cell-specific marker RPE65 using immunofluorescence. We examined the EMT response of ARPE-19 cells to the following glaucoma-related stimuli: cyclic mechanical stretch, mechanical stiffness, transforming growth factor beta (TGFβ), and tumour necrosis factor alpha (TNFα). The gene expression was measured using the PCR of the epithelial tight junction marker zona occludens 1 (ZO-1) and the mesenchymal markers alpha smooth muscle actin (αSMA) and vimentin. A scratch assay was used to assess the ARPE-19 migration. Significant RPE-65 staining was demonstrated in the glaucomatous ONH. The cyclic stretching and substrate stiffness of the ARPE-19 cells caused a significant decrease in ZO-1 (p = 0.04), and an increase in αSMA (p = 0.04). The scratch assays demonstrated increased migration of ARPE19 in the presence of TNFα (p = 0.02). Furthermore, ARPE-19 cells undergo an EMT-like transition (gain of αSMA, loss of ZO-1 and increased migration) in response to glaucomatous stimuli. This suggests that during PPA, RPE cells have the potential to migrate into the ONH and differentiate into fibroblast-like cells, contributing to glaucomatous ONH cupping.