Skip to main content

Advertisement

Log in

Novel potential mechanisms for diabetic macular edema: Leveraging new investigational approaches

  • Published:
Current Diabetes Reports Aims and scope Submit manuscript

Abstract

This article evaluates the current knowledge of the molecular mechanisms by which diabetes ocular and systemic inflammation induce breakdown of the blood-retinal barrier resulting in macular edema. We also summarize the relationship between molecular targets and the use of therapeutic inhibitors in preclinical studies and clinical trials. Further studies are needed to understand the regulation of normal blood-retinal barrier physiology and the relationship between events in animal models of diabetic retinopathy and humans with diabetes.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Similar content being viewed by others

References and Recommended Reading

  1. Erickson KK, Sundstrom JM, Antonetti DA: Vascular permeability in ocular disease and the role of tight junctions. Angiogenesis 2007, 10:103–117.

    Article  PubMed  Google Scholar 

  2. Barber AJ, Antonetti DA: Mapping the blood vessels with paracellular permeability in the retinas of diabetic rats. Invest Ophthalmol Vis Sci 2003, 44:5410–5416.

    Article  PubMed  Google Scholar 

  3. Nitta T, Hata M, Gotoh S, et al.: Size-selective loosening of the blood-brain barrier in claudin-5-deficient mice. J Cell Biol 2003, 161:653–660.

    Article  PubMed  CAS  Google Scholar 

  4. Phillips BE, Cancel LM, Tarbell JM, Antonetti DA: Occludin regulates permeability under hydrostatic pressure and cell division in retinal pigment epithelial cells. Invest Ophthalmol Vis Sci 2008 Feb 8 (Epub ahead of print).

  5. Maines LW, Antonetti DA, Wolpert EB, Smith CD: Evaluation of the role of P-glycoprotein in the uptake of paroxetine, clozapine, phenytoin and carbamazepine by bovine retinal endothelial cells. Neuropharmacology 2005, 49:610–617.

    PubMed  CAS  Google Scholar 

  6. Stewart PA, Wiley MJ: Developing nervous tissue induces formation of blood-brain barrier characteristics in invading endothelial cells: a study using quail-chick transplantation chimeras. Dev Biol 1981, 84:183–192.

    Article  PubMed  CAS  Google Scholar 

  7. Felinski EA, Cox AE, Phillips BE, Antonetti DA: Glucocorticoids induce transactivation of tight junction genes occludin and claudin 5 in retinal endothelial cells via a novel cis-element. Exp Eye Res 2008, 86:867–878.

    Article  PubMed  CAS  Google Scholar 

  8. Masland RH: The fundamental plan of the retina. Nat Neurosci 2001, 4:877–886.

    Article  PubMed  CAS  Google Scholar 

  9. Johnson MA, Lutty GA, McLeod DS, et al.: Ocular structure and function in an aged monkey with spontaneous diabetes mellitus. Exp Eye Res 2005, 80:37–42.

    Article  PubMed  CAS  Google Scholar 

  10. Gariano RF, Gardner TW: Retinal angiogenesis in development and disease. Nature 2005, 438:960–966.

    Article  PubMed  CAS  Google Scholar 

  11. Scott IU, Edwards AR, Beck RW, et al.: A phase II randomized clinical trial of intravitreal bevacizumab for diabetic macular edema. Ophthalmology 2007, 114:1860–1867.

    Article  PubMed  Google Scholar 

  12. Zacchigna S, Ruiz de Almodovar C, Carmeliet P: Similarities between angiogenesis and neural development: what small animal models can tell us. Curr Top Dev Biol 2008, 80:1–55.

    Article  PubMed  Google Scholar 

  13. Gardner TW, Antonetti DA, Barber AJ, et al.: Diabetic retinopathy: more than meets the eye. Surv Ophthalmol 2002, 47(Suppl 2):S253–S262.

    Article  PubMed  Google Scholar 

  14. Karalliedde J, Buckingham RE: Thiazolidinediones and their fluid-related adverse effects: facts, fiction and putative management strategies. Drug Saf 2007, 30:741–753.

    Article  PubMed  CAS  Google Scholar 

  15. Sander B, Thornit DN, Colmorn L, et al.: Progression of diabetic macular edema: correlation with blood retinal barrier permeability, retinal thickness, and retinal vessel diameter. Invest Ophthalmol Vis Sci 2007, 48:3983–3987.

    Article  PubMed  Google Scholar 

  16. Soliman W, Sander B, Hasler PW, Larsen M: Correlation between intraretinal changes in diabetic macular oedema seen in fluorescein angiography and optical coherence tomography. Acta Ophthalmol 2008, 86:34–39.

    PubMed  Google Scholar 

  17. Antonetti DA, Barber AJ, Bronson SK, et al.: Diabetic retinopathy: seeing beyond glucose-induced microvascular disease. Diabetes 2006, 55:2401–2411.

    Article  PubMed  CAS  Google Scholar 

  18. Diabetic Retinopathy Clinical Research Network; Browning DJ, Glassman AR, Aiello LP, et al.: Relationship between optical coherence tomography-measured central retinal thickness and visual acuity in diabetic macular edema. Ophthalmology 2007, 114:525–536.

    Article  PubMed  Google Scholar 

  19. Writing Committee for the Diabetic Retinopathy Clinical Research Network; Fong DS, Strauber SF, Aiello LP, et al.: Comparison of the modified Early Treatment Diabetic Retinopathy Study and mild macular grid laser photocoagulation strategies for diabetic macular edema. Arch Ophthalmol 2007, 125:469–480.

    Article  PubMed  Google Scholar 

  20. Wellen KE, Hotamisligil GS: Inflammation, stress, and diabetes. J Clin Invest 2005, 115:1111–1119.

    PubMed  CAS  Google Scholar 

  21. Dana GW: Type of diabetes mellitus associated with diabetic retinitis. AMA Arch Ophthalmol 1953, 50:123–124.

    PubMed  CAS  Google Scholar 

  22. Diabetes Prevention Program Research Group: The prevalence of retinopathy in impaired glucose tolerance and recent-onset diabetes in the Diabetes Prevention Program. Diabet Med 2007, 24:137–144.

    Article  Google Scholar 

  23. Meleth AD, Agron E, Chan CC, et al.: Serum inflammatory markers in diabetic retinopathy. Invest Ophthalmol Vis Sci 2005, 46:4295–4301.

    Article  PubMed  Google Scholar 

  24. El-Remessy AB, Al-Shabrawey M, Khalifa Y, et al.: Neuroprotective and blood-retinal barrier-preserving effects of cannabidiol in experimental diabetes. Am J Pathol 2006, 168:235–244.

    Article  PubMed  CAS  Google Scholar 

  25. Al-Shabrawey M, Rojas M, Sanders T, et al.: Role of NADPH oxidase in retinal vascular inflammation. Invest Ophthalmol Vis Sci 2008 Mar 31 (Epub ahead of print).

  26. Reiter CEN, Wu X, Sandirasegarane L, et al.: Diabetes reduces basal retinal insulin receptor signaling: reversal with systemic and local insulin. Diabetes 2006, 55:1148–1156.

    Article  PubMed  CAS  Google Scholar 

  27. Seki M, Tanaka T, Nawa H, et al.: Involvement of brain-derived neurotrophic factor in early retinal neuropathy of streptozotocin-induced diabetes in rats: therapeutic potential of brain-derived neurotrophic factor for dopaminergic amacrine cells. Diabetes 2004, 53:2412–2419.

    Article  PubMed  CAS  Google Scholar 

  28. Storkebaum E, Carmeliet P: VEGF: a critical player in neurodegeneration. J Clin Invest 2004, 113:14–18.

    PubMed  CAS  Google Scholar 

  29. Klein R, Klein BE, Moss SE, Cruickshanks KJ: The Wisconsin Epidemiologic Study of Diabetic Retinopathy: XVII. The 14-year incidence and progression of diabetic retinopathy and associated risk factors in type 1 diabetes. Ophthalmology 1998, 105:1801–1815.

    Article  PubMed  CAS  Google Scholar 

  30. Mohamed Q, Gillies MC, Wong TY: Management of diabetic retinopathy: a systematic review. JAMA 2007, 298:902–916.

    Article  PubMed  CAS  Google Scholar 

  31. PKC-DMES Study Group: Effect of ruboxistaurin in patients with diabetic macular edema: thirty-month results of the randomized PKC-DMES clinical trial. Arch Ophthalmol 2007, 125:318–324.

    Article  Google Scholar 

  32. Gillies MC, Sutter FK, Simpson JM, et al.: Intravitreal triamcinolone for refractory diabetic macular edema: two-year results of a double-masked, placebo-controlled, randomized clinical trial. Ophthalmology 2006, 113:1533–1538.

    Article  PubMed  Google Scholar 

  33. Csaky KG, Richman EA, Ferris FL 3rd: Report from the NEI/FDA Ophthalmic Clinical Trial Design and Endpoints Symposium. Invest Ophthalmol Vis Sci 2008, 49:479–489.

    Article  PubMed  Google Scholar 

  34. Joussen AM, Murata T, Tsujikawa A, et al.: Leukocyte-mediated endothelial cell injury and death in the diabetic retina. Am J Pathol 2001, 158:147–152.

    PubMed  CAS  Google Scholar 

  35. Skondra D, Noda K, Almulki L, et al.: Characterization of azurocidin as a permeability factor in the retina: involvement in VEGF-induced and early diabetic blood-retinal barrier breakdown. Invest Ophthalmol Vis Sci 2008, 49:726–731.

    Article  PubMed  Google Scholar 

  36. Antonetti DA, Barber AJ, Khin S, et al.: Vascular permeability in experimental diabetes is associated with reduced endothelial occludin content: vascular endothelial growth factor decreases occludin in retinal endothelial cells. Diabetes 1998, 47:1953–1959.

    Article  PubMed  CAS  Google Scholar 

  37. Navaratna D, McGuire PG, Menicucci G, Das A: Proteolytic degradation of VE-cadherin alters the blood-retinal barrier in diabetes. Diabetes 2007, 56:2380–2387.

    Article  PubMed  CAS  Google Scholar 

  38. Aiello LP: The potential role of PKC beta in diabetic retinopathy and macular edema. Surv Ophthalmol 2002, 47(Suppl 2):S263–S269.

    Article  PubMed  Google Scholar 

  39. Antonetti DA, Wolpert EB, Demaio L, et al.: Hydrocortisone decreases retinal endothelial cell water and solute flux coincident with increased content and decreased phosphorylation of occludin. J Neurochem 2002, 80:667–677.

    Article  PubMed  CAS  Google Scholar 

  40. Ishii H, Jirousek MR, Koya D, et al.: Amelioration of vascular dysfunctions in diabetic rats by an oral PKC beta inhibitor. Science 1996, 272:728–731.

    Article  PubMed  CAS  Google Scholar 

  41. Kuppermann BD, Blumenkranz MS, Haller JA, et al.: Randomized controlled study of an intravitreous dexamethasone drug delivery system in patients with persistent macular edema. Arch Ophthalmol 2007, 125:309–317.

    Article  PubMed  CAS  Google Scholar 

  42. Aiello LP, Davis MD, Girach A, et al.: Effect of ruboxistaurin on visual loss in patients with diabetic retinopathy. Ophthalmology 2006, 113:2221–2230.

    Article  PubMed  Google Scholar 

  43. Giebel SJ, Menicucci G, McGuire PG, Das A: Matrix metalloproteinases in early diabetic retinopathy and their role in alteration of the blood-retinal barrier. Lab Invest 2005, 85:597–607.

    Article  PubMed  CAS  Google Scholar 

  44. Behzadian MA, Wang XL, Windsor LJ, et al.: TGF-beta increases retinal endothelial cell permeability by increasing MMP-9: possible role of glial cells in endothelial barrier function. Invest Ophthalmol Vis Sci 2001, 42:853–859.

    PubMed  CAS  Google Scholar 

  45. Rungger-Brandle E, Dosso AA, Leuenberger PM: Glial reactivity, an early feature of diabetic retinopathy. Invest Ophthalmol Vis Sci 2000, 41:1971–1980.

    PubMed  CAS  Google Scholar 

  46. Wilkinson-Berka JL, Fletcher EL: Angiotensin and bradykinin: targets for the treatment of vascular and neuro-glial pathology in diabetic retinopathy. Curr Pharm Des 2004, 10:3313–3330.

    Article  PubMed  CAS  Google Scholar 

  47. Hata Y, Clermont A, Yamauchi T, et al.: Retinal expression, regulation, and functional bioactivity of prostacyclin-stimulating factor. J Clin Invest 2000, 106:541–550.

    Article  PubMed  CAS  Google Scholar 

  48. Duh EJ, Yang HS, Haller JA, et al.: Vitreous levels of pigment epithelium-derived factor and vascular endothelial growth factor: implications for ocular angiogenesis. Am J Ophthalmol 2004, 137:668–674.

    Article  PubMed  CAS  Google Scholar 

  49. Abu El-Asrar AM, Dralands L, Missotten L, Geboes K: Expression of antiapoptotic and proapoptotic molecules in diabetic retinas. Eye 2007, 21:238–245.

    Article  PubMed  CAS  Google Scholar 

  50. Ramasamy R, Vannucci SJ, Yan SS, et al.: Advanced glycation end products and RAGE: a common thread in aging, diabetes, neurodegeneration, and inflammation. Glycobiology 2005, 15:16R–28R.

    Article  PubMed  CAS  Google Scholar 

  51. Aiello LP, Bursell SE, Clermont A, et al.: Vascular endothelial growth factor-induced retinal permeability is mediated by protein kinase C in vivo and suppressed by an orally effective beta-isoform-selective inhibitor. Diabetes 1997, 46:1473–1480.

    Article  PubMed  CAS  Google Scholar 

  52. Hollis TM, Gardner TW, Vergis GJ, et al.: Antihistamines reverse blood-ocular barrier breakdown in experimental diabetes. J Diabetic Complications 1988, 2:47–49.

    Article  CAS  Google Scholar 

  53. Gardner TW, Eller AW, Friberg TR, et al.: Antihistamines reduce blood-retinal barrier permeability in patients with type I (insulin-dependent) diabetes and nonproliferative diabetic retinopathy. A Pilot Study. Retina 1995, 15:134–140.

    Article  PubMed  Google Scholar 

  54. Krady JK, Basu A, Allen CM, et al.: Minocycline reduces proinflammatory cytokine expression, microglial activation, and caspase-3 activation in a rodent model of diabetic retinopathy. Diabetes 2005, 54:1559–1565.

    Article  PubMed  CAS  Google Scholar 

  55. Vincent JA, Mohr S: Inhibition of caspase-1/interleukin-1beta signaling prevents degeneration of retinal capillaries in diabetes and galactosemia. Diabetes 2007, 56:224–230.

    Article  PubMed  CAS  Google Scholar 

  56. Kern TS, Miller CM, Du Y, et al.: Topical administration of nepafenac inhibits diabetes-induced retinal microvascular disease and underlying abnormalities of retinal metabolism and physiology. Diabetes 2007, 56:373–379.

    Article  PubMed  CAS  Google Scholar 

  57. Muranaka K, Yanagi Y, Tamaki Y, et al.: Effects of peroxisome proliferator-activated receptor gamma and its ligand on blood-retinal barrier in a streptozotocin-induced diabetic model. Invest Ophthalmol Vis Sci 2006, 47:4547–4552.

    Article  PubMed  Google Scholar 

  58. Zhang SX, Wang JJ, Gao G, et al.: Pigment epithelium-derived factor (PEDF) is an endogenous antiinflammatory factor. FASEB J 2006, 20:323–325.

    PubMed  CAS  Google Scholar 

  59. Joussen AM, Poulaki V, Mitsiades N, et al.: Nonsteroidal anti-inflammatory drugs prevent early diabetic retinopathy via TNF-alpha suppression. FASEB J 2002, 16:438–440.

    PubMed  CAS  Google Scholar 

  60. Barile GR, Pachydaki SI, Tari SR, et al.: The RAGE axis in early diabetic retinopathy. Invest Ophthalmol Vis Sci 2005, 46:2916–2924.

    Article  PubMed  Google Scholar 

  61. Gao BB, Clermont A, Rook S, et al.: Extracellular carbonic anhydrase mediates hemorrhagic retinal and cerebral vascular permeability through prekallikrein activation. Nat Med 2007, 13:181–188.

    Article  PubMed  CAS  Google Scholar 

  62. Cunningham ET Jr, Adamis AP, Altaweel M, et al.: A phase II randomized double-masked trial of pegaptanib, an antivascular endothelial growth factor aptamer, for diabetic macular edema. Ophthalmology 2005, 112:1747–1757.

    Article  PubMed  Google Scholar 

  63. Gardner TW, Sander B, Larsen ML, et al.: An extension of the Early Treatment Diabetic Retinopathy Study (ETDRS) system for grading of diabetic macular edema in the Astemizole Retinopathy Trial. Curr Eye Res 2006, 31:535–547.

    Article  PubMed  Google Scholar 

  64. Sjolie AK, Porta M, Parving HH, et al.: The DIabetic REtinopathy Candesartan Trials (DIRECT) Programme: baseline characteristics. J Renin Angiotensin Aldosterone Syst 2005, 6:25–32.

    Article  PubMed  Google Scholar 

  65. Tsilimbaris MK, Panagiotoglou TD, Charisis SK, et al.: The use of intravitreal etanercept in diabetic macular oedema. Semin Ophthalmol 2007, 22:75–79.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Thomas W. Gardner.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Gardner, T.W., Antonetti, D.A. Novel potential mechanisms for diabetic macular edema: Leveraging new investigational approaches. Curr Diab Rep 8, 263–269 (2008). https://doi.org/10.1007/s11892-008-0047-5

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11892-008-0047-5

Keywords

Navigation