RetINal Toxicity And HydroxyChloroquine Therapy (INTACT): protocol for a prospective population-based cohort study.

PURPOSE: Hydroxychloroquine (HCQ) is an important medication for patients with systemic lupus erythematosus (SLE), rheumatoid arthritis (RA) and other rheumatic diseases. Although it is well-tolerated and cost-effective, the risk of HCQ retinal toxicity is of increasing concern. The aim of this study is to re-examine the HCQ retinal toxicity incidence rate, risk factors and clinical course after discontinuation. METHODS: We designed a prospective population-based cohort study in adult patients with SLE or RA, currently receiving HCQ for five or more years, who are residents of British Columbia (BC), Canada. Based on administrative data, we identified 5508 eligible participants (1346 SLE and 4162 RA). They will participate in annual or biannual retinal screening over 5 years in alignment with the recently revised American Academy of Ophthalmology guidelines. To standardise procedures for retinal screening, imaging, diagnostic criteria, severity staging and data transfer, a consensus meeting was convened in December 2019 with participation of BC retinal specialists and the research team. Agreement was attained on: use of spectral domain-optical coherence tomography as the primary objective screening modality; classification of images into categories of normal, equivocal or abnormal; and transferring the equivocal and abnormal images plus corresponding subjective test results via cloud-based server from each clinic to a reading centre. Confirmation of HCQ retinal toxicity diagnoses and severity staging will be performed by three independent and masked reviewers. The incidence of HCQ retinal toxicity will be calculated, accounting for the competing risk of death. Hazard ratios for each risk factor will be calculated for the risk of HCQ retinopathy, after adjusting for confounders. We will also estimate the risk of HCQ retinal toxicity progression over 5 years. ETHICS AND DISSEMINATION: This study has received approval from the University of British Columbia Clinical Research Ethics Board (H20-00736) and the Vancouver Coastal Health Research Institute.

PREVALENCE AND RISK FACTORS FOR THE DEVELOPMENT OF PHYSICIAN-GRADED SUBRETINAL FIBROSIS IN EYES TREATED FOR NEOVASCULAR AGE-RELATED MACULAR DEGENERATION.

PURPOSE: To assess the prevalence and incidence of and risk factors for subretinal fibrosis (SRFi) in eyes with neovascular age-related macular degeneration (nAMD) that underwent vascular endothelial growth factor inhibitor treatment for up to 10 years. METHODS: A cross-sectional and longitudinal analysis was performed on data from a neovascular age-related macular degeneration registry. The presence and location of SRFi were graded by the treating practitioner. Visual acuity, lesion characteristics (type, morphology, and activity), and treatment administered at each visit was recorded. RESULTS: The prevalence of SRFi in 2,914 eyes rose from 20.4% at year interval 0-1 to 40.7% at year interval 9 to 10. The incidence in 1,950 eyes was 14.3% at baseline and 26.3% at 24 months. Independent characteristics associated with SRFi included poorer baseline vision (adjusted odds ratio 5.33 [95% confidence interval 4.66-7.61] for visual acuity ≤35 letters vs. visual acuity ≥70 letters, P < 0.01), baseline lesion size (adjusted odds ratio 1.08 [95% confidence interval 1.08-1.14] per 1000 µm, P = 0.03), lesion type (adjusted odds ratio 1.42 [95% confidence interval 1.17-1.72] for predominantly classic vs. occult lesions, P = 0.02), and proportion of active visits (adjusted odds ratio 1.58 [95% confidence interval 1.25-2.01] for the group with the highest level of activity vs. the lowest level of activity, P < 0.01). CONCLUSION: Subretinal fibrosis was found in 40% of eyes after 10 years of treatment. High rates of lesion activity, predominantly classic lesions, poor baseline vision, and larger lesion size seem to be independent risk factors for SRFi.

Epidemiology of bacterial corneal ulcers at tertiary centres in Vancouver, B.C.

OBJECTIVE: To report the epidemiology of culture-positive bacterial corneal ulcers in Vancouver, B.C., Canada. DESIGN: Retrospective, observational case series. METHODS: Predetermined search terms were entered into the hospitals' electronic microbiology databases to create a cohort of patients who had undergone corneal scrapings for ulcers from April 2006 to March 2011. All specimens were plated on culture media. Cultured species were identified, and antimicrobial sensitivities were obtained. Clinical charts were then reviewed to identify associated risk factors. RESULTS: In total 281 corneal scrapings were included, with a positive culture recovery rate of 75%. Bacterial keratitis accounted for 84.8% of culture-positive ulcers, followed by fungi (10%) and finally Acanthamoeba (5.2%); 73% of ulcers were monomicrobial in origin and 28% polymicrobial. We found an increase in Gram-negative micro-organisms over time. General sensitivity to antibiotics did not change over time. A major risk factor for Gram-positive involvement was ocular surface disease, whereas contact lens wear was a major risk factor for Gram-negative involvement. CONCLUSIONS: Bacterial keratitis was found to be the major cause of infectious keratitis in Vancouver, B.C. The majority of bacterial ulcers were caused by Gram-positive bacteria. However, we found an increase in Gram-negative involvement over time. Contact lens wear was identified as the major risk factor for development of Gram-negative ulcers. Pre-existing ocular disease was associated with Gram-positive infection. Susceptibility of Gram-negative bacteria to common broad-spectrum antibiotics was high, but susceptibility of Gram-positive bacteria to these antibiotics was lower and more variable.

Efficient Production of Photoreceptor Precursor Cells from Human Embryonic Stem Cells.

Transplantation of photoreceptor precursor cells (PPCs) differentiated from human embryonic stem cells (hESCs) is a promising approach to treat common blinding diseases such as age-related macular degeneration and retinitis pigmentosa. However, existing PPC generation methods are inefficient. To enhance differentiation protocols for rapid and high-yield production of PPCs, we focused on optimizing the handling of the cells by including feeder-independent growth of hESCs, using size-controlled embryoid bodies (EBs), and addition of triiodothyronine (T3) and taurine to the differentiation medium, with subsequent removal of undifferentiated cells via negative cell-selection. Our novel protocol produces higher yields of PPCs than previously reported while reducing the time required for differentiation, which will help understand retinal diseases and facilitate large-scale preclinical trials.

In vivo characterization of neural crest-derived fibro/adipogenic progenitor cells as a likely cellular substrate for craniofacial fibrofatty infiltrating disorders.

The cellular substrate underlying aberrant craniofacial connective tissue accumulation that occurs in disorders such as congenital infiltration of the face (CILF) remain elusive. Here we analyze the in vivo properties of a recently identified population of neural crest-derived CD31-:CD45-:alpha7-:Sca1+:PDGFRa+ fibro/adipogenic progenitors (NCFAPs). In serial transplantation experiments in which NCFAPs were prospectively purified and transplanted into wild type mice, NCFAPs were found to be capable of self-renewal while keeping their adipogenic potential. NCFAPs constitute the main responsive FAP fraction following acute masseter muscle damage, surpassing the number of mesoderm-derived FAPs (MFAPs) during the regenerative response. Lastly, NCFAPs differentiate into adipocytes during muscle regeneration in response to pro-adipogenic systemic cues. Altogether our data indicate that NCFAPs are a population of stem/primitive progenitor cells primarily involved in craniofacial muscle regeneration that can cause tissue degeneration when the damage co-occurs with an obesity inducing diet.

Concise review: identifying limbal stem cells: classical concepts and new challenges.

The presence of a clear cornea is required for vision, and corneal epithelial cells play a key role. There is a long held view, supported by decades of study, that corneal epithelial stem cells reside at the limbus to regulate homeostatic cell turnover and wound healing. However, the identification of specific markers that allow the isolation and characterization of limbal stem cells remains elusive. Here, we review the classical concepts of limbal stem cell identity and highlight the current state of the field.

Differentiation of human embryonic stem cells using size-controlled embryoid bodies and negative cell selection in the production of photoreceptor precursor cells.

We proposed to optimize the retinal differentiation protocols for human embryonic stem cells (hESCs) by improving cell handling. To improve efficiency, we first focused on the production of just one retinal precursor cell type (photoreceptor precursor cells [PPCs]) rather than the production of a range of retinal cells. Combining information from a number of previous studies, in particular the use of a feeder-free culture medium and taurine plus triiodothyronine supplements, we then assessed the values of using size-controlled embryoid bodies (EBs) and negative cell selection (to remove residual embryonic antigen-4-positive hESCs). Using size-controlled 1000 cell EBs, significant improvements were made, in that 78% CRX+ve PPCs could be produced in just 17 days. This could be increased to 93% PPCs through the added step of negative cell selection. Improved efficiency of PPC production will help in efforts to undertake shorter and larger preclinical studies as a prelude to future clinical trials.

Mesenchymal stem cells and potential applications in treating ocular disease.

Mesenchymal stem cells (MSCs) are remarkable in stem cell biology. Not only do they have significant tissue regeneration potential, but more recently their paracrine effects (either innate or through genetic augmentation) have become increasingly recognized as useful therapeutic approaches. In particular, clinical roles for MSC therapy in neuroprotection and immune suppression are likely to emerge. These therapeutic effects will be particularly advantageous in work on neurological tissues, because MSC-based molecular therapy could overcome some of the difficulties of long-term drug delivery to tissues, such as the eye, which are relatively inaccessible to systemic delivery (for example due to the blood retina barrier). MSC therapy is, therefore, poised for significant impact in ocular molecular therapeutics, particularly for chronic diseases, such as retinal degeneration, glaucoma, and uveitis. Other molecular and tissue regeneration effects of MSCs are also likely to have impact in the management of ocular surface disease and oculoplastics.

Muscle injury activates resident fibro/adipogenic progenitors that facilitate myogenesis.

Efficient tissue regeneration is dependent on the coordinated responses of multiple cell types. Here, we describe a new subpopulation of fibro/adipogenic progenitors (FAPs) resident in muscle tissue but arising from a distinct developmental lineage. Transplantation of purified FAPs results in the generation of ectopic white fat when delivered subcutaneously or intramuscularly in a model of fatty infiltration, but not in healthy muscle, suggesting that the environment controls their engraftment. These cells are quiescent in intact muscle but proliferate efficiently in response to damage. FAPs do not generate myofibres, but enhance the rate of differentiation of primary myogenic progenitors in co-cultivation experiments. In summary, FAPs expand upon damage to provide a transient source of pro-differentiation signals for proliferating myogenic progenitors.

Depot-specific differences in adipogenic progenitor abundance and proliferative response to high-fat diet.

White adipose tissue (fat) is the primary organ for energy storage and its regulation has serious implications on human health. Excess fat tissue causes significant morbidity, and adipose tissue dysfunction caused by excessive adipocyte hypertrophy has been proposed to play a significant role in the pathogenesis of metabolic disease. Studies in both humans and animal models show that metabolic dysfunction is more closely associated with visceral than subcutaneous fat accumulation. Here, we show that in mice fed a high-fat diet, visceral fat (VAT) grows mostly by hypertrophy and subcutaneous fat (SAT) by hyperplasia, providing a rationale for the different effects of specific adipose depots on metabolic health. To address whether depot expansion is controlled at the level of stem/progenitor cells, we developed a strategy to prospectively identify adipogenic progenitors (APs) from both depots. Clonogenic assays and in vivo bromodeoxyuridine (BrdU) studies show that APs are eightfold more abundant in SAT than VAT, and that AP proliferation is significantly increased in SAT but not VAT in response to high-fat diet. Our results suggest that depot-specific differences in AP abundance and proliferation underlie whether a fat depot expands by hypertrophy or hyperplasia, and thus may have important implications on the development of metabolic disease. In addition, we provide the first evidence that dietary inputs can modulate the proliferation of adipogenic progenitors in adults.