# Peroxisome Proliferator-Activated Receptor and Age-Related Macular Degeneration

Authors: Alexandra A. Herzlich; Jingsheng Tuo; Chi-Chao Chan
Journal: PPAR Research
 (2008)

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## Abstract

Age-related macular degeneration (AMD) is the leading cause
of new blindness in the western world and is becoming more of
a socio-medical problem as the proportion of the aged
population increases.  There are multiple efforts underway to
better understand this disease process.  AMD involves the
abnormal retinal pigment epithelium (RPE), drusen formation,
photoreceptor atrophy, and choroidal neovascularization.
Peroxisome proliferator-activated receptors (PPARs) play an
important role in lipid degeneration, immune regulation,
regulation of reactive oxygen species (ROSs), as well as
regulation of vascular endothelial growth factor (VEGF),
matrix metalloproteinase-9 (MMP-9), and
docosahexaenoic acid (DHA).   These molecules have all been
implicated in the pathogenesis of AMD.  In addition, PPAR
gamma is expressed in RPE, an essential cell in photoreceptor
regeneration and vision maintenance.  This review summarizes
the interactions between PPAR, AMD-related molecules, and
AMD-related disease processes.


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## Body

## 1. Introduction

Improvements in public health and medical advancements have led to increasing lifespan among
the population today and consequently, a mounting burden of many disorders of
deteriorating body systems such as age-related macular degeneration (AMD). Currently AMD is the leading cause of
blindness in developed countries [1]. With the general aging of the population,
this debilitating disease promises to become an even bigger health care problem. As the demand for therapy increases, much
effort is being directed toward the elucidation of the mechanisms underlying
AMD pathogenesis.Peroxisome proliferator-activated receptors (PPARs) are members of the steroid/thyroid
nuclear receptor superfamily of ligand-activated transcription factors. PPARs are involved in lipid and glucidic
metabolism, immune regulation, and cell differentiation. Because of these functions, PPARs and their
synthetic agonists have been marketed as fibrates and thiazolidinediones for
hypercholesterolemia and type 2 diabetes mellitus, respectively [2]. There is much speculation regarding the
potential role of PPARs in other disease mechanisms. Recently, PPARs have been associated with
age-related changes in Alzheimer’s disease [3] and Parkinson’s disease [4], suggesting that PPARs might also
play a role in the pathogenesis of AMD.


## 2. Age-Related Macular Degeneration

The
normal aging process of the eye can include a spectrum of changes in the eyes [5] as follows. Photoreceptors
decrease in density, retinal pigment epithelium (RPE) undergoes loss of melanin;
formation of lipofuscin granules, and accumulation of residual bodies; and basal
laminar deposits accumulate in Bruch’s membrane. AMD is a degenerative disease of the central
portion of the retina (the macula) which results primarily in loss of central
vision [6]. The disease can progress in two different ways
and, therefore, can be classified into a dry form (geographic atrophy) and a
wet form (neovascular AMD).In both subtypes of AMD, the RPE is a crucial cell in the pathogenesis of AMD [6]. A pivotal function of the RPE is the
phagocytosis of the outer segments of the photoreceptors and subsequent
regeneration of the rods and cones. As
one ages, metabolic waste builds up and imposes an increasing burden on the
RPE. The waste, now partially degraded
in a phagolysosome, is visualized histologically as residual bodies and serves
as a substrate for lipofuscin formation.
These residual bodies increase in number until they are extruded and
accrue in Bruch’s membrane, thickening the membrane itself and forming dome
shaped basal linear deposits in Bruch’s membrane referred to as drusen. When the deposits become large (> 125 μm in diameter), soft (amorphous and poorly
demarcated), and confluent, they cause interruptions in the choroidal
capillaries, compromising blood flow within the RPE layer. The extracellular deposits in Bruch’s
membrane also instigate chronic inflammation, promoting invasion by phagocytes and
other immune cells, cytokine release, and production of reactive oxygen species
(ROSs) [7].The retina, because of its high oxygen consumption, its high levels of cumulative
irradiation, and its composition of polyunsaturated fatty acids, which are
readily oxidized and can initiate a cytotoxic chain reaction, is an ideal
environment for the generation of ROS [8]. Moreover, the process by which RPE
phagocytizes is itself an oxidative stress that results in ROS generation. The combined effects from chronic sustained
inflammation and ROS generation promote the development
of RPE damage seen in AMD [6, 9, 10]. Thinning or destruction of
theRPE leads to its degeneration
and to the subsequent death of rods and cones that depend on the RPE for their
nutrition. This translates into visual
loss. As the RPE degenerates,
choriocapillaris beneath the RPE becomes less fenestrated, reducing the
transport of macromolecules between the retina and choroidal blood supply and
then disappearing altogether, creating a hypoxic environment. Hypoxia then increases the secretion of
growth factors such as vascular endothelial growth factor (VEGF) that promotes choroidal
neovascularization (CNV). The friable,
small vessels comprising CNV are easily damaged and leak, creating the wet or
exudative form of macular degeneration.
The other more-common and less-severe form, termed dry AMD, occurs in
the absence of neovascularization and with a region of atrophy in a geographic
distribution [6].


### 2.1. Risk Factors for AMD

The etiology of AMD remains elusive. A major feature of AMD is its association with age, with the highest prevalence among
those 85 years of age or older [1]. Other certain risk factors include smoking
and family history or genetics [6, 11–17]. There have been recent studies showing
certain association between AMD and CFH [18–23], LOC38775/ARMS2 (age-related maculopathy susceptibility 2) [24–27], HrtA-1 [28, 29], and APOE [30–34]genes. Recently, VEGF
single nucleotide polymorphism and matrix metalloproteinases (MMP)-9
microsatellite polymorphism are reported to be associated with wet AMD [35–37]. Studies have also considered
an association between exposure to sunlight and AMD [6].The Age-Related Eye Disease Study (AREDS), a controlled randomized clinical trial
reports the use of high doses of antioxidants (vitamin C, vitamin E, and beta
carotene) and zinc reduce
the risk of advanced AMD by about 25% in patients with moderate risk of
developing AMD [38]. Supplementation of various nutrients in the
literature have demonstrated risk reduction for AMD, and these findings support
the potential role of PPARs in AMD, especially since diet is an important
modifiable risk factor when discussing PPARs, which regulate lipid metabolism
and homeostasis [39, 40]. PPAR is one of the two characterized types of
polyunsaturated fatty acid-responsive transcriptional factors. Because humans do not have the capability for
de novo synthesis of essential
fatty acids, which are particularly rich in long-chain polyunsaturated fatty
acid (LCPUFA), we are dependant on dietary sources of these compounds [9]. Importantly, a recent AREDS study has
demonstrated that participants reporting high-dietary intake of
lutein/zeaxanthin, an LCPUFA which counteracts photochemical damage and
generation of reactive oxygen species that attack cellular lipids, proteins,
and other nuclear material, are statistically less likely to have advanced AMD
(both neovascularizationand geographic atrophy) or large or
extensive intermediate drusen than thosereporting lowest dietary intake
of lutein/zeaxanthin [41].
Thus, it is possible that the beneficial
effects of lutein/zeaxanthin LCPUFAs are related to their ability to activate fatty
acid-responsive PPARs, suggesting a protective role of PPARs in AMD
pathogenesis.


### 2.2. Clinical Presentation

Though the etiology
of AMD remains unclear, the clinical progression of this disease is well characterized. With dry AMD, patients may complain of a gradual loss of
vision, from several months to years, in one or both eyes due to progressive
loss of photoreceptors [42]. This gradual loss of
vision is often first noticed as difficulty in reading or driving, scotomas, or increased
reliance on brighter light or a magnifying lens for tasks that require fine
visual acuity [43]. Vision loss that has
occurred acutely over a period of days or weeks may represent wet AMD due to
subretinal/retinal hemorrhage resulting from leakage or breaks of choroidal
neovascular vessels. These patients may
report an acute distortion in vision due to retinal hemorrhage, especially
distortion of straight lines, or loss of central vision. Symptoms of wet AMD usually appear in one eye
although AMD pathology is generally present in both eyes [44].


### 2.3. Pathological Findings

The nonneovascular abnormalities in AMD include drusen as well as abnormalities of
the RPE highlighted by accumulation of lipofuscin granules. The main component of lipofuscin is A2E,
which is cytotoxic to RPE and induces RPE apoptosis. Clinically, drusen are round, dull yellow
lesions, located under the sensory neuroretina and RPE, which upon fluorescein
angiography, light up and stain late with no leakage. Histologically this material corresponds to
the abnormal thickening of the inner aspect of Bruch’s membrane. The thickening involves basal laminar
deposits, collagen accumulation between the plasma membrane of the RPE cells
and the inner aspect of the basement membrane of the RPE, as well as basal
linear deposits outside the RPE basement membrane referred to as drusen [6].How
and why drusen develop is unknown, however much is deduced from its
contents. Drusen often have a core of
glycoproteins and their outer domes contain crystallins, chaperone proteins,
apolipoprotein E, vitronectin, proteins related to inflammation (amyloid P, C5,
and C5b-9), and sometimes fragments of RPE cells [45]. Drusen appear as electron-dense granules
within the inner aspect of Bruch’s membrane. The thickening of the membrane
causes a sharp reduction in fluid and nutrient transport across the
membrane. Its diminished function also
results in decreased cell adhesion and anoikis of the photoreceptors, RPE cells,
and possibly choriocapillaris endothelial cells [6]. These deposits around Bruch’s membrane are
also the cause of chronic local inflammation further promoting AMD development
and progression.The presence of drusen may lead to
RPE degeneration and subsequently, deterioration of photoreceptors, which are
dependent upon maintenance by RPE [46]. When the atrophy of the RPE and
photoreceptors covers a distinct and contiguous area, it is termed geographic
atrophy. Histologically, geographic
atrophy is characterized by roughly oval patches of hypopigmentation as a
consequence of RPE atrophy. The
underlying choroidal vessels are more readily visible and the outer retina may
appear thin secondary to loss of the photoreceptor and RPE cells. At the periphery of the hypopigmented regions
there may be hyperpigmented changes from RPE cell proliferation. If the atrophy is less defined, with a mottled
appearance, then it is called nongeographic atrophy. If the disease continues to progress, there comes a point
when the components of the drusen begin to disappear; this is termed regressed
drusen [46]. Additionally there may be small pinpoint
glistening of the drusen where calcium has been deposited.The third key component of AMD is
choroidal neovascularization [47]. With the thinning and destruction of the RPE
the underlying choriocapillaries become less fenestrated, impairing transport
of macromolecules, such as oxygen, between the retina and choroidal blood
supply. The resulting hypoxia stimulates
neovascularization through vascular endothelial growth factor (VEGF). VEGF, which will be discussed in more detail
below, acts as a stimulus for neovascularization [48]. There can be both new vascular growths from the
choroidal vessels, growing through Bruch’s membrane into the subretinal
space. Clinically CNV appears as a
purple-grey discoloration beneath the retina.
With the increase in blood flow within the retina due to CNV, there may
even be a focal sensory retinal detachment and cystoid edema. New vessels also promote fibroblast
proliferation and disruption of normal retinal architecture. Moreover, these neovascular blood vessels are
extremely leaky, and hemorrhage from these friable vessels leads to sudden
vision loss secondary to accumulation of fluid or blood in the subretinal space
and/or within the retina itself [49].


## 2.1. Risk Factors for AMD

The etiology of AMD remains elusive. A major feature of AMD is its association with age, with the highest prevalence among
those 85 years of age or older [1]. Other certain risk factors include smoking
and family history or genetics [6, 11–17]. There have been recent studies showing
certain association between AMD and CFH [18–23], LOC38775/ARMS2 (age-related maculopathy susceptibility 2) [24–27], HrtA-1 [28, 29], and APOE [30–34]genes. Recently, VEGF
single nucleotide polymorphism and matrix metalloproteinases (MMP)-9
microsatellite polymorphism are reported to be associated with wet AMD [35–37]. Studies have also considered
an association between exposure to sunlight and AMD [6].The Age-Related Eye Disease Study (AREDS), a controlled randomized clinical trial
reports the use of high doses of antioxidants (vitamin C, vitamin E, and beta
carotene) and zinc reduce
the risk of advanced AMD by about 25% in patients with moderate risk of
developing AMD [38]. Supplementation of various nutrients in the
literature have demonstrated risk reduction for AMD, and these findings support
the potential role of PPARs in AMD, especially since diet is an important
modifiable risk factor when discussing PPARs, which regulate lipid metabolism
and homeostasis [39, 40]. PPAR is one of the two characterized types of
polyunsaturated fatty acid-responsive transcriptional factors. Because humans do not have the capability for
de novo synthesis of essential
fatty acids, which are particularly rich in long-chain polyunsaturated fatty
acid (LCPUFA), we are dependant on dietary sources of these compounds [9]. Importantly, a recent AREDS study has
demonstrated that participants reporting high-dietary intake of
lutein/zeaxanthin, an LCPUFA which counteracts photochemical damage and
generation of reactive oxygen species that attack cellular lipids, proteins,
and other nuclear material, are statistically less likely to have advanced AMD
(both neovascularizationand geographic atrophy) or large or
extensive intermediate drusen than thosereporting lowest dietary intake
of lutein/zeaxanthin [41].
Thus, it is possible that the beneficial
effects of lutein/zeaxanthin LCPUFAs are related to their ability to activate fatty
acid-responsive PPARs, suggesting a protective role of PPARs in AMD
pathogenesis.


## 2.2. Clinical Presentation

Though the etiology
of AMD remains unclear, the clinical progression of this disease is well characterized. With dry AMD, patients may complain of a gradual loss of
vision, from several months to years, in one or both eyes due to progressive
loss of photoreceptors [42]. This gradual loss of
vision is often first noticed as difficulty in reading or driving, scotomas, or increased
reliance on brighter light or a magnifying lens for tasks that require fine
visual acuity [43]. Vision loss that has
occurred acutely over a period of days or weeks may represent wet AMD due to
subretinal/retinal hemorrhage resulting from leakage or breaks of choroidal
neovascular vessels. These patients may
report an acute distortion in vision due to retinal hemorrhage, especially
distortion of straight lines, or loss of central vision. Symptoms of wet AMD usually appear in one eye
although AMD pathology is generally present in both eyes [44].


## 2.3. Pathological Findings

The nonneovascular abnormalities in AMD include drusen as well as abnormalities of
the RPE highlighted by accumulation of lipofuscin granules. The main component of lipofuscin is A2E,
which is cytotoxic to RPE and induces RPE apoptosis. Clinically, drusen are round, dull yellow
lesions, located under the sensory neuroretina and RPE, which upon fluorescein
angiography, light up and stain late with no leakage. Histologically this material corresponds to
the abnormal thickening of the inner aspect of Bruch’s membrane. The thickening involves basal laminar
deposits, collagen accumulation between the plasma membrane of the RPE cells
and the inner aspect of the basement membrane of the RPE, as well as basal
linear deposits outside the RPE basement membrane referred to as drusen [6].How
and why drusen develop is unknown, however much is deduced from its
contents. Drusen often have a core of
glycoproteins and their outer domes contain crystallins, chaperone proteins,
apolipoprotein E, vitronectin, proteins related to inflammation (amyloid P, C5,
and C5b-9), and sometimes fragments of RPE cells [45]. Drusen appear as electron-dense granules
within the inner aspect of Bruch’s membrane. The thickening of the membrane
causes a sharp reduction in fluid and nutrient transport across the
membrane. Its diminished function also
results in decreased cell adhesion and anoikis of the photoreceptors, RPE cells,
and possibly choriocapillaris endothelial cells [6]. These deposits around Bruch’s membrane are
also the cause of chronic local inflammation further promoting AMD development
and progression.The presence of drusen may lead to
RPE degeneration and subsequently, deterioration of photoreceptors, which are
dependent upon maintenance by RPE [46]. When the atrophy of the RPE and
photoreceptors covers a distinct and contiguous area, it is termed geographic
atrophy. Histologically, geographic
atrophy is characterized by roughly oval patches of hypopigmentation as a
consequence of RPE atrophy. The
underlying choroidal vessels are more readily visible and the outer retina may
appear thin secondary to loss of the photoreceptor and RPE cells. At the periphery of the hypopigmented regions
there may be hyperpigmented changes from RPE cell proliferation. If the atrophy is less defined, with a mottled
appearance, then it is called nongeographic atrophy. If the disease continues to progress, there comes a point
when the components of the drusen begin to disappear; this is termed regressed
drusen [46]. Additionally there may be small pinpoint
glistening of the drusen where calcium has been deposited.The third key component of AMD is
choroidal neovascularization [47]. With the thinning and destruction of the RPE
the underlying choriocapillaries become less fenestrated, impairing transport
of macromolecules, such as oxygen, between the retina and choroidal blood
supply. The resulting hypoxia stimulates
neovascularization through vascular endothelial growth factor (VEGF). VEGF, which will be discussed in more detail
below, acts as a stimulus for neovascularization [48]. There can be both new vascular growths from the
choroidal vessels, growing through Bruch’s membrane into the subretinal
space. Clinically CNV appears as a
purple-grey discoloration beneath the retina.
With the increase in blood flow within the retina due to CNV, there may
even be a focal sensory retinal detachment and cystoid edema. New vessels also promote fibroblast
proliferation and disruption of normal retinal architecture. Moreover, these neovascular blood vessels are
extremely leaky, and hemorrhage from these friable vessels leads to sudden
vision loss secondary to accumulation of fluid or blood in the subretinal space
and/or within the retina itself [49].


## 3. Peroxisome Proliferator-Activated  Receptors

Peroxisome proliferator-activated receptors (PPARs) seem to be associated with chronic diseases such as diabetes
mellitus, obesity, atherosclerosis, cancer, and neurodegenerative diseases [2, 4, 50]. Like androgens, steroids, retinoid, and
thyroid hormone receptors groups, PPARs are members of nuclear receptor
superfamily of ligand-activated transcription factors [2]. Though they are among the best-categorized
nuclear receptor families, the evolution of these molecules remains
unclear. PPARs have three known subtypes:
α, β, and γ. The α subtype is present in
adipose tissue, liver, brain, heart, and skeletal muscle. A synthetic agonist to this subtype has been
created as a cholesterol-lowering therapy. The PPAR β subtype, also known as δ or NUC1, is present in the gut,
kidney, brain, and heart. PPARγ, the
subtype most widely studied, is expressed on adipocytes, colon, brain, renal
epithelium, monocytes, and macrophages.
The γ subtype is the model for therapy such as thiazolidinediones
(troglitazone, rosiglitazone, pioglitazone) for increased insulin sensitivity
in noninsulin-dependent diabetes (type 2) [51, 52]. This receptor is also expressed in the
retina, specifically in the RPE and choroidal vascular endothelial cells [53]. Figure 1 shows positive immunoreactivity
against PPARγ in the normal human retina.
The association of PPAR with RPE cells, as well as neuronal cells,
supports the hypothesis that PPAR may play a role in the pathogenesis of AMD;
therefore, PPAR may present a possible target for AMD treatment.Figure 1
Microphotograph showing normal human retina stained for PPARγ in the ganglion cell, inner nuclear layer, outer
nuclear layer, and RPE (avidin-biotin-complex immunoperoxidase).In response to binding by fatty acids, PPARs form heterodimers with retinoid X
receptor (RXR), and the PPAR-RXR heterodimer binds to specific response
elements (PPREs) consisting of a direct repeat of the nuclear receptor
hexameric DNA core recognition motif spaced by one nucleotide to influence the
transcription of numerous target genes [54]. Because PPAR is widely expressed as a
transcription factor, it also plays a role in many processes including lipid
homeostasis, glucose regulation, inflammation, atherosclerosis, ischemia,
cancer, and neurodegenerative diseases [2, 36, 37, 54–62] with the subtypes overlapping
in activity, function, and location.


## 4. Proposed Mechanisms of AMD and the  Links to PPAR

The etiology of AMD is not well understood, an explanation in itself for the
various proposed mechanisms for how and why AMD progresses. Theories include aging, oxidative stress, endoplasmic
reticulum stress, and inflammation. Interestingly, these processes are shared
among diseases with similar pathophysiological changes to those seen in AMD and
also involve PPAR.Oxidative stress arises from a significant increase in reactive oxygen species (ROS)
concentration and/or a decrease in detoxification mechanisms. ROS include free radicals, hydrogen peroxide,
and singlet oxygen. There are many
natural sources of oxidative stress such as exposure to environmental oxidants,
ionizing and UV radiation, heat shock, and inflammation. The ROSs usually have one or more unpaired
electrons in their outer orbits, and in order to achieve a stable state,
extract electrons from other molecules, which themselves become unstable,
causing a chain reaction [8]. High levels of oxidative stress exert a toxic
effect on biomolecules, such as DNA, proteins, and lipids. As we know ROS may start an oxidative
cascade, mediated in part by ROS-induced activation of NF-κB, STAT, and AP-1transcription
factors, altering the composition of the cellular membrane, changing protein
conformations, and lead to an upregulation of proinflammatory genes
and cytokines, further potentiating damage [62, 63].Oxidative stress plays a role in ischemic-reperfusion injuries, atherosclerosis,
hypertension, inflammation, cystic fibrosis, type 2 diabetes, Alzheimer’s, and
Parkinson’s disease [62]. Oxidative stress has also been linked to
aging [64]. The retina has a very high concentration of
lipids [9] and therefore easily falls
pray to such mechanisms of destruction [8].Oxidative stress such as aging and light exposure is considered to be associated with
AMD. RPE and photoreceptors are
particularly susceptible to oxidative stress because of high oxygen consumption
by photoreceptors [8], high
concentration of LCPUFA in the outer segments [65], exposure to visible light, and presence of lipofuscin, a
photo-inducible generator of ROS in RPE [66, 67]. Clinical data supporting a beneficial effect of
antioxidants in AMD provide direct validation of the role of oxidative injury
in AMD treatment. Subgroup analysis of a
multicenter, randomized, placebo-controlled AREDS trial revealed that an
antioxidant cocktail of vitamins C and E, β-carotene, and zinc can reduce the progression of moderate
atrophic AMD to late-stage disease [38]. Epidemiologic data showing that
smoking leads to a significantly increased risk of the disease is consistent
with the antioxidant approach as smoking is known to depress antioxidants such
as vitamin C and carotenoids, and to induce hypoxia and ROS generation [68, 69].PPARs are known to stimulate peroxisome enlargement and proliferation, as well as
upregulation ofβ-oxidation enzymes. Since
the peroxisome houses a variety of oxidative metabolic processes, they are an
obvious cause of oxidative stress [64]. Oxidative damage and proinflammatory
cytokines, TNF-α, INF-γ,
and MMPs have been cited to play roles in each of the disease processes
mentioned above [3, 50, 70–74], establishing PPAR as a
common link between them.Another theory regarding drusen formation involves a phenomenon known as endoplasmic
reticulum (ER) stress. The ER is central
to protein and lipid synthesis and maturation, as most newly formed proteins
are assembled in the ER. Incorrectly
folded proteins tend to form aggregates that are harmful to the cells and thus,
ER-resident and/or visiting chaperone molecules facilitate protein folding and
clearance of terminally misfolded proteins [75]. Any condition which impairs protein folding,
for example, mutations in proteins that affect folding or ER malfunction, is
termed ER-stress. Increased ER-stress, therefore,
leads to protein and lipid buildup within cells, and this buildup in the eye
might translate into RPE damage and drusen deposition.The argument for a role for ER stress in AMD pathogenesis is supported by the
well-characterized role of ER stress in several AMD-related neurodegenerative
diseases. Alzheimer’s disease and Lewy
Body diseases, such as Parkinson’s disease, are characterized by deposition of
abnormal substances, which may parallel the abnormal deposition of drusen in
the eye. The classical histopathological
hallmarks of Alzheimer’s disease [3, 4] include deposition of
fibrillar amyloid in neuritic plaques as well as intracellular deposits of
hyperphosphorylated tau protein. This
results in the formationof neurofibrillary tangles and finally
neuronal death, causing progressive memory loss and decline in
cognitive functions [4]. In Parkinson’s disease,
suffering dopaminergic neurons are found to contain Lewy bodies and
neuromelanin, an end
product in catabolism by autoxidation [3]. In atherosclerosis there are abnormal lipid
depositions in blood vessels leading to plaque formation and partial occlusion
of these vessels [76]. In an AMD model of Ccl2−/−/Cx3cr1−/−
deficient mice abnormal ER protein is detected and associated with disease pathogenesis [75].Recent articles have discovered a role for PPAR in ER stress. Dirkx et al. found that absence of
peroxisomes in hepatocytes had repercussions on different subcellular
compartments, including mitochondria, ER, and lysosomes [77]. Another study found that intracellular
calcium mobilization by PPARγ
ligands in rat liver epithelial cells interferes with proper protein
foldingin the ER, thus promoting ER stress [73]. A third article discovered that under
conditions of impaired translation, PPARγ ligands stimulate the
expression of a number of ER stress-responsive genes, such as GADD
153, BiP, and HSP70 in rat pancreatic β
cells. They concluded that PPARγ ligands induce ER stress [78].In addition to the obvious parallels, between amyloid, Lewy bodies, cholesterol,
and drusen, there are also similar processes such as inflammation that may play
a role in inciting the damage associated with each disease.Various immunological molecules and inflammatory mediators, cytokines, and chemokines
have been identified in AMD lesions [79, 80]. Many of them are produced locally by RPE, choroid,
and retina [81]. It has been hypothesized that RPE dysfunction
is the critical event in drusen formation, making drusen a product of a
localized inflammatory response, possibly involving HLA antigens and the
complement system [82]. The hypothesis is based on many different
findings scattered among the literature and within different fields of
medicine. Drusen, the hallmark of AMD, are found higher in membranoproliferative glomerulonephritis II (MPGNII), a complement-medicated
immune deficiency. These cuticular
drusen are identical, clinically, histologically, and immunohistochemically to
the drusen in AMD [83–85]. Drusen has also been cited as having similar
features to lipid-laden plaques of atherosclerosis [82, 86]. The relationship here is inferred from the
histological as well as local inflammatory similarities between dysfunctional
endothelial cells and the subendothelial deposition of modified LDL-cholesterol
in atherosclerotic deposits within arterial vessels to those of drusen in the
eye [86–88]. In addition, molecules such
as MMP-9 seem to be involved in both processes.
Inhibition of MMP-9 in atherosclerotic lesions has been cited to oppose
remodeling, as suggested by the inhibition of intimal thickening and
outward arterial remodeling [89]; while in AMD it is thought
to be involved in microvessel formation duringearly phases of
angiogenesis, in the reabsorption ofneovascularization, and in involution and
regression of vessels inlater stages [90]. Similarities to the local inflammatory
components seen in Alzheimer’s also support this theory where accumulations of neurofibrillary
tangles or insoluble deposits of beta amyloid peptide are the inciting agents
of local inflammation [86].The association betweencomplement factor H (CHF) single
nucleotide polymorphisms and increased risk of AMD also uncovers an important
link between the complement system (inflammation) and the development of
maculopathy (AMD) [18–20, 91]. The gene for CHF is located within the chromosomal region (1q32) linked to AMD [82, 92]. The CHF gene encodes a protein, complement response factor (CRF), that functions as
part of the complement system and has been found in drusen from AMD patients [82, 93]. Furthermore, the same environmental risk
factors, smoking, that influence levels of complement in serum are also
associated with increased risk of developing AMD [86, 94].In Alzheimer’s, atherosclerosis,
and AMD similar local proinflammatory pathways are stimulated, thereby leading
to the deposition of activated complement components, acute-phase proteins, and
other inflammatory mediators in tissues affected by each disease process. The cumulative impact is chronic
tissue-specific low-grade inflammation exacerbating the effects of the primary
pathogenic lesion [86]. PPARs act to inhibit many proinflammatory
genes, which may result in protection of these diseases.


## 5. Molecules That Interact with PPAR and their Relationship with AMD: An Introduction to VEGF, MMP, and DHA

### 5.1. Vascular Endothelial Growth Factor A, VEGF

VEGF was first identified in the early 1970s as a tumor-angiogenesis factor that is
mitogenic to capillary endothelial cells in human tumors [95]. VEGF is now recognized as an essential
regulator of normal and abnormal vessel growth.
It regulates both vascular proliferation, as well as permeability, and
functions as an antiapoptotic factor for newly formed blood vessels [95]. VEGF is expressed in response to hypoxia,
oncogenes, or cytokines [96]. In this process, VEGF binds to and stimulates
autophosphorylation of two distinct receptor tyrosine kinases, VEGFR1 or Flt-1
(fms-related tyrosine kinase 1) and VEGFR2 or KDR/FlK-1 (kinase insert domain
containing receptor/fetal liver kinase 1) [97]. This activates an MAPK pathway causing
neovascular channel growth from the choroidal vasculature and extension into
the space between the RPE and Bruch’s membrane thus activating the RPE to
migrate into stroma of the CNV lesion [98, 99]. VEGF blockade has been shown to have a direct
and rapid antivascular effect in tumors by deprivation of tumor vascular supply
and inhibition of endothelial proliferation.
Recently, VEGF has also been shown to target CNV in AMD [100]. The first anti-VEGF compound, pegaptanib, was
approved by the FDA in 2004 and followed closely by approval of two other
treatments, bevacizumab (Avastin) and ranibizumab (Lucentis). With monthly intravitreal injections of ranibizumab,
growth of neovascular membranes is halted and there is prevention of severe
vision loss in 90% of patients and improvement of visual acuity in 30–40% of patients [101–104].


### 5.2. Matrix Metalloproteases, MMPs

The regulated turnover of extracellular matrix macromolecules is crucial to a
variety of important biological processes.
MMPs, a member of the class of proteases, degrade components of
extracellular membranes [105]. MMPs, zinc-dependent endopeptidases, are
expressed by activated macrophage foam cells and smooth muscle cells, and are
important in the resorption of extracellular matrixes in both physiological and
pathological processes. MMPs are
secreted by macrophages as a proenzyme and once activated can completely
degrade extracellular matrix components, such as elastin and collagen,
including the structural backbone of the basement membrane, type IV
collagen. Mostly this group of enzymes
acts locally where they are expressed to aid in cell migration by clearing a
path through the matrix, exposing cryptic sites on the cleaved proteins that
promote cell binding and/or cell migration, promoting cell detachment so that a
cell can move onward, or by releasing extracellular signal proteins that
stimulate cell migration [105].MMP-9, a specific MMP, is thought to degrade the fibrinous cap found on
atherosclerotic plaques, destabilizing the plaque, and priming it for rupture [106]. Since AMD is associated with sustained
chronic inflammation and loss of integrity of Bruch’s membrane, it has been
hypothesized that MMPs may play a role in the pathogenesis of the disease [107]. MMP-9 and MMP-2, two subtypes of MMPs, have
been identified in Bruch’s membrane in AMD eyes, and cell-culture studies have
documented its role in the development of CNV [108–110]. A recent study found the first association
between AMD and MMP-9 [108]. Significantly elevated plasma MMP-9 levels were
reported in both wet and dry AMD patients as compared to age-matched
controls. In addition, circulating
plasma levels of MMP-9 were approximately three times higher in AMD patients than
in control patients with no confounding illnesses. MMP transcriptional activity is regulated by
genetic polymorphisms of the promotor region and carriers repeats of the MMP-9
promotor, numbering greater than or equal to 22, have a more than doubled risk
of developing AMD [37]. Facilitating this MMP-9 expression may act as
a factor in increasing vascular permeability of the vessels or in the
neovascularization seen in exudative AMD.


### 5.3. Docosahexaenoic Acid, DHA

Docosahexaenoic
acid (DHA) is a major dietary omega-3 LCPUFA.
It is also a major structural lipid of retinal photoreceptor outer
segment membranes with the highest concentrations per unit weight found
here. Omega-3 LCPUFA have the capacity
to play roles in many processes of AMD, such as retinal neovascularization,
inflammation of the retinal vasculature, and alterations in the retinal
capillary structure and integrity [9]. DHA has been shown to promote survival,
inhibit apoptosis of photoreceptors, possibly via signaling cascades, play a
role in rhodopsin regeneration, and exert neural protection through an RPE-secreted
neuroprotective mediator, NPD-1. Tissue
DHA insufficiency can affect retinal signaling and is associated with
alterations in retinal function [9]. It has also been documented that there exists
an inverse relationship between dietary intake of the omega-3 LCPUFA and risk
of developing AMD [111].Despite the benefits of polyunsaturated fatty acids, humans lack the Δ15 and 12
desaturase enzymes to synthesize these compound de novo and are dependent on dietary sources. In addition, the biochemical nature of DHA
and the proximity of these compounds to metabolically active ocular tissue and
high oxygen tension of the choriocapillaries facilitate the formation of
ROSs. ROSs may start an oxidative
cascade altering the DHA and changing the composition of the cellular membrane and
increasing the expression ofproinflammatory genes and cytokines, thereby
damaging the retina [62, 63]. ROS are therefore extremely dangerous because
they damage DHA, a necessary yet limited resource needed to keep retina
healthy.


## 5.1. Vascular Endothelial Growth Factor A, VEGF

VEGF was first identified in the early 1970s as a tumor-angiogenesis factor that is
mitogenic to capillary endothelial cells in human tumors [95]. VEGF is now recognized as an essential
regulator of normal and abnormal vessel growth.
It regulates both vascular proliferation, as well as permeability, and
functions as an antiapoptotic factor for newly formed blood vessels [95]. VEGF is expressed in response to hypoxia,
oncogenes, or cytokines [96]. In this process, VEGF binds to and stimulates
autophosphorylation of two distinct receptor tyrosine kinases, VEGFR1 or Flt-1
(fms-related tyrosine kinase 1) and VEGFR2 or KDR/FlK-1 (kinase insert domain
containing receptor/fetal liver kinase 1) [97]. This activates an MAPK pathway causing
neovascular channel growth from the choroidal vasculature and extension into
the space between the RPE and Bruch’s membrane thus activating the RPE to
migrate into stroma of the CNV lesion [98, 99]. VEGF blockade has been shown to have a direct
and rapid antivascular effect in tumors by deprivation of tumor vascular supply
and inhibition of endothelial proliferation.
Recently, VEGF has also been shown to target CNV in AMD [100]. The first anti-VEGF compound, pegaptanib, was
approved by the FDA in 2004 and followed closely by approval of two other
treatments, bevacizumab (Avastin) and ranibizumab (Lucentis). With monthly intravitreal injections of ranibizumab,
growth of neovascular membranes is halted and there is prevention of severe
vision loss in 90% of patients and improvement of visual acuity in 30–40% of patients [101–104].


## 5.2. Matrix Metalloproteases, MMPs

The regulated turnover of extracellular matrix macromolecules is crucial to a
variety of important biological processes.
MMPs, a member of the class of proteases, degrade components of
extracellular membranes [105]. MMPs, zinc-dependent endopeptidases, are
expressed by activated macrophage foam cells and smooth muscle cells, and are
important in the resorption of extracellular matrixes in both physiological and
pathological processes. MMPs are
secreted by macrophages as a proenzyme and once activated can completely
degrade extracellular matrix components, such as elastin and collagen,
including the structural backbone of the basement membrane, type IV
collagen. Mostly this group of enzymes
acts locally where they are expressed to aid in cell migration by clearing a
path through the matrix, exposing cryptic sites on the cleaved proteins that
promote cell binding and/or cell migration, promoting cell detachment so that a
cell can move onward, or by releasing extracellular signal proteins that
stimulate cell migration [105].MMP-9, a specific MMP, is thought to degrade the fibrinous cap found on
atherosclerotic plaques, destabilizing the plaque, and priming it for rupture [106]. Since AMD is associated with sustained
chronic inflammation and loss of integrity of Bruch’s membrane, it has been
hypothesized that MMPs may play a role in the pathogenesis of the disease [107]. MMP-9 and MMP-2, two subtypes of MMPs, have
been identified in Bruch’s membrane in AMD eyes, and cell-culture studies have
documented its role in the development of CNV [108–110]. A recent study found the first association
between AMD and MMP-9 [108]. Significantly elevated plasma MMP-9 levels were
reported in both wet and dry AMD patients as compared to age-matched
controls. In addition, circulating
plasma levels of MMP-9 were approximately three times higher in AMD patients than
in control patients with no confounding illnesses. MMP transcriptional activity is regulated by
genetic polymorphisms of the promotor region and carriers repeats of the MMP-9
promotor, numbering greater than or equal to 22, have a more than doubled risk
of developing AMD [37]. Facilitating this MMP-9 expression may act as
a factor in increasing vascular permeability of the vessels or in the
neovascularization seen in exudative AMD.


## 5.3. Docosahexaenoic Acid, DHA

Docosahexaenoic
acid (DHA) is a major dietary omega-3 LCPUFA.
It is also a major structural lipid of retinal photoreceptor outer
segment membranes with the highest concentrations per unit weight found
here. Omega-3 LCPUFA have the capacity
to play roles in many processes of AMD, such as retinal neovascularization,
inflammation of the retinal vasculature, and alterations in the retinal
capillary structure and integrity [9]. DHA has been shown to promote survival,
inhibit apoptosis of photoreceptors, possibly via signaling cascades, play a
role in rhodopsin regeneration, and exert neural protection through an RPE-secreted
neuroprotective mediator, NPD-1. Tissue
DHA insufficiency can affect retinal signaling and is associated with
alterations in retinal function [9]. It has also been documented that there exists
an inverse relationship between dietary intake of the omega-3 LCPUFA and risk
of developing AMD [111].Despite the benefits of polyunsaturated fatty acids, humans lack the Δ15 and 12
desaturase enzymes to synthesize these compound de novo and are dependent on dietary sources. In addition, the biochemical nature of DHA
and the proximity of these compounds to metabolically active ocular tissue and
high oxygen tension of the choriocapillaries facilitate the formation of
ROSs. ROSs may start an oxidative
cascade altering the DHA and changing the composition of the cellular membrane and
increasing the expression ofproinflammatory genes and cytokines, thereby
damaging the retina [62, 63]. ROS are therefore extremely dangerous because
they damage DHA, a necessary yet limited resource needed to keep retina
healthy.


## 6. Important Molecules Involved in PPAR’s  Potential Role in AMD

### 6.1. VEGF, PPARγ, and their Role in AMD

As previously discussed, VEGF has been shown to play a critical role in
neovascularization via the MAPK kinase pathway, associated with the wet form of
AMD [103, 104]. PPARγ with expression localized to the RPE
and choroidal endothelial cells of ocular tissue [53] may have an effect on
endothelial cells and may have a direct antagonistic relationship with VEGF.It has been demonstrated that vascular endothelial cells express PPAR-γ mRNA and
protein [61, 112]. PPAR-γ ligands inhibit growth factor-induced
proliferation of endothelial cells, increase plasminogen activator inhibitor-1
expression and suppress endothelin-1 secretion [113, 114], overall providing support to
the theory that PPAR-γ plays an antagonistic role to that of VEGF [115]. More directly Murata and colleagues demonstrated that PPARγ inhibits MAPK-dependent
migration of smooth muscle and may act as a downstream inhibitor to VEGF. This group also showed that troglitazone and
rosiglitazone, synthetic agonists of PPARγ, inhibited the endothelial effects
of VEGF in a dose-dependent manner. In vivo studies with the troglitazone
demonstrated that intravitreal injections dramatically inhibited the percentage
of lesions as well as leakage per lesion, making a strong case for therapeutic
value of this drug [53].


### 6.2. Matrix Metalloproteinase (MMP), PPARγ, and their Role in AMD

Ricote showed that PPARγ inhibits the expression of MMP-9 in response to a naturally
occurring ligand, prostaglandin D2 metabolite 15-deoxy-Δ12,14 prostaglandin
J2 (15d-PGJ2), and synthetic PPARγ ligands activated macrophages by
antagonizing the activities of the transcription factors AP-1, STAT, and NF-κB [52]. PPARγ activators decrease MMP-9 expression
in vascular smooth muscle [116] and treatment with PPAR
agonist troglitazone has shown decreased atherosclerotic lesions in various
animal models [107]. In addition PPARγ-mediated suppression of
NF-κB activity may decrease proinflammatory cytokines in macrophages, including
MMP-9 [117].This intricate relationship demonstrates that PPARγ downregulates MMP expression
and inhibits MMP-9’s subsequent accumulation in Bruch’s membrane where it may
play an integral role in the degradation of the extracellular matrix and be a
stimulus for migration of the RPE into Bruch’s membrane, in this way
contributing to the pathophysiology of AMD.


### 6.3. DHA, PPARγ, and their Role in AMD

DHA is a naturally occurring ligand to all subtypes of the PPAR family. It binds specific DNA motifs to modulate the
activity of PPAR and RXR as transcription factors [9]. As being well known, PPARs play an important
regulatory role in oxidative stress by inducing the transcription of
antioxidant genes, such as glutamate cysteine ligase (GCL) and heme oxidase-1
(HO-1) [118]. These antioxidants then work through MAPK
kinase pathways to curb ROS. A functional PPRE is located at the
catalase gene promoter, a gene known to protect cells from the toxic effects of hydrogen peroxide (H2O2)
by catalyzing its decomposition, indicating that catalase expression is
directly regulated by PPARγ [62].
To further test this relationship, catalase expression was analyzed in
the striatum of rats subjected to intracranial bleeds with and without 15-dPGJ2
treatment. Treated rats showed 1.6-,
2.1-, and 1.7 fold higher levels of catalase mRNA expression compared to the
saline controls at 1, 3, and 24 hours [63]. Girnun et al. found
similar increases in catalase mRNA when using known PPAR agonists rosiglitazone
and ciglitazone in rat brain microvascular endothelium cells, one of the cell
types damaged during inflammatory responses induced by ROS generation [62].In short, PPARγ has a special role in counteracting the damaging effects of ROS
generation by upregulating antioxidant genes and downregulating proinflammatory
genes. By decreasing damage to LCPUFAs,
such as DHA, there is preservation of the protective effects these essential
molecules confer to the retina. Enhancing this ability of the RPE to protect itself from oxidative
injury may provide a therapeutic opportunity to delay or hinder the development
of AMD.


## 6.1. VEGF, PPARγ, and their Role in AMD

As previously discussed, VEGF has been shown to play a critical role in
neovascularization via the MAPK kinase pathway, associated with the wet form of
AMD [103, 104]. PPARγ with expression localized to the RPE
and choroidal endothelial cells of ocular tissue [53] may have an effect on
endothelial cells and may have a direct antagonistic relationship with VEGF.It has been demonstrated that vascular endothelial cells express PPAR-γ mRNA and
protein [61, 112]. PPAR-γ ligands inhibit growth factor-induced
proliferation of endothelial cells, increase plasminogen activator inhibitor-1
expression and suppress endothelin-1 secretion [113, 114], overall providing support to
the theory that PPAR-γ plays an antagonistic role to that of VEGF [115]. More directly Murata and colleagues demonstrated that PPARγ inhibits MAPK-dependent
migration of smooth muscle and may act as a downstream inhibitor to VEGF. This group also showed that troglitazone and
rosiglitazone, synthetic agonists of PPARγ, inhibited the endothelial effects
of VEGF in a dose-dependent manner. In vivo studies with the troglitazone
demonstrated that intravitreal injections dramatically inhibited the percentage
of lesions as well as leakage per lesion, making a strong case for therapeutic
value of this drug [53].


## 6.2. Matrix Metalloproteinase (MMP), PPARγ, and their Role in AMD

Ricote showed that PPARγ inhibits the expression of MMP-9 in response to a naturally
occurring ligand, prostaglandin D2 metabolite 15-deoxy-Δ12,14 prostaglandin
J2 (15d-PGJ2), and synthetic PPARγ ligands activated macrophages by
antagonizing the activities of the transcription factors AP-1, STAT, and NF-κB [52]. PPARγ activators decrease MMP-9 expression
in vascular smooth muscle [116] and treatment with PPAR
agonist troglitazone has shown decreased atherosclerotic lesions in various
animal models [107]. In addition PPARγ-mediated suppression of
NF-κB activity may decrease proinflammatory cytokines in macrophages, including
MMP-9 [117].This intricate relationship demonstrates that PPARγ downregulates MMP expression
and inhibits MMP-9’s subsequent accumulation in Bruch’s membrane where it may
play an integral role in the degradation of the extracellular matrix and be a
stimulus for migration of the RPE into Bruch’s membrane, in this way
contributing to the pathophysiology of AMD.


## 6.3. DHA, PPARγ, and their Role in AMD

DHA is a naturally occurring ligand to all subtypes of the PPAR family. It binds specific DNA motifs to modulate the
activity of PPAR and RXR as transcription factors [9]. As being well known, PPARs play an important
regulatory role in oxidative stress by inducing the transcription of
antioxidant genes, such as glutamate cysteine ligase (GCL) and heme oxidase-1
(HO-1) [118]. These antioxidants then work through MAPK
kinase pathways to curb ROS. A functional PPRE is located at the
catalase gene promoter, a gene known to protect cells from the toxic effects of hydrogen peroxide (H2O2)
by catalyzing its decomposition, indicating that catalase expression is
directly regulated by PPARγ [62].
To further test this relationship, catalase expression was analyzed in
the striatum of rats subjected to intracranial bleeds with and without 15-dPGJ2
treatment. Treated rats showed 1.6-,
2.1-, and 1.7 fold higher levels of catalase mRNA expression compared to the
saline controls at 1, 3, and 24 hours [63]. Girnun et al. found
similar increases in catalase mRNA when using known PPAR agonists rosiglitazone
and ciglitazone in rat brain microvascular endothelium cells, one of the cell
types damaged during inflammatory responses induced by ROS generation [62].In short, PPARγ has a special role in counteracting the damaging effects of ROS
generation by upregulating antioxidant genes and downregulating proinflammatory
genes. By decreasing damage to LCPUFAs,
such as DHA, there is preservation of the protective effects these essential
molecules confer to the retina. Enhancing this ability of the RPE to protect itself from oxidative
injury may provide a therapeutic opportunity to delay or hinder the development
of AMD.


## 7. Summary

Though there is limited literature directly linking PPAR dysfunction with AMD
pathology, there is evidence that PPARs may be involved in various mechanisms
and pathways associated with this disease process. PPARγ is localized to the neuroretina and
RPE, the essential component to photoreceptor degeneration and vision
loss. PPAR acts to inhibit inflammatory
processes, which are linked to AMD. VEGF
is a known driving factor for neovascularization, a main causal element of wet
macular degeneration and PPARs directly inhibit VEGF function. High levels of MMP-9 have been detected in
retinas afflicted with AMD. In turn,
PPARs are known to decrease expression of MMP.
PPARs play a direct role in upregulation of antioxidative enzymes, one
of the many possible causes of macular pathology. PPARs bind various ligands including LCPUFAs
and their metabolites, possibly shedding light on how PPARs interfere with NFκB as one way in which omega-3 LCPUFAs are
protective against AMD. It is evident
that PPARs must play a certain role in the development of AMD. Figure 2 demonstrates the many ways that
PPARs interact with processes closely related to progression of AMD. Future studies are warranted to better
elucidate the pathogenic and therapeutic potentials of PPARs in AMD.Figure 2
Schematic graph showing PPAR interactions with VEGF, ROS, MMP-9, LCPUFA, DHA, and RPE cells and their role in the development of AMD.



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*Source: 389507-2008-01-27.xml*