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ABSTRACT: To evaluate clinical results after the use of a novel integrated imaging and laser device to perform focal retinal navigated laser photocoagulation in perifoveal abnormalities and retinovascular disease.
Interventional case series of 25 consecutive eyes with perifoveal and retinovascular diseases treated with a navigated laser photocoagulator Navilas (OD-OS, Berlin, Germany). We treated eyes with perifoveal telangiectasia (n = 3), central serous chorioretinopathy (n = 2), and diabetic macular edema with focal leakage (n = 20).
The treatments were performed without a contact lens and without topical anesthesia. There was no inadvertent photocoagulation of the fovea, and all laser applications accurately hit the preplanned points. Mean and median (± standard deviation) foveal thickness at baseline was 535 ± 171 μm and 402 ± 152 μm, respectively. Mean and median (± standard deviation) foveal thickness at 6 months was 318 ± 112 μm and 221 ± 127 μm, respectively. This represents a statistically significant decrease in foveal thickness (P = 0.003). Mean and median visual acuity at baseline was 20/80 and 20/50, respectively. Mean and median visual acuity at 6 months was 20/50 and 20/40, respectively, which represents a significant improvement (P = 0.011).
Precise retinal targeting with a navigated laser photocoagulator resulted in highly accurate perifoveal laser application and no foveal damage. At 6 months after the treatment, significant decreases in central foveal thickness and significant improvements in visual acuity were identified.
Retina (Philadelphia, Pa.) 08/2011; 32(5):930-5. · 2.93 Impact Factor
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ABSTRACT: To describe the appearance on spectral domain optical coherence tomography of the peripheral retina and overlying vitreous after scleral buckling surgery.
Retrospective case series of patients who underwent scleral buckle surgery and had subsequent scanning laser ophthalmoscopy/spectral-domain optical coherence tomography images over the area of buckled retina. Twelve eyes from 11 patients were identified and show a variety of retinal anatomies, vitreous configurations, and clinical applications.
Twelve eyes from 11 patients were studied, and in all eyes, the peripheral retina could be visualized with 10 cases of successful retinal reattachment and 2 cases of scleral buckle failure. Vitreous including strands to the causative retinal tear was seen in three eyes and overlying vitreous in four additional eyes. The scleral buckle indentation was seen in nine eyes, and in the two failed scleral buckles, unsupported retinal breaks, residual vitreous traction, and persistent subretinal fluid over the scleral buckle could be visualized and followed as it resolved.
Simultaneous scanning laser ophthalmoscopy/spectral-domain optical coherence tomography allows detailed examination of the peripheral retina and overlying vitreous after scleral buckle surgery. Along with confirmation that the retina is attached and retinal breaks are closed, the scanning laser ophthalmoscopy/spectral-domain optical coherence tomography can be used in the postoperative management of scleral buckles to identify residual vitreous traction and monitor areas of subretinal fluid.
Retina (Philadelphia, Pa.) 03/2011; 31(8):1493-9. · 2.93 Impact Factor
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ABSTRACT: To evaluate the clinical use and accuracy of a new retinal navigating laser technology that integrates a scanning slit fundus camera system with fluorescein angiography (FA), color, red-free, and infrared imaging capabilities with a computer steerable therapeutic 532-nm laser.
Interventional case series.
Eighty-six eyes of 61 patients with diabetic retinopathy and macular edema treated by NAVILAS.
The imaging included digital color fundus photographs and FA. The planning included graphically marking future treatment sites (microaneurysms for single-spot focal treatment and areas of diffuse leakage for grid pattern photocoagulation) on the acquired images. The preplanned treatment was visible and overlaid on the live fundus image during the actual photocoagulation. The NAVILAS automatically advances the aiming beam location from one planned treatment site to the next after each photocoagulation spot until all sites are treated. Aiming beam stabilization compensated for patient's eye movements. The pretreatment FA with the treatment plan was overlaid on top of the posttreatment color fundus images with the actual laser burns. This allowed treatment accuracy to be calculated. Independent observers evaluated the images to determine if the retinal opacification after treatment overlapped the targeted microaneurysm.
Safety and accuracy of laser photocoagulation.
The images were of very good quality compared with standard fundus cameras, allowing careful delineation of target areas on FA. Toggling from infrared, to monochromatic, to color view allowed evaluation and adjustment of burn intensity during treatment. There were no complications during or after photocoagulation treatment. An analysis of accuracy of 400 random focal targeted spots found that the NAVILAS achieved a microaneurysm hit rate of 92% when the placement of the treatment circle was centered by the operating surgeon on the microaneurysm. The accuracy for the control group analyzing 100 focal spots was significantly lower at 72% (P<0.01).
Laser photocoagulation using the NAVILAS system is safe and achieves a higher rate of accuracy in photocoagulation treatments of diabetic retinopathy lesions than standard manual-technique laser treatment. Precise manual preplanning and positioning of the treatment sites by the surgeon is possible, allowing accurate and predictable photocoagulation of these lesions.
Proprietary or commercial disclosure may be found after the references.
Ophthalmology 01/2011; 118(6):1119-24. · 5.45 Impact Factor
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ABSTRACT: The purpose of this study was to use spectral domain-optical coherence tomography in imaging retina and vitreoretinal relationship in healed cytomegalovirus (CMV) retinitis.
Patients with a history of confirmed CMV retinitis and a healed CMV scar on clinical examination underwent spectral domain-optical coherence tomography examinations using a Spectralis Heidelberg retinal angiograph/optical coherence tomography instrument (Heidelberg Engineering, Heidelberg, Germany). Horizontal and vertical cross-sectional B-scans 6 mm x 6 mm passing through the center and margins of healed CMV scars and adjacent retina were obtained. We analyzed the integrity of retinal layers in the area of the CMV scar, integrity of retinal layers at the margins of the CMV scar, margins of the scar and adjacent nonaffected retina, and any structural alterations in the retina or vitreous.
Eleven eyes (50%) had vitreous detached, and 11 eyes attached over the area of healed retinitis. Nineteen eyes (86%) had an epiretinal membrane, and 12 eyes (54%) had vitreoretinal gliosis present over the healed retinitis or in its vicinity. The epiretinal membrane and vitreoretinal gliosis occurred concomitantly in 10 eyes and could be well differentiated on scans. None of these were found in control eyes.
This first in vivo study of vitreoretinal interface in inactive CMV retinitis shows that the vitreoretinal interface in healed CMV is pathologically changed. The presence of epiretinal membranes, vitreoretinal gliosis, and traction may help explain the higher incidence of retinal elevation, retinal breaks, and retinal detachment in these eyes.
Retina (Philadelphia, Pa.) 09/2010; 30(8):1262-6. · 2.93 Impact Factor
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ABSTRACT: The purposes of this study were to evaluate with spectral domain-optical coherence tomography the relationship between the retina and overlying silicone oil tamponade after macular hole surgery and to evaluate how this relationship changes with patient positioning.
We studied a retrospective consecutive case series of 10 eyes from 9 patients who underwent macular hole surgery with silicone oil tamponade and subsequent spectral domain-optical coherence tomography scans. Four of the included eyes were also imaged with patients in face-down posture to determine whether the silicone-retina apposition changes with prone positioning. Finally, a single patient was also scanned in the lateral and supine positions.
The posterior surface of the silicone oil bubble was well visualized in all 10 eyes. In the majority of eyes (7 of 10), the oil tamponade bridged the macular hole, creating a prefoveal fluid space, but in 3 eyes the silicone oil filled the macular hole and was seen in touch with the underlying foveal depression or retinal pigment epithelium. In 75% of eyes (3 of 4), the silicone oil-retinal approximation did not vary with face-down position. Supine positioning clearly floated the silicone tamponade anteriorly and off the retinal surface.
Silicone oil tamponade can either bridge macular holes or, in a novel finding, fill the underlying foveal depression or macular hole space. Generally, the oil position is stable between face-forward and prone spectral-domain optical coherence tomography images, suggesting that either of these patient positions allows waterproofing of the underlying macular hole. Finally, our images confirm that supine positioning should be avoided postoperatively because it leads to loss of oil-retinal tamponade.
Retina (Philadelphia, Pa.) 06/2010; 30(6):924-9. · 2.93 Impact Factor
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ABSTRACT: To evaluate the integrity of the photoreceptor inner segment/outer segment (IS/OS) junction using spectral-domain optical coherence tomography (SD OCT) in patients with diabetic macular edema and to correlate the relationship between the integrity of the IS/OS junction and visual acuity.
Retrospective, comparative, consecutive case series.
Sixty-two eyes from 38 patients with diabetic macular edema underwent SD OCT imaging. For each patient, 2 experienced observers masked to visual acuity measured several SD OCT variables, including central macular thickness, retinal volume, global disruption scale of outer retina, percentage disruption of the outer retina, and history of previous treatments. Visual acuity recorded as number of Early Treatment Diabetic Retinopathy Study letters was used as the outcome variable in univariate and multivariate analysis testing the measured SD OCT variables as predictors.
A statistically significant correlation between percentage disruption of the IS/OS junction and visual acuity was found (P = .0312). Additionally, there was a strong trend suggesting a relationship between macular volume and visual acuity, although borderline significance was found (P = .07).
Disruption of the photoreceptor IS/OS junction is an important predictor of visual acuity among diabetic macular edema patients.
American journal of ophthalmology 05/2010; 150(1):63-67.e1. · 3.83 Impact Factor
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ABSTRACT: The purpose of this study was to evaluate the predictive value of spectral domain-optical coherence tomography-determined integrity of the photoreceptor inner segment/outer segment (IS/OS) junction on visual acuity in patients with epiretinal membranes (ERMs).
This is a retrospective consecutive case series of 54 eyes from 48 patients with primary ERMs who underwent spectral domain-optical coherence tomography scans. Regression analysis was used to calculate the relative contribution of several variables, including photoreceptor IS/OS disruption, grade of IS/OS disruption, macular thickness, and ERM grade on fundus imaging to visual acuity.
The strongest individual predictor of visual acuity among patients with ERM was central retinal thickness on spectral domain-optical coherence tomography (r(2) = 0.16, P = 0.0024), but the most efficient model was the combination of macular thickness and presence or absence of photoreceptor IS/OS disruption (r(2) = 0.24, P = 0.0008). Additional measured variables did not significantly contribute to visual acuity prediction. Inner segment/outer segment layer integrity was also an independent predictor of visual acuity, and patients with IS/OS disruption were 6.88 times as likely to have 20/50 or worse vision than patients with intact photoreceptor layers (odds ratio: 6.88, confidence interval: 1.56-30.43, P = 0.01).
Disruption of the photoreceptor IS/OS junction is a statistically significant predictor of poor visual acuity among patients with ERM and is most useful when combined with central retinal thickness measurement.
Retina (Philadelphia, Pa.) 05/2010; 30(5):713-8. · 2.93 Impact Factor
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ABSTRACT: The purpose of this study was to determine the morphologic patterns of angiographic macular edema using simultaneous colocalization of fluorescein angiography and spectral-domain optical coherence tomography (SD-OCT) images in diabetes, epiretinal membrane, uveitic and pseudophakic cystoid macular edema, and vein occlusion.
Eighty-seven consecutive patients (107 eyes) with macular edema from 5 different etiologies were imaged by simultaneous scanning laser ophthalmoscopy/OCT to study the morphologic patterns of edema on SD-OCT and then correlated/colocalized with the fluorescein angiographic patterns of leakage. Statistical analysis was done to analyze the differences in the morphologic OCT pattern by different diseases.
Spectral-domain OCT characteristics of macular edema showed a significant difference across different diseases (P = 0.037). Cystic fluid pockets were found to be more commonly seen in patients with diabetic macular edema and retinal vein occlusions, whereas those cases with macular edema secondary to epiretinal membrane showed noncystic changes on OCT. Seventy of the 107 eyes had diffuse angiographic leakage, and the remaining 37 eyes had cystoid leakage on angiography. Of the 70 eyes with diffuse leakage, 24.28% showed microcysts on SD-OCT in the area of edema, and 70% eyes had diffuse thickening or distorted architecture without cyst. All 37 eyes with cystoid leakage showed cysts in the area of edema by SD-OCT. A total of 3.73% of eyes with fluorescein angiographic leakage had no abnormalities on SD-OCT.
Eyes with diabetic macular edema and retinal vein occlusions have a significantly higher incidence of cyst formation on SD-OCT. There was no correlation between visual acuity and cyst formation. Diffuse noncystoid angiographic macular edema may show microcysts on SD-OCT, but diffuse edema is more commonly associated with thickening or distortion of the retinal layers without cyst formation. Cystoid leakage on fluorescein angiography is always associated with cystic changes on SD-OCT.
Retina (Philadelphia, Pa.) 03/2010; 30(3):383-9. · 2.93 Impact Factor
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ABSTRACT: To review the cases of viral retinitis after intravitreal steroid administration at a single center, to estimate the incidence, and to propose risk factors for its occurrence.
Retrospective, observational case series.
Seven hundred thirty-six intravitreal triamcinolone (IVTA) injections were administered in the clinic and operating room by 3 retina specialists at a single academic medical center between September 2002 and November 2008. Inclusion criteria were simply a history of 1 or more IVTA injections during the period. The overall incidence of viral retinitis after IVTA injection was calculated. Subsequently, a chart audit was performed to estimate the number of patients with immune-altering conditions who had received IVTA during the period, and the incidence within this subgroup was calculated.
Viral retinitis developed after IVTA injection in 3 patients, yielding an overall incidence of 3 in 736 or 0.41%. An estimated 334 injections were administered to patients with an immune-altering condition, including diabetes. All 3 of the patients in whom viral retinitis developed after IVTA injection possessed abnormal immune systems, yielding an incidence rate of 3 in 334 or 0.90% within this subgroup.
Our high reported incidence for this potentially devastating complication can be attributed to multiple factors, including coexisting medical immunocompromising comorbidities, a higher dose with a longer duration of local immunosuppression in the vitreous, multiple injections, as well as previous viral retinitis. Caution with a high index of clinical suspicion and frequent follow-up is advised in patients receiving IVTA injection with potentially immune-altering conditions, even after apparent immune recovery.
American journal of ophthalmology 03/2010; 149(3):433-40.e1. · 3.83 Impact Factor
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ABSTRACT: To determine the ability to detect normal vitreous structure, evolving posterior vitreous detachment (PVD), and related vitreoretinal changes with combined spectral-domain optical coherence tomography (SD-OCT) and scanning laser ophthalmoscopy (SLO).
Observational cross-sectional study.
Simultaneous SD-OCT and SLO imaging instruments (SD-OCT/SLO) were used to image both eyes of patients with symptoms of PVD. The vitreous cortex, preretinal lacunae, hyaloid, and its relations to the retinal surface were analyzed. In addition, ultrasound was performed in a subset of patients to determine the stage of PVD.
Two-hundred two eyes of 113 subjects were scanned. There was a high correlation between diagnosis of complete PVD by clinical examination and OCT (95 vs 93 eyes, respectively; kappa, 0.82). A partial PVD was detected more frequently by SD-OCT/SLO than by biomicroscopy examination (45 vs 7 eyes; P < .0001). Ultrasound was performed in a subset of 30 eyes. A high agreement was found between ultrasound and SD-OCT/SLO results for both complete PVD (kappa, 0.933) and incomplete PVD (kappa, 0.91). Vitreous cortex was detected in 181 eyes, and posterior precortical vitreous pocket was detected in 85 eyes. The effects of PVD, including vitreoretinal traction, paravascular lamellar holes, and fine changes at the fovea, could be visualized reliably in detail only with SD-OCT/SLO. In all these eyes, SD-OCT/SLO allowed improved visualization of the vitreoretinal relationship.
SD-OCT/SLO provides unprecedented in vivo information about the physiologic and pathologic vitreous structure; it allows an extremely detailed analysis of the vitreoretinal interface, and it is particularly useful for defining focal changes and PVD.
American journal of ophthalmology 02/2010; 149(4):641-50. · 3.83 Impact Factor
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Ophthalmology 12/2009; 116(12):2482. · 5.45 Impact Factor
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Retina (Philadelphia, Pa.) 10/2009; 29(9):1367-70. · 2.93 Impact Factor
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ABSTRACT: To study the appearance of margins of geographic atrophy in high-resolution optical coherence tomography (OCT) images and to correlate those changes with fundus autofluorescence (FAF) imaging.
Retrospective, observational case study.
Patients with geographic atrophy secondary to dry age-related macular degeneration were assessed by means of spectral-domain OCT (Spectralis Heidelberg Retinal Angiograph/OCT; Heidelberg Engineering, Heidelberg, Germany; or OTI Inc, Toronto, Canada) as well as autofluorescence imaging (Heidelberg Retinal Angiograph or Spectralis; Heidelberg Engineering). The outer retinal layer alterations were analyzed in the junctional zone between normal retina and atrophic retina and were correlated with corresponding FAF.
Twenty-three eyes of 16 patients between 62 and 96 years of age were examined. There was a significant association between OCT findings and the FAF findings (r = 0.67; P < .0001). Severe alterations of the outer retinal layers at margins on spectral-domain OCT correspond significantly to increased autofluorescence; smooth margins on OCT correspond significantly to normal FAF (kappa, 0.7348; P < .0001).
Spectral-domain OCT provides in vivo insight into the pathogenesis of geographic atrophy and its progression. Visualization of reactive changes in the retinal pigment epithelial cells at the junctional zone and correlation with increased FAF; secondary to increased lipofuscin, together these methods may serve as determinants of progression of geographic atrophy.
American journal of ophthalmology 06/2009; 148(3):439-44. · 3.83 Impact Factor
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Acta ophthalmologica 05/2009; 88(2):e7-8. · 2.44 Impact Factor
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Archives of ophthalmology 02/2009; 127(2):218. · 3.86 Impact Factor
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ABSTRACT: To characterize the clinical and histologic features of primary graft failure after Descemet's stripping and automated endothelial keratoplasty (DSAEK).
Retrospective observational case series.
Sixteen cases of DSAEK graft failure from 15 patients, all with detailed histologic examination of failed graft tissue.
Hematoxylin-eosin, periodic acid-Schiff staining, and light microscopy were used to examine the failed DSAEK graft tissue from all patients.
Examination of specimens for corneal endothelial cell viability and host-donor interface characteristics.
Clinical history revealed that 88% (14/16) of studied DSAEK grafts detached before failure, and pathologic examination found that 75% (12/16) of failed grafts had atrophic corneal endothelium. Examples of residual host Descemet's membrane in the graft site and improper donor trephination were also identified.
Marked loss of the corneal endothelium is the prominent feature of primary DSAEK graft failure. Examples of surgical features, such as incomplete Descemet's stripping and residual full-thickness cornea with a DSAEK graft, are shown.
Ophthalmology 11/2008; 116(4):609-14. · 5.45 Impact Factor
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David B Kantor,
Onanong Chivatakarn,
Katherine L Peer, Stephen F Oster,
Masaru Inatani,
Michael J Hansen,
John G Flanagan,
Yu Yamaguchi,
David W Sretavan,
Roman J Giger,
Alex L Kolodkin
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ABSTRACT: The response of neuronal growth cones to axon guidance cues depends on the developmental context in which these cues are encountered. We show here that the transmembrane protein semaphorin 5A (Sema5A) is a bifunctional guidance cue exerting both attractive and inhibitory effects on developing axons of the fasciculus retroflexus, a diencephalon fiber tract associated with limbic function. The thrombospondin repeats of Sema5A physically interact with the glycosaminoglycan portion of both chondroitin sulfate proteoglycans (CSPGs) and heparan sulfate proteoglycans (HSPGs). CSPGs function as precisely localized extrinsic cues that convert Sema5A from an attractive to an inhibitory guidance cue. Therefore, glycosaminoglycan bound guidance cues provide a molecular mechanism for CSPG-mediated inhibition of axonal extension. Further, axonal HSPGs are required for Sema5A-mediated attraction, suggesting that HSPGs are components of functional Sema5A receptors. Thus, neuronal responses to Sema5A are proteoglycan dependent and interpreted according to the biological context in which this membrane bound guidance cue is presented.
Neuron 01/2005; 44(6):961-75. · 14.74 Impact Factor
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ABSTRACT: In the mammalian CNS, glial cells repel axons during development and inhibit axon regeneration after injury. It is unknown whether the same repulsive axon guidance molecules expressed by glia and their precursors during development also play a role in inhibiting regeneration in the injured CNS. Here we investigate whether optic nerve glial cells express semaphorin family members and, if so, whether these semaphorins inhibit axon growth by retinal ganglion cells (RGCs). We show that each optic nerve glial cell type, astrocytes, oligodendrocytes, and their precursor cells, expressed a distinct complement of semaphorins. One of these, sema5A, was expressed only by purified oligodendrocytes and their precursors, but not by astrocytes, and was present in both normal and axotomized optic nerve but not in peripheral nerves. Sema5A induced collapse of RGC growth cones and inhibited RGC axon growth when presented as a substrate in vitro. To determine whether sema5A might contribute to inhibition of axon growth after injury, we studied the ability of RGCs to extend axons when cultured on postnatal day (P) 4, P8, and adult optic nerve explants and found that axon growth was strongly inhibited. Blocking sema5A using a neutralizing antibody significantly increased RGC axon growth on these optic nerve explants. These data support the hypothesis that sema5A expression by oligodendrocyte lineage cells contributes to the glial cues that inhibit CNS regeneration.
Journal of Neuroscience 06/2004; 24(21):4989-99. · 7.11 Impact Factor
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ABSTRACT: During development, EphB proteins serve as axon guidance molecules for retinal ganglion cell axon pathfinding toward the optic nerve head and in midbrain targets. To better understand the mechanisms by which EphB proteins influence retinal growth cone behavior, we investigated how axon responses to EphB were modulated by laminin and L1, two guidance molecules that retinal axons encounter during in vivo pathfinding. Unlike EphB stimulation in the presence of laminin, which triggers typical growth cone collapse, growth cones co-stimulated by L1 did not respond to EphB. Moreover, EphB exposure in the presence of both laminin and L1 resulted in a novel growth cone inhibition manifested as a pause in axon elongation with maintenance of normal growth cone morphology and filopodial activity. Pauses were not associated with loss of growth cone actin but were accompanied by a redistribution of the microtubule cytoskeleton with increased numbers of microtubules extending into filopodia and to the peripheral edge of the growth cone. This phenomenon was accompanied by reduced levels of the growth cone microtubule destabilizing protein SCG10. Antibody blockade of SCG10 function in growth cones resulted in both changes in microtubule distribution and pause responses mirroring those elicited by EphB in the presence of laminin and L1. These results demonstrate that retinal growth cone responsiveness to EphB is regulated by co-impinging signals from other axon guidance molecules. Furthermore, the results are consistent with EphB-mediated axon guidance mechanisms that involve the SCG10-mediated regulation of the growth cone microtubule cytoskeleton.
Journal of Neuroscience 03/2004; 24(8):1976-86. · 7.11 Impact Factor
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ABSTRACT: Retinal axon pathfinding from the retina into the optic nerve involves the growth promoting axon guidance molecules L1, laminin and netrin 1, each of which governs axon behavior at specific regions along the retinal pathway. In identifying additional molecules regulating this process during embryonic mouse development, we found that transmembrane Semaphorin5A mRNA and protein was specifically expressed in neuroepithelial cells surrounding retinal axons at the optic disc and along the optic nerve. Given that growth cone responses to a specific guidance molecule can be altered by co-exposure to a second guidance cue, we examined whether retinal axon responses to Sema5A were modulated by other guidance signals axons encountered along the retinal pathway. In growth cone collapse, substratum choice and neurite outgrowth assays, Sema5A triggered an invariant inhibitory response in the context of L1, laminin, or netrin 1 signaling, suggesting that Sema5A inhibited retinal axons throughout their course at the optic disc and nerve. Antibody-perturbation studies in living embryo preparations showed that blocking of Sema5A function led to retinal axons straying out of the optic nerve bundle, indicating that Sema5A normally helped ensheath the retinal pathway. Thus, development of some CNS nerves requires inhibitory sheaths to maintain integrity. Furthermore, this function is accomplished using molecules such as Sema5A that exhibit conserved inhibitory responses in the presence of co-impinging signals from multiple families of guidance molecules.
Development 03/2003; 130(4):775-84. · 6.60 Impact Factor
