 So I left you last time with kind of you know walking through the neural retina of the RPE and today I want to kind of finish the complex off by I'm going to start with vitreous because every time I give these lectures for 10 years vitreous always get stuck at the end and and you never get to it, so I thought I'd start today would talk about the vitreous You know that's that this deal down in here and then talk about Brooks membrane corroid And then I want to come back at the end if we have time and kind of tell you a little bit about our work on Macular degeneration as it applies to kind of the histology we've talked about last time and today and See if we can get to that place so of course vitreous this Total gel-like substance that fills the middle of the eye You know I used to have a function slide for the vitreous But I don't know what its function is and I think there's a lot of speculation But remember from last time I talked The vitreous really is the basal surface of the neural retina, right? So if you think about how that I formed as we talked about and where the basement membrane for that epithelium is It sits on the vitreous So you know put another way without a vitreous you really have a retina There's just kind of hanging up there by its by its fingernails, right? And and I think that's actually part of the problem with late-age onset retinal detachments and things very Complicated synthesis during development and I have some slides in the larger deck that I'll give to you and you guys can Always look through that as we go along Lots and lots of discussion about Morphology, but I think for you guys as clinicians the important things to know is that there's a vitreous cortex That's nothing more than really dense collagen a denser layer of collagen that sits right up next to the retina From my perspective, it's probably the same deal that dense collagen kind of maintains some shape and gives the retina something to sit on but there's a lot of discussion about all these Bursey and I think they do exist why they exist is is anybody's guess So of course, you know that the numbers 98% plus water Macromolecules that are important the lot of collagen molecules and a very complicated structure of collagens And it's really the collagen fibrils in the spacing between those fibrils Which is maintained in large part by glycosaminoglycan chains That kind of gives the vitreous. It's it's mechanical 3d structure Lots of other extracellular matrix micro fibrils, etc So typical extracellular matrix The I think the important part the part that you all might not be completely aware of is that you know The vitreous has these Hyalicytes that sit there very poorly studied cells We did quite a bit of work ten years ago or so and showed that these are actually dendritic cells And there's a parallel story. I'll talk about when we get to the corroid But there seems to be along the basal surface of that neuro epithelium that forms the retina in the RPE There seems to be a bunch of these dendritic cells that's probably sit there as Sentinels and kind of sense what's happening from an immunological basis. So I think fascinating story But just remember You peel out the vitreous and you probably remove a huge number of these hyalicites which which probably have a function That's important These these macro fibrils a very complex structure And I want to bore you with the details but mostly made up of type 5 and type 2 collagen and again They're they're really packed tight for collagen fibrils and that's mostly From these type 9 collagens shown here in black and it's the glycosaminoglycans side chains on that type 9 collagen That mediate interaction between this fibril and the next fibril and kind of keep them separated in space That all changes of course with aging and a lot of Cineresis is due to that change Of course the what you guys would call the vitreal retinal interface is is really nothing more Than the basal lamina of the retina. Okay, it's primarily made by Mueller cells and it's a typical basal lamina That sits there and mediates interaction between the vitreous collagen fibers In fact, this picture is one of my favorites if you look really closely You can see these fibers coming in and they actually splay out an anchor into that basal lamina of course surgically You guys we talked a lot about peeling this basal lamina which drives me absolutely crazy To think that you actually go in there and if you've ever looked at one of these histologically after you've peeled it It's a disaster. I mean you have ripped all these basal feet off of the Mueller cells So it might serve a purpose clinically, but I think we can do a lot better than that Sites of adhesion so all of you will be faced, you know in in disease with these sites of really firm adhesion Probably the strongest adhesion straddles the orosirata here called the vitreous base really really firm adhesion Another side of adhesion behind the lens here and then around of course the the optic nerve and macular region So important that you know where those are if you're doing vitrectomies. You're doing whatever You really can run into some problems with those sites of strong adhesion So years ago, this is just this is the anterior aspect of the retina going into the ciliary body here And you can see how dense those collagen fibers are at that vitreous base and years ago Steve Russell I don't know if you know Steve and Karen Gears from from Iowa We developed a drug actually to serve to dis-insert the vitreous and you can see here Very strong distribution of chondroitin sulfates sitting that mediating that adhesion between the vitreous We developed a drug chondroitinase that actually just completely dis-inserted the vitreous and then you could actually just go in here and And suck that out you're seeing some some we lost that drug because it was purchased by Bosch and Lohman They stuck it on a shelf for eight years, which was a disaster, but Vitrease is is aimed towards doing a similar thing, but it really just doesn't work very well We we've learned a lot more mostly from Paul Bishop over at He's the chairman of ophthalmology at Manchester in in the UK Paul has done a ton of work on that on the vitreous in that interface and he identified this this Interesting molecule called optocin that actually does help mediate that interaction between the ILM and and the vitreous and Probably place this huge anti-angiogenic role in its native state. It doesn't allow cells to adhere Angiogenic cells, endothelial cells to adhere to the vitreous. So a great discovery There's tons of it the turnover of optocin is this is huge and I think you'll see some some Practical drugs come out of this optocin Probably in playing some anti-angiogenic role. So all of this goes away when you do a vitrectomy, right? All these defense mechanisms are gone So be thinking about that Of course age and disease related pathologies I think you're familiar with all of these, you know, certainly vitreous liquefaction mostly because of loss of this chondroitin sulfate side chain that I told you everything just kind of Collapses on on one another and as that vitreous collapses, of course, it starts pulling in places that it shouldn't Macular holes very much an issue In our work in Africa We have seen so much blindness from from creation of Macular holes and the vitreomacular traction in the African people seems to be even more robust than Caucasians So I think a lot of blindness in Africa from macular holes could easily be dealt with if you had one of these disinsertion agents that Could remove that Of course Regmetogenous retinal detachments a huge problem very much caused by this liquefaction of vitreous pounding around in the back of the eye and in Disinserting retinas and of course proliferative diabetic retinopathy I think you know Paul's work on opposite Opticin may actually deal with that and I haven't had a chance to talk to him in a while. So so there we go vitreous Let's get to the other side to the good side of the eye You know before I even start Brooks membrane and corroid. I think there are so understudied from a scientific perspective And the work has really ramped up and we're learning a ton about how important the corroid really is I mean, it's obvious it's protect or it's important because of vascular supply to the retina But there's so much more going on in that corroid You know we often talk about Brooks membrane being this five layered structure again that drives me crazy to it's it's not really it's just it's just the way it is anatomically About two to four microns thick, but it's really comprised of two basal lamina So it's the basal lamina of the retinal pigmented epithelium. It's the basal lamina of the coriocapillary endothelial cells The crux of the structure is a layer of elastin and you can see this layer here Flanked on each side by two collagenous layers Very different properties a lot of changes in this structure with age that we'll talk about here in a minute Functions, of course I think once again the the retina and the coriocapillaris really need a stiff structure to hang on to right Imagine trying to pump the volume of blood you're pumping through the coriocapillaris if you didn't have it adherent and years ago We actually described small feet that come out of the coriocapillary endothelial cells and insert in this in this complex of Brooks Membrane and probably serve to anchor that coriocapillaris On the other side, of course the retinal pigmented epithelium Really needs something to hang on to and one of the biggest problems in macular degeneration is the fact that they RPE loses the ability to do that So little known fact and I think this this has a lot to do with probably a lot of diseases And I think it's very much underappreciated You know we realized years ago that if you look in the extra macula and you've stained a section of Human eye with anti elastin antibodies you can very nicely pick out the elastin layer in Brooks membrane If you look in the macula you just get these little glimpses of Elastic layer okay, and so that elastic layer is multi-layered But it kind of looks like this and layers upon layers of elastin that have a porosity at the end of the day And this is actually in a 20 year old so so absolutely normal eye But these two Ems are taking it exactly the same mag and you can see how thick this elastin layer is In the extra macular regions, and this is what you get in the macula. So must have a real function Probably very important again. You can see the same thing at high mag very thick elastin layer with very few pores in it In the extra macula and just a very porous In the macula we quantified the data in probably 400 pairs of eyes and clearly a huge difference Between macula and extra macula then the question was in diseases like macular degeneration Do you see even thinner? Features in the in the truth is yes, so with a p-value of point oh one The integrity in the macula is lost even more in patients with macular degeneration. So interesting Point of fact is the elastin gene is actually turned off in the third trimester only to be turned back on When you have these elastin degradation peptides, and so we've spent a lot of time in macular degeneration looking Those peptides will actually signal cells to make new elastin in pathological conditions like keloid formations And that's happening back in the coroid in a subset of patients with macular degeneration Elastin's made everywhere, but for some reason the body doesn't know how to lay it back down where it belongs and It's intrigues me if you kind of if you look at Integrity or thickness of the elastic layer, and you kind of plot that on Foss you get something like this with blue being the thinnest here in the dead center macula But if you really look at this plot it corresponds to the extent of lesions in almost any macular disease Right you never see geographic atrophy extending much past a region like this Where this is thin and and very porous, so I don't know why Probably because something to do with the RPE not being able to adhere to that that Brooks membrane that's that's thin and very porous But probably needs to be more porous to get you know nutrients and things back and forth between between the macula and the coroid Lots of age related changes in Brooks membrane I think the problem with this and there's a huge literature on changes that occur But nobody's really looked at it from a kind of genotype phenotype correlation So yes, you can make general statements with aging But most of the literature was based on small numbers of tissues not really focused on disease versus non disease And in today's world, I think we'll come back full blast and show that a lot of these changes are Gene associated disease gene associated, but Brooks membrane accumulates a lot of debris both lipids and proteins It becomes thicker It calcifies in a subset of patients which you can actually see on OCT and you know keep your eyes out for that Because I think it's probably associated with macular degeneration Lots of cross-linking lots of oxidative damage in that right if you think about that environment There's huge amounts of lipids being turned over back there, but there's also you know a ton of oxygen and a ton of blood flow so a lot of damage caused by cross-linking of collagen and other proteins these so-called adducts and Lots of changes in protein composition, but again, I think we need to do better and tie those things together There's been a lot of focus the last oh ten years Let's say on this so-called lipid wall which Christine Curcio will be here. I think next month and she'll probably talk about this There's just and it's been known for a long time going clear back to Daniel Polayakov who showed that there were increased lipids in Brooks membrane with age And Christine followed that up and showed that yeah, it's a real story But I think the story will go now that they're not as important as a lot of the protein changes So I don't think this lipid wall is playing as much of a detrimental role as thought so this is just fun I don't know if you've ever seen the sewers of London But this they're full of congealed fat. So how'd you like to have that job? You know functional changes are you know have been characterized very well mostly by John Marshall and his colleagues over time But there's a huge decrease in hydraulic conductivity Overage and that's been nicely qualified or quantified and it does correspond somewhat to these increased levels of lipids although I saw John in Paris last month and he's thinking again that it's not as much the Lipid as it is the changes in some of the proteins So he's very keen on these changes in the metalloproteinases that are accumulating Let's talk a little bit about the Coroid Again fascinating structure and you guys are probably starting to see more and more of that clinically a lot of discussion on OCTs about thin Coroids and thick Coroids and do they correlate to anything? I would argue. Yeah, thin Coroid probably correlates With a lot of of damage to the underlying retina, but again, you know, we're just starting to explore these changes But I think you're all familiar Primarily vascular volume in the Coroid, you know and three layers that we typically talk about Howlers or these big arteries and veins on the outermost aspect And then this Sattler's layer which kind of mid-sized arterioles and vanuels and then the Corio Capillaris which is this an incredibly fascinating structure And if you were here when Jerry Luddy spoke last year, I mean he's done The large majority of work and we're doing a lot with him currently on on the Corio Capillaris And I'll talk a little bit about that There's a really interesting space and it's truly a space that lies between the Coroid and the Sclerum Called the super Coroidal space. I think in your careers, you're going to be playing with that space a lot, okay? It's we did studies 25 years ago, and if you inject tracers even in an animal a primate up in in The Trebecular mesh work say they will get clear back to the macula in the super Coroidal space very quickly so, you know function unknown it probably allows Was probably designed to allow slippage right between a really rigid Sclerum But there are new instruments Have you seen the instrument that the little cannula that can get probed that has a little light on the end of it So I think we're working with companies. I think we'll probably start doing gene therapy delivery of viruses through that super Coroidal space And we can talk about that a little bit more, but fascinating space Lots of extracellular matrix and you know fibrosis of the of the Coroid is something that's not talked about a lot But I'll show you that in macular degeneration. It's making a big difference Of course, lots of nerve plexus Always still today argued whether this nerve plexus actually regulates Blood flow and volume in the Coroid so jury's still out Really interesting we know nothing about the function of these melanocytes other than they probably adsorbed stray light And there's lots of interesting stories again with these dendritic cells and that dendritic cells just like they did on the vitreous side Like the hyalocytes they'll sit right here on the top of Brooks membrane Probably again serving as sentinels to kind of have a look from an immunological perspective about what's going on I'm not going to bore you with all the details of the vasculature. I'm sure you're you're quite familiar with the vascular But most of the vascular the input on the arterial side comes from the lateral and medial posterior ciliary arteries and I should have put Where's the Central retinal artery is in here, too I just forgot to put it but all of your your blood supply to the Coroid comes from from those branches Of course the system then Drains into the Coriocapularis, which is the fascinating structure and then out back through the vortex veins But here's a little known fact and we've actually been intrigued and done some work with with Kathleen degree But little known fact is in many cases the the ophthalmic artery passes in some cases I should say passes over the top of the optic nerve like it is here in other cases It passes under the optic nerve and that you know from my perspective. It's about a 75 percent 25 percent split Kathleen and I have looked to see if we can see that With the 3t instrument and indeed you could you could do a really neat study following The path of these ophthalmic arteries in patients with and with immacular degeneration for example But the question would be you know does this architecture the architecture affects how all of these these other Arteries the branching pattern of these other arteries to the back of the eye and may well explain a lot of the watershed zones You see in fluoresceins It'd be a really neat study to to look at this and in Quantified and see if there's an association with vascular disease in the back of the eye Coriocapillaris just this fascinating structure, of course very dense Vascular bed that sits right on top of Brooks membrane The largest capillaries in the body as far as I Am aware but a very very unique structure. So these These small arterials come into these lobular structures of Coriocapillaris and basically Interestingly enough these things come in and then they make a right angle these arterials Which I think is probably at the crux of a lot of problems with the pathology in the Coriocapillaris Feed that central part of the lobule and then they drain Peripherally into into the venous system and out Kind of a terrible design in some ways these lobules are smallest in the macular region about 150 microns in diameter But they can vary in different parts of the of the macula between say 180 and 460 and the shape of the lobules changes So for whatever reason very much round in the macular region and as you work your way out towards the equatorial regions They become less dense and actually more elongated and until the point they almost turn into a typical parallel arterial venous Structure, but lots of diseases. I think you're going to find our The Coriocapillaris structure might be at the root of in fact There was a beautiful patient our paper on caroteremia just last week that showed a direct correlation between these lobule structures And the development of caroteremia of course every time you lose one of these lobules You're likely to cause dysfunction of the underlying RPE and and ultimately the retina I think So it fascinating structure We're showing some huge differences between chromosome 1 and chromosome 10 directed macular degeneration I'll come back and show you a little bit about that But if you think a reticular pseudo drusen I've argued for quite a few years here that those pseudo drusen mimic the distribution of these Coriocapillary lobules and if indeed pseudo drusen are accumulations of lipid and debris in the sub retinal space It probably is directly correlated to Dysfunction and death of those Coriocapillary lobules You can see again early filling, you know in those those core structures You can see the small arterial filling and then the lateral filling In the venous phase as you move out. I mean, yeah, so sohan. Hey ray Did a lot of this work in the back in the 70s, and it's just it's beautiful literature if you have time to go look at it Very leaky vessels of course You're all aware highest blood flow in the body through this Coriocapillary is probably 1020x as much oxygen and blood as you really need in the back of the eye and the question becomes You know why expend that much energy pumping that much oxygen and blood back there? When you probably don't need as much I think the comforting thing there is you can lose Probably half of your Coriocapillary and still maintain a functional retina so the the Finistrations on the Coriocapillary sit on the basal surface next to the RPE The the surfaces that that face the Coroidal stroma are not Finistrated and that's you can see that here with this antibody that's very specific to these these diaphragms slit diaphragms in the finastery So if you take an EM section across that basal surface highly Finistrated with diaphragm Finistrations, this is a Freeze fracture image. I took long time ago, but it's one of my favorite pictures actually So you're sitting here as if you're looking from the RPE at the basal surface of that Coriocapillary So you can really appreciate how Finistrated it is here's one of those anchors that I told you about it broke off in the freeze fracture But it would be poking out at you and anchoring This endothelium to to Brooks membrane so fascinating structures Age changes with respect to the Coriocapillary are huge There's there's actually age changes. There's disease associated changes But in general you go from this this highly dense Coriocapillary with lobular structures Typically to a much more tubular System and loss a huge loss of vascular volume That's been quantified with age and it's it's being quantified with respect to a lot of Macular diseases as we speak And the vortex veins of course in the story So lots of diseases of the Cori that you guys are familiar with so I'm not going to bore you but a lot of vascular diseases You know occlusions. I think one that's we're learning a lot more about are these these polypoidal Coroidal vascular apathies that are very very prominent in Asians And clearly driven by chromosome 10 and we'll come back and talk about that Lots of diabetic complications lots of of course inflammatory diseases uveatic diseases But I thought I'd use that as a segue to talk a little bit about macular Degeneration show you a little bit about what we're doing, but show you how you know Macular degeneration really does affect that entire interface from the coroid to the retina And even the vitreous Little bit of history. I think the first description of drusen Was by Donders back in 1854 And he actually coined the term drusen, which is is a word in German that means geode Okay, so these are I guess geodes from from Germany But it wasn't until 1874 that Jonathan Hutchinson published the first Observations of what he called of senile macular degeneration, but again very much characterized by The abnormal deposition of these deposits called drusen I think if I look at the disease and you guys as clinicians This is kind of what you see in the clinic every day, but I've been fascinated by the clinical phenotypic Diversity that one sees and yet and yet we call this a single disease, right? And so even geographic atrophy can can you know be Monod or one lobule or multi lobular If you think about it late-stage disease Lots of phenotypes, right? And I think one of the biggest problems with the advent of anti-begeps is you're not paying attention to all this You're just saying okay got fluid on an OCT and we're gonna inject and I I've just been able to show in in even in the Moran The number of people that are being injected that don't have neovascularization Is huge and I think that's probably a real problem So we're really losing sight of of all of this phenotypic diversity, you know a bleed is a bleed Well, it's not if you think about neovascular disease You've got choroidal lesions. You've got a Colton classic lesions, which may be different You've got these polypoidal lesions you've got rap lesions in the retina and yet you call it you you'd lump it into one thing and so I would Suggest that you try not to do that The other thing that you know if you think about it these structures that we call drusen are not always drusen From a from a histological perspective, so I'd like to remind everybody that a druse is not a druse Certainly clinically in the case of pseudo drusen. These pseudo drusen are so often called drusen And they're in a totally different compartment And I think it's important you can always recognize in in these infrared images a one-to-one Correspondence if there is there's not any regular drusen there at all and these are probably not the same disease as somebody that truly has drusen Histologically the same thing this is a pattern that you see quite often I think it's probably you'll see it in about four or five percent of your geographic atrophy Patients none of these are drusen. They're actually lipid accumulations in the retinal pigmented epithelium So so you need to be very careful about diagnoses and about making genus or a phenotypic pathological correlations And again, even if you look clinically and I've been struck by this for a long time These are all donors we that we had clinical data on and in each and every case you would probably classify these individuals as having macular soft drusen right and they but Those can manifest from a lot of different pathologies and that's the point So these drusen really were manifest by this material that's not drusen at all This is material called basal laminar deposit that forms between the RPE's basal surface in its own Basal laminate. Okay, very different compartment than the compartment that this guy sits in So this is more of typical hard drusen Or substance-filled drusen looks like this on em But a lot of things we call drusen or nothing more than cirrus pigment epithelial attachments And they don't necessarily have to be these huge things. They can be very small And they're just fluid filled really detachments of the RPE so lots of variation Again showing in another way these basal laminar deposits form here between the basal surface of the RPE and its own plasma membrane And you can see these deposits very unique Deposits we know from Dick Green's work years ago that those deposits definitely are associated with development immaculate degeneration But typical compartment that drusen sit in would be here between Brooks membrane and the basal laminar of the RPE So again, you know lots of diversity that you probably don't think a lot about clinically So just very quickly a little overview of what what we've done You know when I first started in the field actually I started as a marine biologist Living on Catalina there are days where I wonder why I'm not there still But grandmother developed macular degeneration I was so struck back then by the fact that that Nobody wanted to fund it. I sat with the director of the National Eye Institute and Showed him some great pictures of drusen and he said very I'll never fund you to work on this disease and and you know He did apologize back in 2005 when we discovered the first gene but We started with a very simple minded thought about macular degeneration and that was you know back then And I'll tell you later. It's not true We always thought that the disease progressed from the development of drusen to ugly stuff GA CNV That's not necessarily true But we asked the very simple question of you know, could we identify what drusen were comprised of and if we could do that Would it teach us anything about the biology of the disease and again very much, you know therapy oriented even 20 years ago Well donor eyes became a critical component of that. That's so we started this this Huge repository of human donor eyes. We knew that we had to get eyes to the lab Under four hours after death otherwise everything's a mess But to make a long story short a big part of my life has been building these these Repositories we now have about 8,000 pairs of eyes up in the lab Since we've come here. We're actually getting about two pairs of eyes per day I saw when I first came five years ago. We're getting about one pair a month So we've really worked hard with the eye bank to ramp up these collections And it takes that volume of eyes to really be able to ask good scientific questions So I think the outcome Really 10 15 years of work back then was that drusen were full of Components of the complement system so every component we could find was there and it really the supposition at that point Was that the complement system was being activated at along this? RPE corroid interface for some reason that we didn't understand and that that was leading to the formation of this large complex called the Mac complex which the job is to lie cells and probably Intercalating itself into the RPE and into the coreo capillary endothelium and killing those cells and so we did a lot of quantitative Measurements back then and there was there was a correlation definite correlation between the presence of Mac and loss of RPE cells and Again, we quantified a lot of a lot of that back then but you can see in purple here There's just massive deposition of these Mac complexes back in Coriocapillaris Brooks membrane and RPE cells and Interestingly enough for us that led us in actually the year 2000 the first piece of data that we had showed that a major regulator of the complement system complement factor H that Mutations in that gene were not only responsible for macular degeneration, but responsible for about 50% of all risk. I mean huge Student came to me at the end of summer and 2000 with these incredible data, right? We had to sequence the gene first We had to design. I mean three years of work To do the genotyping that needed to be done and he came back and we looked at the data He said well, it's associated with 50% of our AMD cohort and I said now that that can't happen I mean we've made some major mistake, but we went back in the years 2001 and to we filed a lot of patents and that's why we didn't publish it early So we still hold about 140 patents on this observation But I think it's one of the most important scientific observations ever and unexpected, right? a major Change in a gene should not be associated with a major disease and and we could talk about that for a long time and why in Caucasians the prevalence of these mutations is so high in Caucasians compared to everywhere else I've been Africa Asia Easter Island So something happened in Caucasians that caused these these variants in factor H to be very common Which probably suggested they may have served a good function some somewhere along the line Maybe they protect it against the black plague or something But the story has turned out That there are two major genes that associate with the disease and I I want you to be very clear on this point because there's so much Confusion out there about all these genes, you know the GWAS study came out last month and said oh temp3 is associated with AMD From our GWAS no temp3 causes source bees disease and a bunch of clinicians put a bunch of source bees Patients into the GWAS study and didn't know what they were doing, right? So you have to be very careful But two major genes chromosome one that's factor H in this whole extended factor H locus we showed actually that Factor H related one and three we identified a huge deletion back in 2006 In about 20% of chromosomes the absence of these two genes is highly protected So I want you to take the message home that chromosome one is not just about risk In fact, it's more about the degree of protection against developing the disease and it's true genetic protection In Africa this this deletion is present in about 80% of chromosomes So it's not really a deletion in Caucasians. It was a duplication that occurred Okay, and it's the subtle differences the other big gene chromosome 10 But between these two genes you can account for about 90 to 95 percent of all risk for this disease Okay, and the other 5% we've we've done some interesting things recently Dug in to all the Moran patients that were identified as being AMD that carried no risk at either one of these and there were like 121 of those patients over the last 10 years and they all almost across the board were Pseudosanthoma or stargarts or other diseases that have just been called macular degeneration Whether these minor genes actually play a role is questionable, but C3 is the next most prominent prominently associated snip in C3 You can take home as I get C3 risk patients that carry no risk at 1 or 10. They're very rare They have no AMD so by itself C3 is not causing the disease on top of 1 and 10. Perhaps it is We also have been thinking a lot about you know every Patient you see for the most part is carrying risk alleles of these genes in the background And so we've started looking at that in some of the other macular Dystrophies if you're homozygous risk at 10 and 1 and you have an RP or an RP gene Does it exacerbate the disease and the answer looks like yes, so so even monogenic disorders are going to be Modified by these two genes in the background, and I think that's a really important story You know it I've as I've traveled around and we I love these experiments of nature I've been very struck by two things first of all We don't have any evidence in the lab or really clinically that Suggest that chromosome 1 and 10 are interacting in the same pathway. Okay, and that's bug me But the more I thought about it. We started becoming very interested Just before I came here in the concept of what is chromosome 1 doing all by itself? And what is chromosome 10 doing all by itself? And I was struck when I started thinking that way if if you go to Africa You see a lot of patients with drusen not a lot, but most of the AMD patients have drusen, but they almost never go to CNV or GA and They are totally chromosome 1 they have no chromosome 10 risk in that population If you go to Asia you see quite the opposite you see very few Asians with with drusen You see a lot of spontaneous CNV formation in Asians, and that's true in all of Asian That really an Asian genetics are all pushing towards 10. Okay, so it really suggests that 1 and 10 are doing very different things And I've never had as much fun as I've had the last five or six years here when Essentially what we've done is taken all of our patients, and we have about 50,000 patients that we have access to all of our patients that carry risk homozygous risk at chromosome 1 or homozygous protection, and I'm not going to talk about that With no background risk intent Okay, and the opposite all of our patients that are risk at 10 with no background risk at 1 and I don't care what we look at I don't care whether it's clinical features or histologic features or gene expression in the eye or gene expression in the peripheral blood Or blood cell composition or co-segregating diseases 1 and 10 are driving very different biologies Okay, so AMD is not AMD Means a lot of your patients have risk at 1 and 10 and that's going to be a real issue But I think a lot of these complement trials are failing simply because They're treating the complement piece of the disease, but they've got half the patients have chromosome 10 in the background So Novartis failed a huge C5 antibody trial Because they didn't do the trial the right way. So one thing we're doing here at the Moran is making sure That we have populations of one pure one patients and pure 10 patients So when the day comes that we can treat and that probably will be later this year We'll put the right drug in the right patients And I think that's that's really what what the data are teaching us, but I'll show you some examples This is a classic chromosome 1 patient lots of your typical a reds grade 3 drusen And we've actually quantified that and I can share those numbers with you in a minute Compared to the chromosome 10 patients These are your patients that walk in with the C and V or GA that you never saw any drusen it Chromosome 10 patients have I shouldn't say they don't want you to take them They don't have any because even in this guy you can see some little white spots here But the drusen in the 10s if they exist are these hard cuticular like drusen. They never change in size They never change in volume You also notice the chromosome 10s very often have a hypertensive retinal vasculature very often have these these big nerve heads and We've been chasing these big nerve heads for a long time because they associate with abdominal aortic aneurysms in our hands And now that we've started looking Aortic aneurysms segregate with chromosome 10 so so these genes are causing a lot of Issues Randy Olson is so fascinated in his Wednesday clinics He probably sends me the highest number of patients in the Moran But he looks at these patients and he's actually sent them off to vascular for for ultrasounds and low and behold a lot of them with aortic aneurysm So these are all chromosome one patients Fascinating but mostly these big giant fluid filled soft drusen that come and go and Form big PEDs and in the likes and so we've we've learned a lot We've just finished quantifying a lot of these data and it's absolutely true that drusen volume is Much much greater in the chromosome ones, but more importantly in that These are pigment epithelial Detachments for the most part so whether you want to call them soft drusen or not most of them are these big pigment epithelial detachments and Histologically here's a donor that had you know an arads grade 3 macula and you can see histologically that what's really happening is The RPE is detaching from Brooks memory and so for years We take these trefine punches in these donor eyes and we've always had a subset where the punch falls off of the retina or off of the Coroid and Has fascinated me and it turns out these are the chromosome one patients So I think at the end of the day These patients have very very weak adhesion to the underlying Brooks membrane and We're doing a lot of gene expression work. We just finished an experiment with allergen Took us three years. We have gene expression on about 800 donors four regions of every eye and The data that are coming out of that study, which was about a 20 million dollar study are massive and a lot of Adhesion issues going on here Chromosome 10s they all look like this. Yes. Here's one of these little tiny blips that you might call a drusen But they just don't have The big soft pigment epithelial detachments that the chromosome ones what you will notice and I think if you have Trained eyes here. You'll take look at these retinas across the board and you go they look kind of thin And they really do I've been struck by it the foveal structures a little bit different than the ones But again if you see it takes sitting down We have an international consortium gene to one I don't know if you guys know gene a very famous retina guy He's the guy that invented retinal translocation with Machomer years ago Gene so fascinating by this he's creating this this huge international consortium I'd I'd invite all of you to become part of that if you're interested I'm not Lohenstein Andy Shackett You know cast of millions that are going to come out here and really work with me to quantify all of this So it turns out the chromosome ones these big softers and they occur in about 60 percent of our chromosome one patients so it's not a hundred percent it's about 60 and Nine-tenths of those patients go on to geographic atrophy So geographic atrophy is much more common in chromosome one patients than it is in chromosome 10 patients Here's a retina from a 10. I think you don't this is actually a 50 year old you don't really have to Think much other than that retina looks terrible And they really do they're just in we're trying to quality quantify all the histology But this is a piece of data that just came out It turns out the orange or the pure chromosome ones This is retinal thickness in in each sector of the ETDRS Chart but the tens are much thinner and it's a very It's about a 25 to 50 micron difference across the back of the eye So the retinas are just thinner if you're a 10 and you smoke in dark blue here The retinas are incredibly thin not so much in the chromosome one smokers So something's really going on in the tens that smoking is exacerbating and causing those retinas to become even thinner Fluid distribution in the ones in tens is dramatically different So in the ones the most of the fluid this is all work that Bryce Did when he was here a couple years ago, and we've we've really kept it going the chromosome one patients mostly sub retinal distribution of Fluid and the chromosome 10s characterized by intra retinal accumulation of fluids very much like CME and And it we can't prove it yet, but it looks like most of the tens are wrapped lesions And so we're working hard now to to really show that these are mostly wrapped lesions in the chromosome 10 so again C and V is not C and V and You know if 10 is driving wrapped lesions and one is driving Coroidal neo vascular lesions that will turn out to be a very interesting story And we do see huge differences between just classic versus occult characterization in the ones And 10s very different distribution of classic versus occult the ones are mostly occult The tens are far too much graded as classics and that probably is because a lot of these are wrapped lesions I Won't get into it But the I hate to say the response to anti-veg yet, but it's the best term I can come up with is very different in the ones and 10s the 10s Typically go to atrophy within the average of six injections, but I don't think it's the anti-veg yet That's driving that I think the retinas are so so bad off at that point compared to the ones That they're just going to go to atrophy anyway Lots and lots of differences between one and ten this this gene expression study is just Really the most nine billion lines of data in that study and it's it's really teaching us a huge amount about the biology in the back of The eye But I thought I'd end you know If you go back to the histology that we've talked about the last two lectures Again, we've always looked for kind of you know phenotype Histological correlations, but when you look at the pure ones and 10s in these large numbers of eyes It turns out in chromosome one risk, of course It's driving these macular drusen that and that association comes out histologically as well Very much associated with thickened Brooks membrane and these very unique RPE spherules which we think are probably the first signs of complement Mac insertion into the RPE and the RPE is doing what cells try to do when they get Mac inserted They're trying to get rid of that basal surface of Mac and I think that's probably what these spherules are chromosome 10 Absolutely associated with basal laminar deposits. Okay, and that's that's so important because We know a lot historically about basal laminar deposit But it's definitely this is basal laminar deposit and it's definitely a chromosome 10 driven Loss of coriocapularis is 10. I don't know if it's a loss or they just start out with less vascular volume So we're working with Carl Chalky right now bringing in a whole bunch of one in 10 patients using the OCT angiography To look and see if there's a difference between Ones and 10s and I'm guessing there will be and 10 is also driving this massive Coroidal fibrosis Again, you can see Here's a chromosome 10 donor Huge vascular problems in the tens both in the retina and and in the coroid these huge vascular cuffing and Very small diameter arterials in this case compared to the chromosome one patients But I think most striking is this just massive deposition of Fibrotic materials in the coroidal stroma all of this material is not supposed to be there all these dark spots are this new Elastin that's being synthesized In the coroid, but it just doesn't know where to put it and I think probably that is leading This is a chromosome one patient It's leading to this massive fibrotic response and probably responsible for thinning of the coroid That's much more prominent in the tens than it is in the ones. So I'm going to stop there Got two minutes. That's not bad