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Cytokines and Pathogenesis of Central Retinal Vein Occlusion Journal of Clinical Medicine Review Cytokines and Pathogenesis of Central Retinal Vein Occlusion Hidetaka Noma *, Kanako Yasuda and Masahiko Shimura Department of Ophthalmology, Hachioji Medical Center, Tokyo Medical University, 1163, Tatemachi, Hachioji, Tokyo 193-0998, Japan; [email protected] (K.Y.); [email protected] (M.S.) * Correspondence: [email protected]; Tel.: +81-42-665-5611; Fax: +81-42-665-1796 Received: 10 September 2020; Accepted: 26 October 2020; Published: 27 October 2020 Abstract: Central retinal vein occlusion (CRVO) causes macular edema and subsequent vision loss and is common in people with diseases such as arteriosclerosis and hypertension. Various treatments for CRVO-associated macular edema have been trialed, including laser photocoagulation, with unsatisfactory results. However, when the important pathogenic role of vascular endothelial growth factor (VEGF) in macular edema was identified, the treatment of CRVO was revolutionized by anti-VEGF therapy. However, despite the success of intraocular injection of anti-VEGF agents in many patients with CRVO, some patients continue to suffer from refractory or recurring edema. In addition, the expression of inflammatory cytokines increases over time, causing more severe inflammation and a condition that is increasingly resistant to anti-VEGF therapy. This indicates that the pathogenesis of macular edema in CRVO is more complex than originally thought and may involve factors or cytokines associated with inflammation and ischemia other than VEGF. CRVO is also associated with leukocyte abnormalities and a gradual reduction in retinal blood flow velocity, which increase the likelihood of it developing from the nonischemic type into the more severe ischemic type; in turn, this results in excessive VEGF expression and subsequent neovascular glaucoma. Here, we review the role of different factors and cytokines involved in CRVO pathogenesis and propose a mechanism that holds promise for the development of novel therapies. Keywords: cytokines; central retinal vein occlusion; macular edema; neovascularization 1. Introduction Central retinal vein occlusion (CRVO) can result in vision loss, the main cause of which is macular edema. Several therapeutic approaches, including retinal photocoagulation, were trialed with little success [1] but once vascular endothelial growth factor (VEGF) was recognized as playing a central role in CRVO-associated macular edema, treatment of the condition was revolutionized by anti-VEGF agents that could be injected into the eye [2]. However, macular edema is recurrent or resistant to anti-VEGF therapy in some patients, suggesting that other factors are involved in its pathogenesis. In addition, diseases such as type 2 diabetes, hyperlipidemia, and hypertension, which are increasing in prevalence due to a rise in unhealthy eating habits and an aging population, are among the significant risk factors for CRVO. This development highlights the need to better understand the pathogenesis of CRVO and to identify novel therapeutic approaches. To this end, we review the pathogenesis of CRVO, exploring the roles of VEGF and other factors. 2. Pathogenesis of CRVO We previously reviewed the pathogenesis of branch retinal vein occlusion (BRVO) [3], but the pathogenesis of CRVO is different from that of BRVO [4]. J. Clin. Med. 2020, 9, 3457; doi:10.3390/jcm9113457 www.mdpi.com/journal/jcm J. Clin. Med. 2020, 9, x 2 of 16 Like BRVO, CRVO can be nonischemic or ischemic, depending on the degree of retinal hypoxia (Figure 1a,b) [4]. CRVO occurs mainly in older people when the central retinal vein is compressed by an arteriosclerotic central retinal artery in the vicinity of the lamina cribrosa, resulting in venous thrombosis [5]. Bleeding in the nerve fiber layer in CRVO causes radial brush-shaped splinter hemorrhages. Cystoid spaces are formed as blood components leak into the retina and accumulate in the outer plexiform layer and internal granular layer. However, CRVO may also occur in younger people without any comorbidity; the pathogenesis of these cases is unclear, but case reports and series have proposed inflammation, exercise and dehydration, and congenital anomalies as potential explanations [6–8]. The macula of the retina gives us detailed vision. The small pit in its center, the fovea, which consists entirely of cones, is responsible for the sharpest visual acuity [9]. CRVO-related macular J. Clin.edema Med. 2020 is thought, 9, 3457 to be caused by the blood–retinal barrier (BRB) breaking down. Other aspects are2 of 16 involved in macula edema, such as hydrostatic and osmotic pressure, which also lead to fluid accumulation and tissue swelling [10]. The cause of this is damage to the tight junctions between Like BRVO, CRVO can be nonischemic or ischemic, depending on the degree of retinal hypoxia capillary endothelial cells [11], coupled with vitreomacular traction and adhesion [12]. This (Figure1a,b) [ 4]. CRVO occurs mainly in older people when the central retinal vein is compressed breakdown of the BRB results in vasopermeability factors, including VEGF, leaking into the vitreous by anfluid arteriosclerotic [13]. central retinal artery in the vicinity of the lamina cribrosa, resulting in venous thrombosisProgression [5]. Bleeding of ischemia in thein CRVO nerve can fiber result layer in neovascular in CRVO causes glaucoma, radial an aggressive brush-shaped condition splinter hemorrhages.that causes Cystoidrapid vision spaces loss are and formed has a poor as blood prognosis. components Both BRVO leak intoand theCRVO retina can andcause accumulate vitreous in the outerhemorrhage plexiform and rubeotic layer and glaucoma: internal these granular sequelae layer. are However, more common CRVO in may CRVO also and occur can inlead younger to peopleblindness without [4], anybut comorbidity;they may also theoccur pathogenesis in BRVO, depending of these on cases the isarea unclear, and severity but case of ischemia. reports and seriesNevertheless, have proposed generally, inflammation, CRVO has exercise a worse and outc dehydration,ome than andBRVO congenital [14]. Therefore, anomalies CRVO as potentialis a explanationspotentially [ 6serious–8]. retinal disease that can lead to severe visual impairment. FigureFigure 1. Images 1. Images of central of central retinal retinal vein occlusion vein occlusion (CRVO). (CRVO). (a) Color (a) fundus Color photographfundus photograph of nonischemic of CRVO.nonischemic (b) Fluorescein CRVO. (b angiogram) Fluorescein showing angiogram ischemic showing CRVO. ischemic (c )CRVO. Mild ( retinalc) Mild hypoxiaretinal hypoxia in a case in of nonischemica case of nonischemic CRVO. (d) SevereCRVO. retinal(d) Severe hypoxia retinal in hypoxia a case ofin a ischemic case of ischemic CRVO. (CRVO.e,f) Optical (e,f) Optical coherence tomography images of macular edema and serous retinal detachment in (e) a case of nonischemic CRVO (in which they can occur even if retinal hypoxia is mild) and (f) a case of ischemic CRVO (in which they are common). The macula of the retina gives us detailed vision. The small pit in its center, the fovea, which consists entirely of cones, is responsible for the sharpest visual acuity [9]. CRVO-related macular edema is thought to be caused by the blood–retinal barrier (BRB) breaking down. Other aspects are involved in macula edema, such as hydrostatic and osmotic pressure, which also lead to fluid accumulation and tissue swelling [10]. The cause of this is damage to the tight junctions between capillary endothelial cells [11], coupled with vitreomacular traction and adhesion [12]. This breakdown of the BRB results in vasopermeability factors, including VEGF, leaking into the vitreous fluid [13]. Progression of ischemia in CRVO can result in neovascular glaucoma, an aggressive condition that causes rapid vision loss and has a poor prognosis. Both BRVO and CRVO can cause vitreous hemorrhage and rubeotic glaucoma: these sequelae are more common in CRVO and can lead to blindness [4], but they may also occur in BRVO, depending on the area and severity of ischemia. J. Clin. Med. 2020, 9, x 3 of 16 coherence tomography images of macular edema and serous retinal detachment in (e) a case of J. Clin. Med. 2020, 9, 3457 3 of 16 nonischemic CRVO (in which they can occur even if retinal hypoxia is mild) and (f) a case of ischemic CRVO (in which they are common). Nevertheless, generally, CRVO has a worse outcome than BRVO [14]. Therefore, CRVO is a potentially 3. VEGF and Macular Edema serious retinal disease that can lead to severe visual impairment. Retinal pigment epithelial cells, retinal glial cells, and vascular endothelial cells all express VEGF 3. VEGF[15]. Upregulation and Macular of Edema VEGF expression is induced by hypoxia and results in increased endothelial cell proliferation, vascular permeability, and angiogenesis [16]; it causes angiogenesis by facilitating Retinal pigment epithelial cells, retinal glial cells, and vascular endothelial cells all express the rearrangement of actin filaments in the cytoplasm. VEGF also increases the phosphorylation of VEGFtight [15 junction]. Upregulation proteins, ofincluding VEGF expression zonula occludens-1 is induced and by occludin hypoxia [17]. and results in increased endothelial cell proliferation,Evidence that vascular VEGF permeability,is involved in CRVO-related and angiogenesis macular [16 edema]; it causes came angiogenesis from our previous by facilitating study the rearrangementof vitreous fluid ofsamples actin filamentstaken during in thevitreous
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