Tumors need the development of new vessels from the pre-existing vasculature to bring nutrients and oxygen to the whole tumor mass. The tumor vascular network is known to be poorly functional due to architectural and functional abnormalities. The end result is an inadequate and heterogeneous tumor perfusion leading to the development of tumor hypoxia. From a therapeutic perspective, hypoxia is a source of radioresistance and the dysfunctional perfusion hampers drug delivery. Historically, tumor hypoxia refers to chronic hypoxia (or diffusion-limited hypoxia) that results from the increasing distance between O2-consuming cells and blood vessels due to the high metabolic rate of tumor cells. Many studies have demonstrated the impact of chronic hypoxia on the clonal selection of tumor cells resistant to conventional anti-cancer therapies. Growing evidence for the existence of another form of hypoxia caused by heterogeneities in tumor perfusion, namely acute or perfusion-limited hypoxia, plead however for a non-genetic source of phenotype conversion reaching not only tumor cells but also the tumor vasculature and in particular endothelial cells. In the cardiovascular field, the cyclic exposure to different pO2 levels is known to precondition cardiac myocytes to resist more prolonged ischemic insults. We hypothesized that this concept of myocardium preconditionning to promote the resistance vs pro-apoptotic stresses could be translated in tumors. Indeed, intermittent hypoxia in tumors is nothing else than cyclic changes in pO2 and radio- and chemotherapy can be viewed as pro-apoptotic stresses that the tumor can face. In particular, in the case of the tumor vasculature, the resistance could be a capacity to re-initiate angiogenesis after treatment. Radioresistance would be further potentiated since low pO2 is per se associated to reversibility of the damages. Also, since intermittent hypoxia is thought to be due in part to fluctuations in tumor blood flow (TBF), access of chemotherapy to the tumor could also further participate to chemoresistance. To address the above hypotheses, we first aimed to explore the extent and the origin of TBF fluctuations in tumor mouse models and to determine whether therapeutic modulation of such potential TBF heterogeneities could improve the efficacy of chemotherapy. We then more directly examined whether and how intermittent hypoxia could influence endothelial cell survival and modulate resistance to radiotherapy. We also took advantage of this study to dissect the molecular mechanisms driving the phenotype conversion of endothelial cells exposed to intermittent hypoxia. Finally, because VEGF plays a major role in hypoxia-mediated angiogenesis but also regulates major pro-survival pathways in endothelial cells, we evaluated the potential role of caveolin as a new therapeutic target to tackle EC resistance. Caveolin is, indeed, a key structural protein recently documented to interact with many downstream targets of VEGF. 1. To explore the extent and the origin of TBF fluctuations in tumor mouse models and to determine whether therapeutic modulation of such potential TBF heterogeneities could improve chemotherapy. We focused this part of the work on the vascular tone modulator endothelin-1. Indeed, this peptide is over-expressed in many mouse and human tumors where it is documented to act as a mitogenic factor in both para- and autocrine manners. Endothelin-1 is also a potent vasoconstrictor acting through the ETA receptors located on VSMCs. In our lab, we previously showed that over-expression of endothelin-1 in tumors accounted for the development of a myogenic tone within the tumor vasculature. We have now documented that an ETA receptor antagonist induces the relaxation of microdissected tumor arterioles and selectively and quantitatively increases tumor blood flow in experimental tumor models. We also combined dye staining of functional vessels, fluorescent microsphere-based mapping, and magnetic resonance imaging to identify heterogeneities in tumor blood flow and to examine the reversibility of such phenomena. We showed that administration of an ETA receptor antagonist reduces the extent of underperfused tumor areas, proving the key role of vessel tone variations in tumor blood flow heterogeneity. We also provided evidence that ETA antagonist could improve the access of cyclophosphamide to the tumor compartment and thereby induces a significant tumor growth delay. 2. To examine whether and how intermittent hypoxia could influence endothelial cell survival and modulate resistance to radiotherapy. To dissect the mechanisms driving the phenotype conversion of endothelial cells exposed to intermittent hypoxia. This second part of our work, is a comprehensive investigation of the consequences of intermittent hypoxia, as caused by TBF heterogeneities, on the endothelial cell phenotype. First, we postulated that intermittent hypoxia (IH) favors endothelial cell (EC) survival, thereby extending the concept of hypoxia-driven resistance to the tumor vasculature. We showed that exposing EC to cycles of hypoxia/re-oxygenation reduces radiation-induced cell death and promotes angiogenesis. In contrast, prolonged hypoxia failed to achieve such protection and even appeared deleterious. We also observed that although HIF-1£ is completely degraded during each re-oxygenation, its abundance is paradoxically found higher at each new hypoxic challenge. Moreover, the use of siRNA targeting HIF-1£ pointed out that HIF-1ƓÑ accumulation account for the increased resistance of EC to radiotherapy. Finally, we extended this concept in vivo by forcing IH in tumor-bearing mice and found that it is associated with less radiation-induced apoptosis within both the vascular and the tumor cell compartments (vs normoxia or prolonged hypoxia). Next, we focused our work on the underlying mechanisms of EC phenotype conversion exposed to IH and particularly on potential actors that may favor HIF-1£ accumulation during IH. Prolylhydroxylases (PHD), MAPK and PI3K/Akt pathways as well as eNOS are known to regulate HIF-1£ abundance and transcriptional activity. We documented that PHD2 and PHD3 abundance are slightly decreased during IH, whereas prolonged hypoxia increases PHD3 expression in EC. We then showed that, ERK, Akt as well as eNOS were phosphorylated during reoxygenation periods of the IH protocol. We also used specific inhibitors of these cascades (i.e. PD98059, LY294002 and L-NAME, respectively), to evaluate their specific impact on HIF-1£ abundance and performed clonogenic assays to evaluate their consequences on EC survival. We showed that although, PD98059 and LY294002 sensitizes EC to pro-apoptotic stresses, only the PI3K/Akt inhibitor abrogates the HIF-1£ signal during IH. Conversely, L-NAME, a non-specific NOS-inhibitor, appears to potentiate the expression of HIF-1£ and to favor the EC survival. 3. To identify new therapeutic targets to prevent endothelial cell resistance by studying VEGF signaling, the major pro-survival and pro-angiogenic growth factor in endothelial cells. Because VEGF plays a central role in hypoxia-mediated angiogenesis and cell survival, the VEGF signaling cascade is a an obvious therapeutic target. To more specifically identify the pathways leading to cell survival and the resistance phenomena that we observed in response to intermittent hypoxia, a careful dissection of the downstream VEGF signaling cascades was performed. In this part of the work, we focused our attention on caveolin since it modulates the activity of eNOS, ERK and Akt that are major effectors acting downstream VEGF stimulation. We demonstrated the paradoxical role of caveolin-1 preventing signaling in basal conditions and ensuring the coupling between VEGFR2 and the downstream cascades upon VEGF stimulation. We used mice deficient for the caveolin-1 gene (Cav-/-) to examine the impact of caveolae suppression in a model of adaptive angiogenesis obtained after femoral artery resection. Evaluation of the ischemic tissue perfusion and histochemical analyses revealed that contrary to Cav+/+ mice, Cav-/- mice fails to recover a functional vasculature and actually loose part of the ligated limbs. We also isolated endothelial cells (ECs) from Cav-/- aorta and showed that on VEGF stimulation, endothelial tube formation is dramatically abrogated when compared with Cav +/+ ECs. The Ser1177 eNOS phosphorylation and Thr495 dephosphorylation but also the ERK phosphorylation were similarly altered in VEGF-treated Cav-/- ECs. Interestingly, caveolin transfection in Cav-/- ECs redirected the VEGFR-2 in caveolar membranes and restored the VEGF-induced ERK and eNOS activation. However, when high levels of recombinant caveolin are reached, VEGF exposure fails to activate ERK and eNOS. Altogether, these data identify caveolin as a new therapeutic target to alter VEGF signaling, in particular the cascades leading to angiogenesis and resistance to stresses.

Positron Emission Tomography, PET, is a noninvasive medical imaging technique to get functional information of the kinetics of radioactive compound injected in the body. The data used in this thesis comes from a total of five H215O PET studies of one patient. This was done in order to study the blood flow in liver metastasis of the patient, before and after treatment. A one compartment model was used to do the ROI based analyses. With a least square method in Matlab the unknown parameters in the model, such as the kinetic rate constants, the dispersion and the fraction of blood in the tissue, was extracted. Also a brief analysis of different parts of the metastases, edge and center, was done to see the variations within the metastases. The results show some increase of the blood flow after the treatment, and two of the three studied metastases showed a distinct difference of the activity in the center versus the edge. Given in the thesis are also some basic PET and compartmental modeling theory. / Positronemissionstomografi, PET, är en icke-invasiv medicinsk bildteknik för att få funktionell information om kinetiken av radioaktiva föreningar injicerade i kroppen. Det data som används i denna kandidatuppsats kommer från totalt fem H215O PET-studier av en patient. Detta gjordes för att studera blodflödet i levermetastaser hos patienten före och efter behandling. En 1-kompartmentmodell användes för att göra ROI-baserade analyser. Med en minsta kvadrat-metod i Matlab kunde de okända parametrarna i modellen, såsom den kinetiska hastighetskonstanten, spridningen och andelen blod i vävnaden, fås ut. En kort analys gjordes också av olika delar av metastaserna, kanten och mitten, för att se variationerna inuti metastaserna. Resultaten visar en viss ökning av blodflödet efter behandlingen, och två av de tre studerade metastaser visade en tydlig skillnad av aktiviteten i mitten jämfört med kanten. I rapporten ges också grundläggande teori om bland annat PET och kompartmentmodellering.

The current thesis examined whether sex-differences in local and whole-body heat loss are evident after accounting for confounding differences in physical characteristics and rate of metabolic heat production. Three experimental studies were performed: the first examined whole-body heat loss in males and females matched for body mass and surface area during exercise at a fixed rate of metabolic heat production; the second examined local and whole-body heat loss responses between sexes during exercise at increasing requirements for heat loss; the third examined sex-differences in local sweating and cutaneous vasodilation to given doses of pharmacological agonists, as well as during passive heating. The first study demonstrates that females exhibit a lower whole-body sudomotor thermosensitivity (553 ± 77 vs. 795 ± 85 W•°C-1, p=0.05) during exercise performed at a fixed rate of metabolic heat production. The second study shows that whole-body sudomotor thermosensitivity is similar between sexes at a requirement for heat loss of 250 W•m-2 (496 ± 139 vs. 483 ± 185 W•m-2•°C-1, p=0.91) and 300 W•m-2 (283 ± 70 vs. 211 ± 66 W•m-2•°C-1, p=0.17), only becoming greater in males at a requirement for heat loss of 350 W•m-2 (197 ± 61 vs. 82 ± 27 W•m-2•°C-1, p=0.007). In the third study, a lower sweat rate to the highest concentration of acetylcholine (0.27 ± 0.08 vs. 0.48 ± 0.13 mg•min-1•cm-2, p=0.02) and methylcholine (0.41 ± 0.09 vs. 0.57 ± 0.11 mg•min-1•cm-2, p=0.04) employed was evidenced in females, with no differences in cholinergic sensitivity. Taken together, the results of the current thesis show that sex itself can modulate sudomotor activity, specifically the thermosensitivity of the response, during both exercise and passive heat stress. Furthermore, the results of the third study point towards a peripheral modulation of the sweat gland as a mechanism responsible for the lower sudomotor thermosensitivity in females.

Heart diseases are the leading cause of death in developed countries, hence, understanding of the hemodynamics of the heart is critically important to enable methods for cardiovascular diagnosis. Assessment of intracardiac blood pressure is highly interesting as blood flow is driven by the pressure differences. Phase-contrast magnetic resonance imaging (PC-MRI) is a tool for measuring blood flow and has a wide range of cardiovascular applications. Based on previous studies, an approach to estimate the relative pressure fields in the human heart from three-dimensional time-resolved PC-MRI velocity data was implemented and evaluated. The relative pressure fields were obtained by solving the pressure Poisson equation, using a multi-grid approach. The method was evaluated on a numerical phantom and on PC-MRI data from one healthy subject and one patient with dilated cardiomyopathy. The pressure field was visualized in combination with blood flow data and morphological images. Results indicate that the used approach works well for cardiac relative pressure estimation and are in agreement with findings from previous research. The complete spatial and temporal coverage of relative pressure enables a higher understanding of physiology and pathophysiology of the human heart and is expected to give new insights for clinical investigations.

Purpose To investigate the impact of cigarrete smoking in a group of otherwise healthy young individuals on: 1) Retinal blood flow using Doppler based SD-OCT, 2) Retinal vascular reactivity using a gas sequencer to provoke hypercapnia via constant changes in PETCO2 (end-tidal partial pressure of CO2) and in PETO2 (end-tidal partial pressure of O2). Methods An automated gas flow controller was used to achieve normoxic hypercapnia in ten non-smokers (mean age 28.9 yrs, SD 4.58) and nine smokers (mean age 27.55 yrs, SD 4.77). Retinal blood flow measurements were obtained using Doppler OCT and cannon laser blood flowmeter (CLBF) during baseline, normoxic hypercapnia (15% increase in PETCO2 relative to homeostatic baseline) and post-hypercapnia in both the groups. Exhaled carbon monoxide level was measured in all subjects. Results In non-smokers, retinal arteriolar diameter, blood velocity and flow increased by +4.1% (SD 2.8, p<0.0001), +16.7% (SD 14.6, p=0.0004) and +29.6% (SD 12.5, p<0.0001) respectively, during normoxic hypercapnia; Similarly, the venous area, venous velocity and total retinal blood flow increased by 7% (SD 8.6, p=0.0418), 18.1% (SD 20.8, p=0.0068) and 26% (SD 22.9, p<0.0001) respectively. In smokers, normoxic hypercapnia resulted in a significant increase in velocity by 12.0% (SD 6.2, p=0.0019) and flow by 14.6% (SD 9.5, p=0.0029); though arteriolar diameter increased by 1.7% (SD 1.7, p=0.2616), the result was not statistically significant. Total retinal blood flow increased significantly by 19.3% (SD 18.4, p=0.002) in response to normoxic hypercapnia. However, there was no significant difference in venous area (p=0.3322) and venous velocity measurements (p=0.1185) during hypercapnia compared to baseline and recovery. Comparing smokers and non-smokers, only the percentage change in arteriolar diameter (p=0.0379) and flow (p=0.0101) was significantly different among the groups. Group mean PETCO2 was increased by 15.9% in the non-smoking group and by 15.7% in the smoking group, with a concomitant increase in PETO2 by approximately 1.5 to 2% in both groups. There was no significant difference in baseline PETCO2 level between smokers and non-smokers. Conclusions Retinal vascular reactivity in response to normoxic hypercapnia is significantly reduced in young healthy individuals who smoke compared to non-smokers. Further studies are needed to elucidate the exact reason behind the impaired retinal autoregulation to provocative stimuli in smokers.

PURPOSE: Systemic hyperoxia has been induced using inspired gases in many studies to investigate vascular reactivity in the retinal vasculature. Technical limitations in the past resulted in inadequate control of systemic partial pressures of O2 and CO2, the latter of which tended to decrease secondary to induced hyperoxia. Recent development of a computerized gas delivery instrument has enabled the specific control of end-tidal CO2 (ETCO2) and fractional expired O2 (FeO2), independent of each other and of minute ventilation. The specific aims of each chapter are as follows: Chapter 3: To compare the magnitude and variability of the retinal vascular reactivity response to an isocapnic hyperoxic stimulus delivered using a manually-operated method to the newly developed computer-controlled gas sequencer. Chapter 4: To investigate the retinal hemodynamic response to incremental changes in hyperoxic stimuli during isocapnia. METHODS: Chapter 3: Ten young, healthy adults inhaled gases in a sequence of normoxic baseline, isocapnic hyperoxia, and normoxic recovery, using both gas delivery systems in random order. Chapter 4: Twelve healthy, young adults participated in a gas protocol consisting of 4 phases at varying fractional expired oxygen levels (FeO2): baseline (15%), hyperoxia I (40%), hyperoxia II (65%), and recovery (15%). End-tidal carbon dioxide (ETCO2) was maintained at an isocapnic level (~ 5%) throughout the experiment. In both Chapters 3 and 4, blood flow was derived from retinal arteriolar diameter and simultaneous blood velocity measurements of the superior temporal arteriole, acquired at 1-minute intervals during each of the phases of the gas protocol. RESULTS: Chapter 3: There was no interaction effect between the phases and gas delivery methods (p = 0.7718), but ETCO2 was significantly reduced during hyperoxia (p = 0.0002) for both methods. However, the magnitude of change in ETCO2 was physiologically insignificant i.e. <1%. The two systems differed in terms of FeO2 during hyperoxia, at a level of 85.27 ± 0.29% for the manual method, and 69.02 ± 2.84% for the computer method (p < 0.05). Despite this difference in oxygen concentrations, there was no difference in the vascular reactivity response for diameter (p = 0.7756), velocity (p = 0.1176), and flow (p = 0.1885) for equivalent gas phases between the two gas delivery systems. The inter-subject variability of retinal hemodynamic parameters was consistently lower using the computer-controlled gas sequencer. Chapter 4: Repeated measures ANOVA showed that there were significant influences of incremental changes in FeO2 on arteriolar diameter (p < 0.0001), blood velocity (p < 0.0001), and blood flow (p < 0.0001) in the retina. Paired t-tests of these retinal hemodynamic parameters during each phase in the gas sequence showed they were significantly different (p < 0.05) from each other, with the exception of baseline and recovery values. Incremental increases in FeO2 caused a linear decrease in group mean arteriolar diameter (R2 = 1, p = 0.002), group mean blood velocity (R2 = 0.9968, p = 0.04), and group mean blood flow (R2 = 0.9982, p= 0.03). CONCLUSIONS: Chapter 3: Inter-subject variability for virtually all retinal hemodynamic parameters was reduced using the computer-controlled method, presumably due to a higher degree of gas control. However, care needs to be exercised in the interprtetation of these results due to the relatively small sample size. A similar retinal hemodynamic response to isocapnic hyperoxia was induced using the two gas delivery systems, despite different levels of maximal FeO2. Chapter 4: Isocapnic hyperoxia elicits vasoconstriction and the reduction of retinal arteriolar blood flow in a dose-dependent manner over the range of FeO2 explored in this study.

The global aim of this thesis was to assess retinal vascular reactivity in glaucoma patients using a standardised hypercapnic stimulus. There is a suggestion of disturbance in the regulation of retinal and optic nerve head (ONH) hemodynamics in patients with Primary Open Angle Glaucoma (POAG), although much of the work to-date has either been equivocal or speculative. Previous studies have used non-standardised hypercapnic stimuli to assess vascular reactivity. To explain, hypercapnia induces hyperventilation which disturbs arterial oxygen concentration, an effect that varies between individuals resulting in the non-standardised provocation of vascular reactivity. Therefore, a normoxic hypercapnic provocation was developed to avoid additional and potentially uncontrolled vasoconstriction in what is thought to be a vasospastic disease. The development of a safe, sustained and stable normoxic hypercapnic stimulus was essential for the assessment of retinal arteriolar vascular reactivity so that repeated hemodynamic measurements could be obtained. Furthermore, most techniques used to measure vascular reactivity do not comprehensively assess retinal hemodynamics, in terms of the simultaneous measurement of vessel diameter and blood velocity in order to calculate flow. In this respect, this study utilized a technique that quantitatively assesses retinal blood flow and vascular reactivity of the major arterioles in close proximity to the ONH. The stimulus and vascular reactivity quantification technique was validated in healthy controls and then was clinically applied in patients with POAG. Newly diagnosed patients with untreated POAG (uPOAG) were recruited in order to avoid any confounding pharmacological effects and patients with progressive POAG (pPOAG) were also selected since they are thought to likely manifest vascular dysregulation. Finally, the results of the functional vascular reactivity assessment were compared to those of systemic biochemical markers of endothelial function in patients with untreated and progressive POAG and in healthy controls. Overall summary A safe, sustained, stable and repeatable normoxic hypercapnic stimulus was developed, evaluated and validated. In terms of the physiology of retinal vascular regulation, the percent magnitude of vascular reactivity of the arterioles and capillaries was found to be comparable in terms of flow. The new stimulus was successfully applied in POAG and in healthy controls to assess vascular reactivity and was also compared to plasma levels of ET-1 and cGMP. In terms of the patho-physiology of POAG, the study revealed a clear impairment of vascular reactivity in the uPOAG and pPOAG groups. There were reduced levels of plasma ET-1 in the uPOAG and ntPOAG groups. In addition, treatment with Dorzolamide improved vascular reactivity in the ntPOAG group in the absence of any change in the expression of plasma ET-1 or cGMP. Future work will address this apparent contradiction between the outcome of the functional vascular reactivity assessment and the biochemical markers of endothelial function in newly diagnosed POAG patients treated with Dorzolamide. Aims of chapters  Chapter 3: To determine the effect of hypercapnia on retinal capillary blood flow in the macula and ONH using scanning laser Doppler flowmetry (SLDF) in young healthy subjects.  Chapter 4: To describe a new manual methodology that permits the comprehensive assessment of retinal arteriolar vascular reactivity in response to a sustained and stable hypercapnic stimulus. The secondary aim was to determine the magnitude of the vascular reactivity response of the retinal arterioles to hypercapnic provocation in young healthy subjects.  Chapter 5: To compare the magnitude of vascular reactivity of the retinal arterioles in terms of percentage change of flow to that of the retinal capillaries using a novel automated standardized methodology to provoke normoxic, or isoxic, hypercapnia.  Chapter 6: To determine the magnitude of retinal arteriolar vascular reactivity to normoxic hypercapnia in patients with untreated POAG (uPOAG), progressive POAG (pPOAG) and controls. The secondary aim was to determine retinal vascular reactivity in newly treated POAG (ntPOAG, i.e. after treatment with 2% Dorzolamide, twice daily for 2 weeks).  Chapter 7: To compare plasma endothelin-1 (ET-1) and cyclic guanosine monophosphate (cGMP) between groups of patients with untreated primary open angle glaucoma (uPOAG), progressive POAG (pPOAG), newly treated POAG (ntPOAG) and controls. The effect of normoxic hypercapnia on plasma ET-1 and cGMP was also assessed. The functional measures of retinal blood flow and vascular reactivity were correlated with systemic biochemical markers of endothelial function. Methods Chapters 3, 4 and 5 were conducted on young healthy control subjects, where as Chapters 6 and 7 were conducted on patients with glaucoma and healthy controls.  Chapter 3: Subjects breathed unrestricted air for 15 minutes (baseline) via a sequential gas delivery circuit and then the fractional (percent) end-tidal concentration of CO2 (FETCO2) was manually raised for 15 minutes by adding a low flow of CO2 to the inspired air. For the last 15 minutes, FETCO2 was returned to baseline values to establish a recovery period. Heidelberg Retina Flowmeter (HRF) images centered on both the ONH and the macula were acquired during each phase.  Chapter 4: Subjects breathed air via a sequential gas delivery circuit for 15 minutes and the air flow was then manually decreased so that subjects inspired gases from the rebreathing reservoir until a stable 10-15% increase in FETCO2 concentration was achieved for 20 minutes. Air flow rate was then manually elevated so that subjects breathed primarily from the fresh gas reservoir to return FETCO2 back to baseline for the last 15 minutes. Retinal arteriolar hemodynamics was assessed using the Canon Laser Blood Flowmeter (CLBF) during all three breathing phases.  Chapter 5: Normoxic, or isoxic, hypercapnia was induced using an automated gas flow controller (RespirActTM, Thornhill Research Inc. Toronto, Canada). Subjects breathed air with PETCO2 normalized at 38 mmHg. An increase in PETCO2 of 15% above baseline, whilst maintaining normoxia, was then implemented for 20 minutes and then PETCO2 was returned to baseline conditions for 10 minutes. Retinal and ONH hemodynamic measurements were performed using the CLBF and HRF in random order across sessions.  Chapter 6: Retinal arteriolar vascular reactivity was assessed in patients with uPOAG, pPOAG (defined by the occurrence of optic disc hemorrhage within the past 24 months) and controls during normoxic hypercapnia. Using the automated gas flow controller, patients breathed air for 10 mins and PETCO2 was maintained at 38mmHg. Following this normoxic hypercapnia (a 15% increase in PETCO2 while PETO2 was maintained at resting levels) was induced for 15 mins and then for the last 10 mins PETCO2 was returned to baseline (post-hypercapnia) to establish recovery blood flow values. Retinal arteriolar diameter, blood velocity and blood flow was assessed using the CLBF in both patient groups and controls. A similar paradigm was repeated in the newly treated POAG group (ntPOAG, i.e. after treatment with 2% Dorzolamide, twice daily for 2 weeks).  Chapter 7: Blood samples were collected from the cubital vein of all participants (uPOAG, pPOAG, ntPOAG and controls) during baseline conditions (PETCO2=38mmHg) and then during normoxic hypercapnia (i.e. a 15% increase in PETCO2 relative to the baseline) using the paradigm described for Chapter 6. ET-1 and cGMP was assessed using immunoassay. Results  Chapter 3: The group mean nasal macula capillary blood flow increased from 127.17 a.u. (SD 32.59) at baseline to 151.22 a.u. (SD 36.67) during hypercapnia (p=0.028), while foveal blood flow increased from 92.71 a.u. (SD 28.07) to 107.39 a.u. (SD 34.43) (p=0.042). There was a concomitant and uncontrolled +13% increase in the group mean PETO2 during the hypercapnic provocation of +14% increase in PETCO2.  Chapter 4: Retinal arteriolar diameter, blood velocity and blood flow increased by 3.2% (p=0.0045), 26.4% (p<0.0001) and 34.9% (p<0.0001), respectively during hypercapnia. There was a stable ¬+12% increase in PETCO2 during hypercapnia and a concomitant -6% decrease in PETO2.  Chapter 5: Using an automated gas flow controller the co-efficient of repeatability (COR) was 5% of the average PETCO2 at baseline and during normoxic hypercapnia. The COR for PETO2 was 10% and 7% of the average PETO2 at baseline and during normoxic hypercapnia, respectively. Group mean PETCO2 increased by approximately +14.4% and there was only a +4.3% increase in PETO2 during hypercapnia across both study sessions. Retinal arteriolar hemodynamics increased during hypercapnia (p<0.001). Similarly, there was an increase in the capillary blood flow of the temporal rim of the ONH (p<0.001), nasal macula (p<0.001) and foveal areas (p<0.006) during hypercapnia. A non-significant trend for capillary blood flow to increase in the macula temporal area (+8.2%) was noted. In terms of percentage change of blood flow, retinal capillary vascular reactivity (i.e. all 4 analyzed areas = 22.4%) was similar to the magnitude of arteriolar (= 24.9%) vascular reactivity.  Chapter 6: Retinal arteriolar diameter, blood velocity and flow did not increase during normoxic hypercapnia in uPOAG compared to controls. Diameter and blood velocity did not change in pPOAG during normoxic hypercapnia but there was a significant increase in blood flow (+9.1%, p=0.030). After treatment with 2% Dorzolamide for 2 weeks there was a 3% (p=0.040), 19% (p<0.001) and 26% (p<0.001) increase in diameter, velocity and flow, respectively, in the ntPOAG group. Group mean PETCO2 increased by approximately +15% in all the groups and there was only a +3% increase in PETO2 during hypercapnia.  Chapter 7: Plasma ET-1 levels were significantly different across groups at baseline (one way ANOVA; p=0.0012) and this was repeated during normoxic hypercapnia (one way ANOVA; p=0.0014). ET-1 levels were lower in uPOAG compared to pPOAG and controls at baseline and during normoxic hypercapnia (Tukey’s honestly significant difference test). Similarly, ntPOAG group also showed lower ET-1 levels compared to the pPOAG and controls at baseline and during normoxic hypercapnia (Tukey’s honestly significant difference test). The cGMP at baseline and during normoxic hypercapnia across all groups was not different. In the control group, the change in ET-1 during normoxic hypercapnia was negatively correlated with change in retinal arteriolar blood flow (r = -0.52, p=0.04), that is, as the change in ET-1 reduced, the change in blood flow increased. A weak correlation was noted between change in cGMP during normoxic hypercapnia and the change in arteriolar blood flow (r = +0.45, p=0.08). Conclusions  Chapter 3: Hypercapnia resulted in a quantifiable capillary vascular reactivity response in 2 of the 3 assessed retinal locations (i.e., nasal macula and fovea). There was no vascular reactivity response of the ONH. It is critical to minimise the concomitant change in PETO2 during hypercapnia in order to obtain robust vascular reactivity responses.  Chapter 4: A technique to comprehensively assess vascular reactivity during stable and sustained hypercapnia was described. Retinal arteriolar diameter, blood velocity and blood flow increased in response to hypercapnia. The vascular reactivity results of this study served as a reference for future studies using the hypercapnic provocation and CLBF. Also, the concomitant change in PETO2 using the partial rebreathing technique was reduced compared to the manual addition of CO2 technique described in Chapter 3 but was still greater than optimal.  Chapter 5: A new automated gas flow controller was used to induce standardised normoxic, or isoxic, hypercapnia. The magnitude of vascular reactivity in both retinal arterioles and capillaries in response to the new hypercapnic stimulus was robust compared to the previous stimuli. There was a clear ONH vascular reactivity response in this study, unlike the result attained in Chapter 3. Although theoretically it is predictable that the percent magnitude of vascular reactivity of the arterioles and capillaries should be similar, this is the first study to show that they are indeed comparable. The magnitude of hypercapnia was repeatable and the concomitant change in PETO2 was minimal and physiologically insignificant.  Chapter 6: The normal response of the retinal arterioles and capillaries to normoxic hypercapnia is impaired in both uPOAG and pPOAG compared to controls. Short term treatment with 2% topical Dorzolamide for two weeks improved retinal vascular reactivity in ntPOAG. However, it is still unclear whether this improvement is a direct effect of Dorzolamide or as a secondary effect of the decrease in intraocular pressure (IOP).  Chapter 7: We found a reduction in the plasma ET-1 at baseline and during normoxic hypercapnia in the uPOAG and in the ntPOAG groups. This is the first study to show a lower plasma ET-1 level in uPOAG. The fact that this finding was repeated after 2 weeks treatment with Dorzolamide in the ntPOAG group further validates these results. It also suggests that Dorzolamide treatment does not impact ET-1 and cGMP measures, although it clearly results in an improvement of vascular reactivity. Correlation results suggest that as the change in ET-1 reduced during normoxic hypercapnia, the change in blood flow increased in the controls.

Introduction Retinal vascular reactivity is impaired in patients with diabetes and is thought to be involved in the onset and progression of diabetic retinopathy (DR). Previous studies that have utilized hyperoxia to assess retinal vascular reactivity have been limited due to confounding factors associated with the administration of oxygen and have used a variety of different instruments to measure retinal blood flow. The influence of blood glucose at the time of blood flow assessment has also not been systemically investigated. The specific aims of each Chapter are as follows: Chapter 3: To compare three systems used to administer hyperoxia to human subjects. Chapter 4: To quantify the magnitude and timeline of change of retinal hemodynamic parameters induced by an isocapnic hyperoxic stimulus. Chapters 5, 6 and 7: To quantify the magnitude of change of retinal hemodynamic parameters induced by hyperoxia, hyperglycemia and combined hyperoxia / hyperglycemia, respectively, in groups of diabetic patients with no clinically visible, and mild-to-moderate, DR and in age-matched subjects without diabetes. Methods Chapter 3: Subjects breathed air followed by oxygen, or oxygen plus carbon dioxide using a non-rebreathing system, or air followed by oxygen using a sequential rebreathing system. The magnitude of change and variability of CO2 concentrations was compared between systems. Chapter 4: Baseline retinal blood flow data was acquired while the subjects breathed air using a sequential rebreathing system. An isocapnic hyperoxic stimulus was initiated and maintained for 20 minutes. Air was then re-administered for 10 minutes. Retinal blood flow measurements were acquired every minute over the course of the study. The magnitude of change of each hemodynamic parameter was determined by fitting individual data with a sigmoidal function. For Chapter 5, 6 and 7 diabetic patients with no clinically visible, and mild-to-moderate, DR were stratified into groups based upon their retinopathy status. Age-matched non-diabetic subjects were recruited as controls. Baseline retinal blood flow data was acquired while subjects breathed air. Retinal blood flow measurements were then acquired after exposure to (a) hyperoxia, (b) hyperglycemia and (c) combined hyperoxic / hyperglycemic stimuli. Change in hemodynamic parameters was compared between groups and correlated with objective measures of retinal edema. Results Chapter 3: The difference in group mean end-tidal CO2 levels between baseline and hyperoxia was significant for oxygen administration using a non-rebreathing system. The sequential rebreathing technique resulted in a significantly lower variability of individual CO2 levels than either of the other techniques. Chapter 4: An ~11% decrease of diameter, ~36% decrease of velocity and ~48% decrease of blood flow was observed in response to isocapnic hyperoxia in young, healthy subjects. A response time of 2.30±0.53 minutes and 2.62±0.54 minutes was observed for diameter and velocity, respectively. Chapter 5: Retinal blood velocity, flow, and WSR significantly decreased in response to isocapnic hyperoxia in all groups. The magnitude of the reduction of blood flow was significantly reduced with increasing severity of retinopathy. There was a significant relationship between baseline objective edema index values and retinal vascular reactivity. Chapter 6: A significant change in blood glucose level was observed for all groups. No significant change in any hemodynamic parameter was found in patients with diabetes and in age-matched subjects without diabetes. Chapter 7: Retinal blood velocity and flow significantly decreased in all groups in response to combined hyperoxic / hyperglycemic provocation. The vascular reactivity response was not significantly different across the groups. Conclusions Chapter 3: Control of CO2 is necessary to attain standardized, reproducible hyperoxic stimuli for the assessment of retinal vascular reactivity. Chapter 4: Arteriolar retinal vascular reactivity to isocapnic hyperoxic provocation occurs within a maximum of 4 minutes. Although there was a trend for diameter to respond before velocity, the response characteristics were not significantly different between diameter and velocity. Different response characteristics of the retinal vasculature to transmural pressure mediated autoregulation as opposed to metabolic mediated vascular reactivity are suggested. Chapter 5: The vascular reactivity response in terms of the reduction of blood flow relative to baseline was significant in all groups but the magnitude of the change in flow was significantly reduced with increasing severity of retinopathy. A loss of retinal vascular reactivity is indicated in patients with moderate DR without clinically evident diabetic macular edema (DME), and in patients with DME. Chapter 6: Unaltered retinal arteriolar blood flow was found 1 hour after glucose ingestion in patients with diabetes and in age-matched subjects without diabetes. These results do not support the theory that retinal blood flow is affected by an acute increase of blood glucose in diabetic patients and in subjects without diabetes. Chapter 7: The vascular reactivity response to a combined hyperoxic / hyperglycemic provocation produced a pronounced reduction in blood flow. Unlike the response to hyperoxia alone, the vascular reactivity response was not significantly different across the groups. This suggests that hyperglycemia may influence the retinal vascular reactivity response to hyperoxia.

PURPOSE: Systemic hyperoxia has been induced using inspired gases in many studies to investigate vascular reactivity in the retinal vasculature. Technical limitations in the past resulted in inadequate control of systemic partial pressures of O2 and CO2, the latter of which tended to decrease secondary to induced hyperoxia. Recent development of a computerized gas delivery instrument has enabled the specific control of end-tidal CO2 (ETCO2) and fractional expired O2 (FeO2), independent of each other and of minute ventilation. The specific aims of each chapter are as follows: Chapter 3: To compare the magnitude and variability of the retinal vascular reactivity response to an isocapnic hyperoxic stimulus delivered using a manually-operated method to the newly developed computer-controlled gas sequencer. Chapter 4: To investigate the retinal hemodynamic response to incremental changes in hyperoxic stimuli during isocapnia. METHODS: Chapter 3: Ten young, healthy adults inhaled gases in a sequence of normoxic baseline, isocapnic hyperoxia, and normoxic recovery, using both gas delivery systems in random order. Chapter 4: Twelve healthy, young adults participated in a gas protocol consisting of 4 phases at varying fractional expired oxygen levels (FeO2): baseline (15%), hyperoxia I (40%), hyperoxia II (65%), and recovery (15%). End-tidal carbon dioxide (ETCO2) was maintained at an isocapnic level (~ 5%) throughout the experiment. In both Chapters 3 and 4, blood flow was derived from retinal arteriolar diameter and simultaneous blood velocity measurements of the superior temporal arteriole, acquired at 1-minute intervals during each of the phases of the gas protocol. RESULTS: Chapter 3: There was no interaction effect between the phases and gas delivery methods (p = 0.7718), but ETCO2 was significantly reduced during hyperoxia (p = 0.0002) for both methods. However, the magnitude of change in ETCO2 was physiologically insignificant i.e. <1%. The two systems differed in terms of FeO2 during hyperoxia, at a level of 85.27 ± 0.29% for the manual method, and 69.02 ± 2.84% for the computer method (p < 0.05). Despite this difference in oxygen concentrations, there was no difference in the vascular reactivity response for diameter (p = 0.7756), velocity (p = 0.1176), and flow (p = 0.1885) for equivalent gas phases between the two gas delivery systems. The inter-subject variability of retinal hemodynamic parameters was consistently lower using the computer-controlled gas sequencer. Chapter 4: Repeated measures ANOVA showed that there were significant influences of incremental changes in FeO2 on arteriolar diameter (p < 0.0001), blood velocity (p < 0.0001), and blood flow (p < 0.0001) in the retina. Paired t-tests of these retinal hemodynamic parameters during each phase in the gas sequence showed they were significantly different (p < 0.05) from each other, with the exception of baseline and recovery values. Incremental increases in FeO2 caused a linear decrease in group mean arteriolar diameter (R2 = 1, p = 0.002), group mean blood velocity (R2 = 0.9968, p = 0.04), and group mean blood flow (R2 = 0.9982, p= 0.03). CONCLUSIONS: Chapter 3: Inter-subject variability for virtually all retinal hemodynamic parameters was reduced using the computer-controlled method, presumably due to a higher degree of gas control. However, care needs to be exercised in the interprtetation of these results due to the relatively small sample size. A similar retinal hemodynamic response to isocapnic hyperoxia was induced using the two gas delivery systems, despite different levels of maximal FeO2. Chapter 4: Isocapnic hyperoxia elicits vasoconstriction and the reduction of retinal arteriolar blood flow in a dose-dependent manner over the range of FeO2 explored in this study.

The global aim of this thesis was to assess retinal vascular reactivity in glaucoma patients using a standardised hypercapnic stimulus. There is a suggestion of disturbance in the regulation of retinal and optic nerve head (ONH) hemodynamics in patients with Primary Open Angle Glaucoma (POAG), although much of the work to-date has either been equivocal or speculative. Previous studies have used non-standardised hypercapnic stimuli to assess vascular reactivity. To explain, hypercapnia induces hyperventilation which disturbs arterial oxygen concentration, an effect that varies between individuals resulting in the non-standardised provocation of vascular reactivity. Therefore, a normoxic hypercapnic provocation was developed to avoid additional and potentially uncontrolled vasoconstriction in what is thought to be a vasospastic disease. The development of a safe, sustained and stable normoxic hypercapnic stimulus was essential for the assessment of retinal arteriolar vascular reactivity so that repeated hemodynamic measurements could be obtained. Furthermore, most techniques used to measure vascular reactivity do not comprehensively assess retinal hemodynamics, in terms of the simultaneous measurement of vessel diameter and blood velocity in order to calculate flow. In this respect, this study utilized a technique that quantitatively assesses retinal blood flow and vascular reactivity of the major arterioles in close proximity to the ONH. The stimulus and vascular reactivity quantification technique was validated in healthy controls and then was clinically applied in patients with POAG. Newly diagnosed patients with untreated POAG (uPOAG) were recruited in order to avoid any confounding pharmacological effects and patients with progressive POAG (pPOAG) were also selected since they are thought to likely manifest vascular dysregulation. Finally, the results of the functional vascular reactivity assessment were compared to those of systemic biochemical markers of endothelial function in patients with untreated and progressive POAG and in healthy controls. Overall summary A safe, sustained, stable and repeatable normoxic hypercapnic stimulus was developed, evaluated and validated. In terms of the physiology of retinal vascular regulation, the percent magnitude of vascular reactivity of the arterioles and capillaries was found to be comparable in terms of flow. The new stimulus was successfully applied in POAG and in healthy controls to assess vascular reactivity and was also compared to plasma levels of ET-1 and cGMP. In terms of the patho-physiology of POAG, the study revealed a clear impairment of vascular reactivity in the uPOAG and pPOAG groups. There were reduced levels of plasma ET-1 in the uPOAG and ntPOAG groups. In addition, treatment with Dorzolamide improved vascular reactivity in the ntPOAG group in the absence of any change in the expression of plasma ET-1 or cGMP. Future work will address this apparent contradiction between the outcome of the functional vascular reactivity assessment and the biochemical markers of endothelial function in newly diagnosed POAG patients treated with Dorzolamide. Aims of chapters  Chapter 3: To determine the effect of hypercapnia on retinal capillary blood flow in the macula and ONH using scanning laser Doppler flowmetry (SLDF) in young healthy subjects.  Chapter 4: To describe a new manual methodology that permits the comprehensive assessment of retinal arteriolar vascular reactivity in response to a sustained and stable hypercapnic stimulus. The secondary aim was to determine the magnitude of the vascular reactivity response of the retinal arterioles to hypercapnic provocation in young healthy subjects.  Chapter 5: To compare the magnitude of vascular reactivity of the retinal arterioles in terms of percentage change of flow to that of the retinal capillaries using a novel automated standardized methodology to provoke normoxic, or isoxic, hypercapnia.  Chapter 6: To determine the magnitude of retinal arteriolar vascular reactivity to normoxic hypercapnia in patients with untreated POAG (uPOAG), progressive POAG (pPOAG) and controls. The secondary aim was to determine retinal vascular reactivity in newly treated POAG (ntPOAG, i.e. after treatment with 2% Dorzolamide, twice daily for 2 weeks).  Chapter 7: To compare plasma endothelin-1 (ET-1) and cyclic guanosine monophosphate (cGMP) between groups of patients with untreated primary open angle glaucoma (uPOAG), progressive POAG (pPOAG), newly treated POAG (ntPOAG) and controls. The effect of normoxic hypercapnia on plasma ET-1 and cGMP was also assessed. The functional measures of retinal blood flow and vascular reactivity were correlated with systemic biochemical markers of endothelial function. Methods Chapters 3, 4 and 5 were conducted on young healthy control subjects, where as Chapters 6 and 7 were conducted on patients with glaucoma and healthy controls.  Chapter 3: Subjects breathed unrestricted air for 15 minutes (baseline) via a sequential gas delivery circuit and then the fractional (percent) end-tidal concentration of CO2 (FETCO2) was manually raised for 15 minutes by adding a low flow of CO2 to the inspired air. For the last 15 minutes, FETCO2 was returned to baseline values to establish a recovery period. Heidelberg Retina Flowmeter (HRF) images centered on both the ONH and the macula were acquired during each phase.  Chapter 4: Subjects breathed air via a sequential gas delivery circuit for 15 minutes and the air flow was then manually decreased so that subjects inspired gases from the rebreathing reservoir until a stable 10-15% increase in FETCO2 concentration was achieved for 20 minutes. Air flow rate was then manually elevated so that subjects breathed primarily from the fresh gas reservoir to return FETCO2 back to baseline for the last 15 minutes. Retinal arteriolar hemodynamics was assessed using the Canon Laser Blood Flowmeter (CLBF) during all three breathing phases.  Chapter 5: Normoxic, or isoxic, hypercapnia was induced using an automated gas flow controller (RespirActTM, Thornhill Research Inc. Toronto, Canada). Subjects breathed air with PETCO2 normalized at 38 mmHg. An increase in PETCO2 of 15% above baseline, whilst maintaining normoxia, was then implemented for 20 minutes and then PETCO2 was returned to baseline conditions for 10 minutes. Retinal and ONH hemodynamic measurements were performed using the CLBF and HRF in random order across sessions.  Chapter 6: Retinal arteriolar vascular reactivity was assessed in patients with uPOAG, pPOAG (defined by the occurrence of optic disc hemorrhage within the past 24 months) and controls during normoxic hypercapnia. Using the automated gas flow controller, patients breathed air for 10 mins and PETCO2 was maintained at 38mmHg. Following this normoxic hypercapnia (a 15% increase in PETCO2 while PETO2 was maintained at resting levels) was induced for 15 mins and then for the last 10 mins PETCO2 was returned to baseline (post-hypercapnia) to establish recovery blood flow values. Retinal arteriolar diameter, blood velocity and blood flow was assessed using the CLBF in both patient groups and controls. A similar paradigm was repeated in the newly treated POAG group (ntPOAG, i.e. after treatment with 2% Dorzolamide, twice daily for 2 weeks).  Chapter 7: Blood samples were collected from the cubital vein of all participants (uPOAG, pPOAG, ntPOAG and controls) during baseline conditions (PETCO2=38mmHg) and then during normoxic hypercapnia (i.e. a 15% increase in PETCO2 relative to the baseline) using the paradigm described for Chapter 6. ET-1 and cGMP was assessed using immunoassay. Results  Chapter 3: The group mean nasal macula capillary blood flow increased from 127.17 a.u. (SD 32.59) at baseline to 151.22 a.u. (SD 36.67) during hypercapnia (p=0.028), while foveal blood flow increased from 92.71 a.u. (SD 28.07) to 107.39 a.u. (SD 34.43) (p=0.042). There was a concomitant and uncontrolled +13% increase in the group mean PETO2 during the hypercapnic provocation of +14% increase in PETCO2.  Chapter 4: Retinal arteriolar diameter, blood velocity and blood flow increased by 3.2% (p=0.0045), 26.4% (p<0.0001) and 34.9% (p<0.0001), respectively during hypercapnia. There was a stable ¬+12% increase in PETCO2 during hypercapnia and a concomitant -6% decrease in PETO2.  Chapter 5: Using an automated gas flow controller the co-efficient of repeatability (COR) was 5% of the average PETCO2 at baseline and during normoxic hypercapnia. The COR for PETO2 was 10% and 7% of the average PETO2 at baseline and during normoxic hypercapnia, respectively. Group mean PETCO2 increased by approximately +14.4% and there was only a +4.3% increase in PETO2 during hypercapnia across both study sessions. Retinal arteriolar hemodynamics increased during hypercapnia (p<0.001). Similarly, there was an increase in the capillary blood flow of the temporal rim of the ONH (p<0.001), nasal macula (p<0.001) and foveal areas (p<0.006) during hypercapnia. A non-significant trend for capillary blood flow to increase in the macula temporal area (+8.2%) was noted. In terms of percentage change of blood flow, retinal capillary vascular reactivity (i.e. all 4 analyzed areas = 22.4%) was similar to the magnitude of arteriolar (= 24.9%) vascular reactivity.  Chapter 6: Retinal arteriolar diameter, blood velocity and flow did not increase during normoxic hypercapnia in uPOAG compared to controls. Diameter and blood velocity did not change in pPOAG during normoxic hypercapnia but there was a significant increase in blood flow (+9.1%, p=0.030). After treatment with 2% Dorzolamide for 2 weeks there was a 3% (p=0.040), 19% (p<0.001) and 26% (p<0.001) increase in diameter, velocity and flow, respectively, in the ntPOAG group. Group mean PETCO2 increased by approximately +15% in all the groups and there was only a +3% increase in PETO2 during hypercapnia.  Chapter 7: Plasma ET-1 levels were significantly different across groups at baseline (one way ANOVA; p=0.0012) and this was repeated during normoxic hypercapnia (one way ANOVA; p=0.0014). ET-1 levels were lower in uPOAG compared to pPOAG and controls at baseline and during normoxic hypercapnia (Tukey’s honestly significant difference test). Similarly, ntPOAG group also showed lower ET-1 levels compared to the pPOAG and controls at baseline and during normoxic hypercapnia (Tukey’s honestly significant difference test). The cGMP at baseline and during normoxic hypercapnia across all groups was not different. In the control group, the change in ET-1 during normoxic hypercapnia was negatively correlated with change in retinal arteriolar blood flow (r = -0.52, p=0.04), that is, as the change in ET-1 reduced, the change in blood flow increased. A weak correlation was noted between change in cGMP during normoxic hypercapnia and the change in arteriolar blood flow (r = +0.45, p=0.08). Conclusions  Chapter 3: Hypercapnia resulted in a quantifiable capillary vascular reactivity response in 2 of the 3 assessed retinal locations (i.e., nasal macula and fovea). There was no vascular reactivity response of the ONH. It is critical to minimise the concomitant change in PETO2 during hypercapnia in order to obtain robust vascular reactivity responses.  Chapter 4: A technique to comprehensively assess vascular reactivity during stable and sustained hypercapnia was described. Retinal arteriolar diameter, blood velocity and blood flow increased in response to hypercapnia. The vascular reactivity results of this study served as a reference for future studies using the hypercapnic provocation and CLBF. Also, the concomitant change in PETO2 using the partial rebreathing technique was reduced compared to the manual addition of CO2 technique described in Chapter 3 but was still greater than optimal.  Chapter 5: A new automated gas flow controller was used to induce standardised normoxic, or isoxic, hypercapnia. The magnitude of vascular reactivity in both retinal arterioles and capillaries in response to the new hypercapnic stimulus was robust compared to the previous stimuli. There was a clear ONH vascular reactivity response in this study, unlike the result attained in Chapter 3. Although theoretically it is predictable that the percent magnitude of vascular reactivity of the arterioles and capillaries should be similar, this is the first study to show that they are indeed comparable. The magnitude of hypercapnia was repeatable and the concomitant change in PETO2 was minimal and physiologically insignificant.  Chapter 6: The normal response of the retinal arterioles and capillaries to normoxic hypercapnia is impaired in both uPOAG and pPOAG compared to controls. Short term treatment with 2% topical Dorzolamide for two weeks improved retinal vascular reactivity in ntPOAG. However, it is still unclear whether this improvement is a direct effect of Dorzolamide or as a secondary effect of the decrease in intraocular pressure (IOP).  Chapter 7: We found a reduction in the plasma ET-1 at baseline and during normoxic hypercapnia in the uPOAG and in the ntPOAG groups. This is the first study to show a lower plasma ET-1 level in uPOAG. The fact that this finding was repeated after 2 weeks treatment with Dorzolamide in the ntPOAG group further validates these results. It also suggests that Dorzolamide treatment does not impact ET-1 and cGMP measures, although it clearly results in an improvement of vascular reactivity. Correlation results suggest that as the change in ET-1 reduced during normoxic hypercapnia, the change in blood flow increased in the controls.