The aim for this thesis was to identify prognostic factors for chronic diabetes complications that exist at the time of diabetes diagnosis. Low level of education (<12 years) and low income (<60% of median) was found to increase the risk to have high (>70 mmol/mol) HbA1c at the time of diagnosis with 34 % and 35 %, respectively. Prevalence of diabetic retinopathy (DR) was 12% in a cohort of patients newly diagnosed with diabetes. Diabetic macular edema was present in 11% of patients with type 2 diabetes (T2D) and 13% of those with Latent Autoimmune Diabetes in Adults (LADA). Low beta cell function and low level of education increased the risk for DR with 110% and 43%, respectively. For every unit of increase in body mass index, the risk for DR was reduced by 3%. The cellular immunology of LADA patients was a mixture of that observed in both type 1 (T1D) and T2D patients. Compared to patients with T1D, LADA patients had more B-regulatory lymphocytes and antigen presenting cells capable of producing interleukine-35. This indicates a higher anti-inflammatory capacity in LADA patients compared to type T1D patients. By imputing age, body mass index, HbA1c at diagnosis, beta cell function and insulin resistance in a cluster analysis, five distinct diabetes clusters were identified. The four clusters representing T2D patients differed in incidence of DR, nephropathy and non-alcoholic fatty liver disease. This was replicated with similar results in three geographically separate populations. By studying socioeconomic background and factors present at the time of diagnosis we can better predict prognosis for chronic diabetes complications. These findings may facilitate better-targeted diabetes screening programs and more individually tailored treatment regimes.

Loss or partial loss of eye sight can have major effect on quality of person's life. One of the most common diseases, which causes loss or partial loss of eye sight are diabetic retinopathy and age releated macular degeneration. Both of these diseases can be prevented or mediated by early detection and proper treatment. The fundus camera, which is used to capture eye retina, has had major effect on increasing quality and speed of early detection. Images captured by fundus camera can be automatically analyzed in order to detect any possible signs of retina damage. This thesis proposes one possible way of automating this process. First part of this thesis describes eye, its diseases and capturing technology. Second part then proposes way of automating detection process and its implementation. Lastly, the results are evaluated.

Diabetic retinopathy and age-related macular degeneration are two of the most common retinal diseases in these days, which can lead to partial or full loss of sight. Due to it, it is necessary to create new approaches enabling to detect these diseases and inform the patient about his condition in advance. The main objective of this work is to design and to implement an algorithm for retinal diseases classification based on images of the patient's retina of previously mentioned diseases. In the first part of this work, there is described in detail each stage of each disease and its the most frequent symptoms. In this thesis, there is also a chapter about fundus camera, which is a tool for image creation of human eye retina. In the second part of this thesis, there is proposed an approach for classification of diabetic retinopathy and age-related macular degeneration. There is also a chapter about algorithmic methods which can be used for image processing and object detection in image. The last part of this thesis contains the test results and their evaluation. Assessment of success of proposed and implemented methods is also part of this chapter.

In this work I present conclusions of clinical-laboratory research focused on the patients with diabetic macular edema (DME). We performed biochemical and immunochemical analyses of vitreous samples that were collected during the pars plana vitrectomy. Moreover, at patients with non-proliferative diabetic retinopathy (NPDR) we assessed morphological characteristics of DME using optical coherence tomography (OCT). According to our findings, the vitreous and serum concentrations of uric acid and glucose were significantly higher in patients with diabetic retinopathy and DME compared to controls. Also total ratio (serum/ vitreous concentration) of uric acid and glucose was in diabetics significantly higher than in controls. The most important determinant of increasing concentration of both uric acid and glucose in the vitreous was the grade of diabetic retinopathy. Moreover, we demonstrated significant correlation between vitreous concentration of uric acid and concentration of the vascular endothelial growth factor (VEGF) in patients with DME and NPDR. We found further, that the volume of the macula (cube volume - CV) computed with the software of Cirrus HD-OCT correlates in diabetics significantly with the vitreous VEGF concentration, but not with uric acid. This OCT parameter could be used to...

Introduction: Relation of diabetes mellitus (DM) to the diabetic keratopathy and various stages of corneal nerve fiber damage has been well accepted. A possible association between changes in the cornea of diabetic patients and diabetic retinopathy (DR), DM duration, and age at the time of DM diagnosis were evaluated. Neuropathies are among the most common long-term complications of diabetes mellitus. Good glycemic control is essential in prevention of this complication. DM patients with similar mean glucose levels or glycated hemoglobin (HbA1c) levels often exhibit differences in evaluation of diabetic complications. One reason for these differences may be the differences in glucose variability. DM patients with similar mean glucose levels or HbA1c levels often exhibit differences in glucose variability Hypothesis: Diabetes mellitus damages the subbasal nerve fibers of the corneal and affects the density of epithelial, endothelial and stromal cells. Corneal changes in patients with DM are dependent on the degree of diabetic retinopathy (DR), age at diagnosis, duration of DM, and compensation parameters. Purpose: To compare changes in cell density in individual layers of cornea and status of subbasal nerve fibers in patients with type 1 DM (DM 1) and in healthy subjects. To evaluate the dependence...

Le système kallicréine-kinines est un système peptidergique complexe impliqué dans les processus inflammatoires, le contrôle du tonus et de la perméabilité vasculaire. Les effets biologiques des kinines sont accomplis par l’intermédiaire de deux types de récepteurs couplés aux protéines G, soit le récepteur B1 (B1R) et le récepteur B2 (B2R). Alors que le B2R est un récepteur constitutif, le B1R est faiblement exprimé en situation physiologique; il est induit par le stress oxydatif, les cytokines pro-inflammatoires (interleukine-1β (IL-1β) et le facteur de nécrose tumorale-α (TNF-α)) ou par des endotoxines bactériennes à la fois au niveau systémique et local, notamment dans la rétine. Des études récentes de notre laboratoire ont montré l’implication du B1R dans la pathogenèse et la progression de la rétinopathie diabétique et de la dégénérescence maculaire liée à l’âge (DMLA). Les objectifs des travaux présentés dans cette thèse consistent à déterminer : 1) le mécanisme par lequel le B1R est impliqué dans la rétinopathie diabétique chez le rat; 2) l’implication de la iNOS en aval dans la cascade inflammatoire activée par le B1R; 3) l’expression et la localisation cellulaire du B1R dans les rétines humaines atteintes de DMLA exsudative et atrophique. Nos résultats ont permis de démontrer une implication du B1R dans la rétinopathie diabétique via l’activation de l’enzyme de synthèse du monoxyde d’azote inductible (iNOS) dans un modèle de diabète de type 1 induit par la streptozotocine (STZ) chez le rat. En plus de sa localisation généralisée dans toute la rétine, le B1R est exprimé dans la couche de l’épithélium pigmentaire qui forme la barrière hémato-rétinienne externe. Les taux d’expression (protéique et ARNm) du B1R, de la iNOS, de la carboxypeptidase M (impliquée dans la biosynthèse des agonistes B1R), de l'IL-1β, du TNF-α, du facteur de croissance de l'endothélium vasculaire A (VEGF-A) et de son récepteur, le VEGF-R2, ainsi que des protéines nitrosylées augmentent à deux semaines dans la rétine diabétique. Ces augmentations ainsi que l’hyperperméabilité vasculaire rétinienne induite par le diabète et par l’injection intravitréenne d’un agoniste du B1R (R-838) sont bloquées par un inhibiteur de la iNOS (1400W) appliqué topiquement à la surface de l’œil pendant 1 semaine (premier article). Les résultats du deuxième article montrent une augmentation significative de l'immunoréactivité du B1R dans les rétines humaines prélevées de patients atteints de DMLA exsudative. Toutefois, les changements d’immunoexpression du B1R ne sont pas significatifs dans les rétines des patients atteints de DMLA atrophique. La réactivité des cellules gliales est plus marquée dans la forme exsudative que dans la forme atrophique de DMLA. Une colocalisation du B1R est observée avec des marqueurs des cellules de Müller, des astrocytes, de la microglie, de la iNOS et de la fibrose, suggérant une implication du B1R dans le processus inflammatoire et la formation de fibrose dans la DMLA exsudative. En revanche, l’expression du B2R demeure stable dans les rétines de DMLA exsudative et atrophique par rapport aux rétines témoins; ce résultat ne supporte pas la possibilité que ce récepteur puisse être impliqué dans la DMLA chez l’humain. / The kallikrein-kinins system is a peptidergic system involved in inflammatory processes, the control of the vascular tone and permeability. These effects are mediated by two G proteincoupled receptors, the Bradykinin type 1 (B1R) and type 2 (B2R) receptors. While the B2R is a constitutive receptor, B1R is almost undetectable in physiological condition; it is, however, induced by oxidative stress, pro-inflammatory cytokines (interleukin-1β (IL-1β) and tumor necrosis factor-α (TNF-α)) or by bacterial endotoxins at both systemic and local levels, notably in the retina. Recent studies from our laboratory supported an implication of B1R in the pathogenesis and progression of diabetic retinopathy and age-related macular degeneration (AMD). This thesis aims at unraveling: 1) the mechanism by which B1R is involved in diabetic retinopathy in rats; 2) the involvement of iNOS in the inflammatory cascade downstream to the B1R; and, 3) the expression and cellular localization of B1R in human retinae with exudative and atrophic AMD. Our results have shown the implication of B1R in diabetic retinopathy via the activation of the inducible nitric oxide synthase (iNOS) in a type 1 model of diabetes induced by streptozotocin (STZ) in rats. In addition to its generalized localization throughout the retina, B1R is expressed in the retinal pigment epithelium which forms the outer blood-retinal barrier. The protein and transcript expression of inflammatory markers; iNOS, carboxypeptidase M, IL-1β, TNF-α, vascular endothelium growth factor A (VEGF-A) and its receptor, VEGF-R2, including B1R as well as nitrosylated proteins are increased in the retina of diabetic rats at 2 weeks post-STZ. These upregulations, as well as the retinal vascular hyperpermeability induced by diabetes and by the intravitreal injection of an B1R agonist (R-838) are blocked by a topical one-week treatment by eye-drop with the selective iNOS inhibitor (1400W) (first manuscript). The results of the second manuscript show significant increases in the immunoreactivity of B1R in exudative AMD retinae. Despite a slight increase, B1R immunostaining does not reach statistical significance in the retina of donors with atrophic AMD. The reactivity of glial cells is more impressive in the exudative than in the atrophic form of AMD. B1R is co-expressed with markers of Müller cells, astrocytes, microglia, iNOS and fibrosis, suggesting an involvement of B1R in the inflammatory events and the formation of fibrosis in exudative AMD. On the other hand, the expression of B2R remains stable in the retinae of exudative and atrophic AMD, supporting a secondary role of this receptor in AMD in humans.

In this work I present conclusions of clinical-laboratory research focused on the patients with diabetic macular edema (DME). We performed biochemical and immunochemical analyses of vitreous samples that were collected during the pars plana vitrectomy. Moreover, at patients with non-proliferative diabetic retinopathy (NPDR) we assessed morphological characteristics of DME using optical coherence tomography (OCT). According to our findings, the vitreous and serum concentrations of uric acid and glucose were significantly higher in patients with diabetic retinopathy and DME compared to controls. Also total ratio (serum/ vitreous concentration) of uric acid and glucose was in diabetics significantly higher than in controls. The most important determinant of increasing concentration of both uric acid and glucose in the vitreous was the grade of diabetic retinopathy. Moreover, we demonstrated significant correlation between vitreous concentration of uric acid and concentration of the vascular endothelial growth factor (VEGF) in patients with DME and NPDR. We found further, that the volume of the macula (cube volume - CV) computed with the software of Cirrus HD-OCT correlates in diabetics significantly with the vitreous VEGF concentration, but not with uric acid. This OCT parameter could be used to...

Indiana University-Purdue University Indianapolis (IUPUI) / Prevention of pathological angiogenesis is a key strategy for treatment of common blinding ocular diseases such as retinopathy of prematurity, proliferative diabetic retinopathy, and wet age-related macular degeneration. The current treatment strategies are associated with partial vision loss and are ineffective in a significant patient population. Hence novel drugs as well as new ways to target ocular angiogenesis are needed for treating these diseases. I pursued a natural antiangiogenic compound, cremastranone, to develop novel drug leads and to find new targets. The objective of my doctoral thesis project was to elucidate cremastranone’s molecular mechanism of action and optimize its structureactivity relationship (SAR). In order to achieve this goal, with the help of chemistry collaborators cremastranone was synthesized for the first time. I showed that cremastranone has 50-fold more potency against endothelial cells as compared to nonendothelial cells, and also tested a novel active isomer, SH-11052. By SAR studies I identified a potent molecule, SH-11037, that has 10-fold more selectivity against retinal endothelial cells as compared to macrovascular endothelial cells. I then elucidated cremastranone’s molecular mechanism using a chemical proteomic approach. I identified ferrochelatase (FECH) as a specific interacting protein partner of cremastranone using photoaffinity chromatography. Hence, I hypothesized that cremastranone exerts its antiangiogenic activities through modulation of the functions of FECH. Cremastranone inhibited the enzymatic activity FECH in endothelial cells. Therefore, I investigated the role of FECH in ocular angiogenesis. Partial loss of FECH, using a siRNA-based knock down approach, decreased retinal angiogenesis both in vitro and in vivo in mouse models. Knock down of FECH decreased the expression levels of key proangiogenic proteins HIF-1α, eNOS, and VEGFR2. This work suggests that ferrochelatase plays an important, previously undocumented role in angiogenesis and that targeting of this enzyme by cremastranone might be exploited to inhibit pathological angiogenesis in ocular diseases.

Les rétinopathies ischémiques prolifératives telles que la rétinopathie diabétique proliférative et la rétinopathie du prématuré sont les principales causes de la perte de la vision dans la population active et pédiatrique des pays industrialisés. Malgré le fait que les événements initiateurs sont différents et propres à chacune des pathologies, les rétinopathies ischémiques prolifératives sont le résultat d’un processus biphasique. On a d’abord une phase initiale de dégénérescence microvasculaire suivie d’une néovascularisation excessive et pathologique de la rétine hypoxique qui tente de réinstaurer l’apport en nutriments et en énergie. Mais au lieu d’aller revasculariser les zones avasculaires de la rétine, ces nouveaux vaisseaux sanguins sont mal orientés et se dirigent plutôt vers le vitré normalement avasculaire. Ceci provoque des tensions physiques dans la rétine et mène à long terme à son détachement et une perte de vision conséquente. Les traitements actuels ne viennent pas sans effets secondaires majeurs. Par exemple, la formation de la cataracte et l’augmentation de la pression intraoculaire avec l’utilisation des corticostéroïdes ou la perte de la vision partielle dans le cas du traitement au laser sont fréquemment observées. De même, la thérapie anti-VEGF (Vascular endothelial growth factor) apporte aussi son lot de complications, telles que la thromboembolie veineuse et l’augmentation de la neurotoxicité après un long usage, vu les propriétés neuro- et vaso-protectrices du VEGF. Le développement d’une nouvelle approche thérapeutique pour les rétinopathies ischémiques prolifératives est donc nécessaire afin de contrer ces limitations thérapeutiques. Dans notre première étude, nous mettons en évidence un nouveau mécanisme par lequel les cellules neuronales sous stress diabétique sont à l’origine d’une forte inflammation oculaire. Nos résultats démontrent que le co-récepteur multi-ligand Neuropiline-1, le VEGF et la Sémaphorine-3A agissent de concert afin d’attirer une sous-population particulière de phagocytes mononucléaires susceptibles d’activer le processus de croissance vasculaire pathologique dans la rétine diabétique. De plus, notre étude propose une base pour de futures recherches sur l’impact des phagocytes mononucléaires exprimant Neuropiline-1 dans les pathologies du système nerveux central caractérisées par une inflammation excessive. Nos résultats permettent aussi de mettre en lumière le caractère anti-inflammatoire potentiel des thérapies actuelles anti-VEGF (à cause du rôle de VEGF dans la mobilisation des phagocytes mononucléaires via Neuropiline-1) au niveau oculaire. Dans notre deuxième étude, nous mettons en évidence l’activation du facteur HIF1α dans les phagocytes mononucléaires présents dans la rétine hypoxique. L’utilisation d’une approche protéomique non biaisée de spectrométrie de masse en tandem nous a permis d’identifier les partenaires interagissant avec HIF1α dans un milieu déficient en oxygène. Nous avons pu ainsi déterminer pour la première fois l’association entre la voie d’HIF1α et celle d’IRE1α (un des trois senseurs de la voie de l’UPR « unfolded protein response ») dans le processus d’adaptation à l’oxygène des phagocytes mononucléaires. Nos résultats révèlent ensuite l’importance d’IRE1α (plus principalement son activité kinase) dans la production d’HIF1α. Nous démontrons finalement que la synergie entre les signalisations d’IRE1α et HIF1α pourrait être responsable du comportement pathogénique des phagocytes mononucléaires via leur libération de cytokines inflammatoires; ce qui participerait ainsi à la progression des rétinopathies. Collectivement, nos travaux ont permis d’identifier d’importants régulateurs de l’activité pathogénique des phagocytes mononucléaires. Nous montrons : 1) le rôle de Neuropiline-1 dans l’infiltration des phagocytes mononucléaires au niveau des zones endommagées de la rétine et 2) l’impact du mécanisme convergent entre les voies d’IRE1α et HIF1α sur leur sécrétion de facteurs pro-inflammatoires durant les rétinopathies. Nos résultats offrent une base pour le développement de nouvelles stratégies thérapeutiques (ciblant Neuropiline-1, IRE1α et HIF1α) dans le traitement de maladies oculaires et d’autres pathologies caractérisées par une inflammation excessive. / Proliferative ischemic retinopathies such as proliferative diabetic retinopathy (PDR) and retinopathy of prematurity (ROP) are the principal causes of vision loss in working age and pediatric populations of industrialized countries. Although they display different initial triggers, proliferative ischemic retinopathies are biphasic ocular diseases that affect retinal vessels. There is an initial degeneration of the microvasculature, followed by a hypoxic stress on the retina. This triggers a second phase of deregulated and destructive blood vessel growth within the retina. Given this sequence of events and prominent clinical features, the currently most widely used local ocular therapeutic interventions directly target pathological blood vessel growth, yet present a number of non-desirable off-target effects such as the destruction of the retina itself. In fact, currently available treatments for proliferative ischemic retinopathies present non-negligible side effects, such as cataract formation with intravitreal use of corticosteroid or reduced visual field with laser-based photocoagulation surgery. Similarly, the anti-VEGF (Vascular endothelial growth factor) therapy may be associated with thromboembolic events, neuronal toxicity and atrophy when used as frequent long-term treatment given the fact that VEGF serves a vaso- and neuro-protective factor in the retina. Overcoming these therapeutic limitations and exploring novel pharmacological avenues are therefore required to ameliorate the safety profiles of current interventions. In our first study, we describe a novel mechanism by which severely stressed neuronal cells in the diabetic retina provoke destructive inflammation in the eye. We demonstrate that the multi-ligand co-receptor Neuropilin-1, VEGF and Semaphorin3A act as potent attractants for a specialized population of immune cells (mononuclear phagocytes) that later promote the exaggerated pathological vessel growth associated with the disease progression. Importantly, we provide evidence for a novel pharmacological intervention that reduces the inflammation associated with pathological retinal vessel growth. Our findings also suggest that current anti-VEGF therapies (a popular treatment for ocular vascular diseases) may in part be effective by reducing destructive ocular inflammation. In our second study, we provide evidence that those mononuclear phagocytes activate HIF1α in the hypoxic and inflamed retina. After using the unbiased proteomic approach of tandem mass spectrometry, we were able to identify HIF1α partners and found a novel link between HIF1α and the UPR (unfolded protein response) sensor IRE1α. Our data next established the crucial role of IRE1α (precisely via its kinase activity) in HIF1α production. We also suggested that the synergy between IRE1α and HIF1α pathways may be responsible of the pathogenic activity of the hypoxic mononuclear phagocytes via their secretion of inflammatory cytokines, thus contributing to the progression of the retinopathy. Collectively, our work identifies important regulators of the pathogenic activity of mononuclear phagocytes. We show that: 1) Neuropilin-1 promotes the infiltration of mononuclear phagocytes in the retina and 2) the convergent mechanism between IRE1α and HIF1α pathways is responsible for their release of pro-inflammatory factors during retinopathy. Our results could be used as a basis for the development of alternative therapeutic strategies (targeting Neuropilin-1, IRE1α and HIF1α) to treat ocular diseases or other pathologies characterized by an excessive inflammation.

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