Typically, PVR is thought to be a condition involving undesirable cell proliferation, cell spreading, and contractility. Indeed, dividing cells have been observed in membranes removed from patients with PVR.
37 38 However, data from animal models suggest that in addition to proliferation, the growth and hypertrophy of Müller cells may play critical roles in the response perhaps by providing a cellular scaffold on which more complex membranes, involving a variety of cell types, can grow. Both proliferation and hypertrophy of Müller cells begin within the first few days after detachment. After 1 week, proliferation declines to low levels, but processes from these cells continue expanding in the subretinal space, apparently as long as the retina remains detached. This is also true for the growth of epiretinal membranes in the vitreous. Müller cell growth on the vitreal surface appears to begin, however, with retinal reattachment, not detachment.
22 Reattachment reduces the proliferative response significantly,
22 but the growth of membranes along the vitreoretinal surface continues because large membranes are generally observed weeks to months after reattachment. The fact that PVR and subretinal fibrosis are complex combinations of proliferation and cell growth may explain why drugs such as 5-fluorouracil that solely target proliferation were not effective at reducing epiretinal membrane formation in human patients.
23 24 The Akt/mTOR pathway, through which palomid acts, has been shown to regulate proliferation and cell spreading.
30 This may provide a mechanism for Palomid 529’s dramatic reduction of proliferation and subretinal gliosis in the rabbit model of detachment, though its precise mechanism of action is unknown. It is presumed that Palomid 529 acts directly on Müller cells because these are the most numerous cell types undergoing division. However, it has been shown that inhibitors of mTOR can affect RPE cells directly by decreasing cell spreading and migration in culture, suggesting that the effects on Muller cells could be indirect, acting through other cell types such as the retinal pigment epithelium.
39 Our data also do not provide an indication of whether the effect of Palomid 529 on increased photoreceptor survival is direct or indirect. It has been shown, however, that activation of the PI3K/Akt signaling pathway can have a neuroprotective effect in the retina by inhibiting light-induced photoreceptor apoptosis,
40 suggesting that the drug may in fact have a direct effect on photoreceptors. Finally, though all the work conducted with this drug, in a variety of cell types and animal models, indicates the effect is specific for the Akt/mTOR pathway (D. Sherris, personal communication, 2009), the data are only suggestive that the Akt/mTOR pathway is activated after detachment and that Palomid 529 inhibits this pathway in the retina. Future studies are planned to address these issues.