Elucidating the Role of Ref-1 in Retinal Neovascularization

Abstract

Retinal neovascularization in retinopathy of prematurity (ROP) and proliferative diabetic retinopathy (PDR) impairs vision. Current treatments of intravitreal (IVT) antivascular endothelial growth factor (VEGF) injections are accompanied by high treatment burden and resistance. Also, VEGF alone is not sufficient for induction of neovascularization, suggesting that targeting multiple disease-relevant pathways may increase therapeutic response. Thus, there is a critical need to develop novel therapies that modulate multiple disease-relevant pathways. APE1/Ref-1, a multifunctional protein with both endonuclease (APE1) and redox regulatory activity (Ref-1), activates multiple transcription factors linked to retinal neovascularization. However, the precise molecular mechanisms of Ref-1 in retinal neovascularization remain unclear. To investigate this, I examined the expression of Ref- 1 in two mouse models of retinal neovascularization – the oxygen-induced retinopathy (OIR) and the Vldlr-/- model – and observed elevated Ref-1 expression at sites of neovascularization. Further, I observed heightened expression of Ref-1 in endothelial cells in human PDR tissue compared to normal eyes. Through cell-based and biochemical approaches, I identified that Ref-1 redox activity modulates canonical Wnt signaling, and inhibition of Ref-1 redox activity blocks Wnt signaling activation. I found that Ref-1 redox activity regulates HIF-1a transcriptional activation in hypoxic human retinal endothelial cells. Hypoxia-induced activation of Wnt signaling was regulated by Ref-1, suggesting a dynamic Ref-1-HIF-1a-Wnt signaling axis. Finally, inhibition of Ref-1 redox activity decreased retinal neovascularization and downregulated expression of Wnt- and angiogenesis-related genes at sites of neovascularization in a mouse model of retinal neovascularization. These findings suggest that Ref-1 redox activity promotes ischemic retinal neovascularization via Wnt signaling activation. This study advanced our understanding of Ref-1’s role in neovascular eye diseases, and targeting Ref-1 with a redox inhibitor could offer a novel therapeutic strategy for retinal neovascularization.