Magnetically Steered Cell Therapy For Functional Restoration Of Intraocular Pressure Control In Open-Angle Glaucoma

Reviewer #1 (Public review):

Summary:

This manuscript describes a novel magnetic steering technique to target human adipose derived mesenchymal stem cells (hAMSC) or induce pluripotent stem cells to the TM (iPSC-TM). The authors show that delivery of the stem cells lowered IOP, increased outflow facility, and increased TM cellularity.

Strengths:

The technique is novel and shows promise as a novel therapeutic to lower IOP in glaucoma. hAMSC are able to lower IOP below the baseline as well as increase outflow facility above baseline with no tumorigenicity. These data will have a positive impact on the field and will guide further research using hAMSC in glaucoma models.

Weaknesses:

The transgenic mouse model of glaucoma the authors used did not show ocular hypertensive phenotypes at 6-7 months of age as previously reported. Therefore, if there is no pathology in these animals the authors did not show a restoration of function, but rather a decrease in pressure below normal IOP.

Reviewer #2 (Public review):

Summary:

This observational study investigates the efficacy of intracameral injected human stem cells as a means to re-functionalize the trabecular meshwork for the restoration of intraocular pressure homeostasis. Using a murine model of glaucoma, human adipose-derived mesenchymal stem cells are shown to be biologically safer and functionally superior at eliciting a sustained reduction in intraocular pressure (IOP). The authors conclude that the use of human adipose-derived mesenchymal stem cells has the potential for long-term treatment of ocular hypertension in glaucoma.

Strengths:

A noted strength is the use of a magnetic steering technique to direct injected stem cells to the iridocorneal angle. An additional strength is the comparison of efficacy between two distinct sources of stem cells: human adipose-derived mesenchymal vs. induced pluripotent cell derivatives. Utilizing both in vivo and ex vivo methodology coupled with histological evidence of introduced stem cell localization provides a consistent and compelling argument for a sustainable impact exogenous stem cells may have on the re-functionalization of a pathologically compromised TM.

Weaknesses:

A noted weakness of the study, as pointed out by the authors, includes the unanticipated failure of the genetic model to develop glaucoma-related pathology (elevated IOP, TM cell changes). While this is most unfortunate, it does temper the conclusion that exogenous human adipose derived mesenchymal stem cells may restore TM cell function. Given that TM cell function was not altered in their genetic model, it is difficult to say with any certainty that the introduced stem cells would be capable of restoring pathologically altered TM function. A restoration effect remains to be seen. Another noted complication to these findings is the observation that sham intracameral-injected saline control animals all showed elevated IOP and reduced outflow facility, compared to WT or Tg untreated animals, which allowed for more robust statistically significant outcomes. Additional comments/concerns that the authors may wish to address are elaborated in the Private Review section.

Reviewer #3 (Public review):

Summary:

The purpose of the current manuscript was to investigate a magnetic cell steering technique for efficiency and tissue-specific targeting, using two types of stem cells, in a mouse model of glaucoma. As the authors point out, trabecular meshwork (TM) cell therapy is an active area of research for treating elevated intraocular pressure as observed in glaucoma. Thus, further studies determining the ideal cell choice for TM cell therapy is warranted. The experimental protocol of the manuscript involved the injection of either human adipose derived mesenchymal stem cells (hAMSCs) or induced pluripotent cell derivatives (iPSC-TM cells) into a previously reported mouse glaucoma model, the transgenic MYOCY437H mice and wild-type littermates followed by the magnetic cell steering. Numerous outcome measures were assessed and quantified including IOP, outflow facility, TM cellularity, retention of stem cells, and the inner wall BM of Schlemm's canal.

Strengths:

All of these analyses were carefully carried out and appropriate statistical methods were employed. The study has clearly shown that the hAMSCs are the cells of choice over the iPSC-TM cells, the latter of which caused tumors in the anterior chamber. The hAMSCs were shown to be retained in the anterior segment over time and this resulted in increased cellular density in the TM region and a reduction in IOP and outflow facility. These are all interesting findings and there is substantial data to support it.

Weaknesses:

However, where the study falls short is in the MYOCY437H mouse model of glaucoma that was employed. The authors clearly state that a major limitation of the study is that this model, in their hands, did not exhibit glaucomatous features as previously reported, such as a significant increase in IOP, which was part of the overall purpose of the study. The authors state that it is possible that "the transgene was silenced in the original breeders". The authors did not show PCR, western blot, or immuno of angle tissue of the tg to determine transgenic expression (increased expression of MYOC was shown in the angle tissue of the transgenics in the original paper by Zode et al, 2011). This should be investigated given that these mice were rederived. Thus, it is clearly possible that these are not transgenic mice. If indeed they are transgenics, the authors may want to consider the fact that in the Zode paper, the most significant IOP elevation in the mutant mice was observed at night and thus this could be examined by the authors. Other glaucomatous features of these mice could also have been investigated such as loss of RGCs, to further determine their transgenic phenotype. Finally, while increased cellular density in the TM region was observed, proliferative markers could be employed to determine if the transplanted cells are proliferating.