1. Introduction
Currently, diabetes mellitus (DM) is a pandemic. The number of people with DM is expected to sharply increase to 643 million by 2030 and projected to rise to 783 million by 2045, representing 10% of the global population [
1,
2]. Key global findings strongly suggest that 541 million adults are at higher risk of developing type 2 DM (T2DM), constituting about 85–95% of all diabetics [
2]. The DM pandemic has resulted in specific cardiovascular, renal, neurologic, and ocular complications, becoming the most frequent causes of end-stage disease worldwide.
From an ophthalmologic viewpoint, diabetic retinopathy (DR) is detected in the ocular fundus examination. In some cases, it is necessary to perform fluorescein angiography, and for the evaluation of macular edema (DME), the use of optical coherence tomography (OCT) and OCT angiography (OCTA) is essential. The DR is a microangiopathic complication that affects patients, mainly in their working age, with any DM type [
1,
2,
3].
The disease involves multiple biochemical alterations that are manifested by changes in the chorioretinal neurovascular couple (NVC) and its cellular components [
4,
5], causing a series of morphological and functional manifestations in the ocular fundus as well as acute or progressive vision impairment and blindness, mainly mediated by the appearance of vitreous hemorrhage and/or (DME) [
6,
7]. A major risk factor for DR is chronic hyperglycemia. Moreover, DR duration, obesity, hypertension blood pressure (HBP), dyslipidemia, and other ocular and systemic diseases have been considered in the onset and progression of retinopathy [
6,
7,
8]. Population studies have also described DR as more likely to appear in diabetics with a family history of the disease. Major non-modifiable risk factors for DR are age, race, and genetic profile. It is worth mentioning that enhancing metabolic DM control results in a significant reduction in eye complications [
8,
9,
10,
11].
The development of clinical DR severity scales is based on the scientific evidence for covering the real needs for solid clinical classification protocols for DR and DME. In fact, the five-stage DR severity classification includes three stages of low–mild risk, severe non-proliferative retinopathy (NPDR), and proliferative retinopathy (PDR). Diabetic macular edema (DME) is classified as apparently present or absent. Therefore, PDR is a long-term complication of diabetes [
8,
9,
10,
11,
12]. In this stage, there are visible microaneurysms, intraretinal hemorrhages, retinal edema, waxy lipid exudates, venous dilations, intraretinal microvascular abnormalities, cotton wool exudates, arteriolar abnormalities, and areas of capillary closure. Moreover, the most important process occurring in this stage is neovascularization caused by abnormal angiogenesis in addition to the inflammation and expansion of extracellular matrix (ECM) components, resulting in the outgrowth of fibrovascular membranes at the vitreoretinal interface, leading to severe complications such as vitreous hemorrhage and tractional retinal detachment [
7,
8,
9,
10,
11,
12].
There is presently no cure for DR. Current diagnostic and therapeutic tools and outstanding new perspectives, including the digital revolution for health care (telemedicine, artificial intelligence, wearable sensors, new apps, etc.) [
13,
14], and enabling innovative medical research in risk factors, pathophysiological mechanisms, and underlying predictors [
15,
16,
17,
18,
19,
20,
21] may help to significantly gain insights for diabetic eye care and management.
Currently, the most widely used key actions for DR/DME include strong metabolic control and the occurrence of related comorbidities (hypertension blood pressure (HBP), dyslipidemia, obesity, etc.) [
15,
22,
23,
24]. However, for the advanced cases, laser treatment, intravitreal therapy (anti-angiogenic, steroid), and vitreoretinal surgery are required. Concerning the prevention of progression, it is widely accepted that panretinal laser photocoagulation is useful for retinal ischemic disease, and grid, sub-threshold diode micropulse laser photocoagulation is useful for DME [
25,
26,
27]. Furthermore, intravitreal injection of anti-angiogenic and/or steroid treatment have been extensively used for PDR and DME [
25,
26,
27,
28,
29]. Vitrectomy is conventionally performed in cases of vitreous hemorrhage and/or tractional retinal detachment [
29]. Despite the existence of the described DR/DME treatments, a significant number of patients experience complications and visual impairment. Thus far, no curative treatments for DR exist, and there is still a long road to effectively avoiding visual impairment and blindness in diabetics.
Reactive oxygen species (ROS) damage nucleic acids, lipids, and proteins [
30,
31,
32]. ROS can modify cell signaling proteins, with functional consequences involving pathological processes. In fact, excessive ROS function as signaling amplifiers to specifically activate cellular stress pathways (protein kinase C (PKC), mitogen-activated protein kinase (MAPK), and nuclear factor kappa B (NF-κB)), leading to the activation of inflammation, angiogenesis, and apoptosis [
22,
30,
31,
32]. Polyol pathway activation (aldose reductase converting excess glucose to sorbitol) contributes to oxidative stress (OS) by increasing the NADH/NAD+ ratio [
23,
33]. Advanced glycation end-products (AGEs), formed by the process of nonenzymatic binding of glucose to proteins, lipids, and nucleic acids, can lead to important changes in the structure and function of proteins, the generation of OS, and inflammation, with the increased expression of lipid peroxidation (LPO) byproducts [
30,
31,
32,
33,
34,
35,
36,
37,
38], pro-inflammatory cytokines [
39,
40], and growth factors [
37,
41,
42].
Moreover, there is growing evidence that neurodegeneration may also be an independent process in DR [
4,
5,
36,
37,
38,
39]. Regarding its pathophysiology, increasing research has demonstrated that DR is a complex neurovascular disease in which chronic hyperglycemia affects both the retinal vasculature and neural tissue [
39]. The neurovascular couple (NVC) concept was introduced from the CNS to the retina at the beginning of the millennium [
4,
5] by referring to the interrelationship between neuronal, glial, immune, and vascular retinal cell phenotypes, that became unable to maintain homeostasis and inner BBR integrity, as well as to appropriately orchestrate blood flow responses to the high metabolic retinal demand. Epidemiological and experimental studies have reported that blood flow regulation and NVC deficiencies may exist before the presence of neural dysfunction in the diabetic retina [
39]. In addition, the accumulation of AGEs and the induction of PKC, polyols, and hexosamine pathways have been classically considered pathogenic mechanisms of DR [
35,
36]. In this regard, OS, neuroinflammation, and glutamate-dependent excitotoxicity result in decreased retinal cell survival. Finally, the alteration of the NVC in the retina leads to hypoxia and progressive neurodegeneration, neuroinflammation, gliosis, BRB dysfunction, edema, angiogenesis, and fibrosis with increasing expression of several molecules, such as cytokines and pro-angiogenic factors (as the VEGF), with all of the abovementioned processes being interconnected during the DR/DME course [
4,
5,
22,
30,
31,
32,
33,
34,
35,
36,
37,
38,
39,
40,
41,
42,
43,
44,
45].
In our previous research, the expression levels of pro-oxidant (malondialdehyde: MDA; 4-hydroxynonenal: 4HNE), pro-inflammatory (interleukins: (IL) IL1β, IL6; tumor necrosis factor (TNF)-α), pro-angiogenic (vascular endothelial growth factor: VEGF), and pro-apoptotic [caspase 3: CAS3; poly adenyl ribose polymerase (PARP) 1] proteins increased to hazardous levels, whereas the levels of antioxidants (superoxide dismutase: SOD; catalase: CAT; total antioxidant capacity: TAC) decreased in DM2 patients with NPDR and PDR [
41,
42,
43,
44,
46,
47]. The abovementioned results and increasing experimental and clinical evidence strongly specify that OS, inflammation, angiogenesis, and apoptosis are involved in the pathogenesis of PDR/DME, independently or all together, responding to a functional link in the diabetic retina [
35,
36,
37,
38,
39,
40,
41,
42,
43,
44,
45,
46,
47]. Taken together, these findings indicate that structural/functional damage to the vascular endothelial cells, pericytes, and resident glia induces deleterious changes in the retinal neurons and ultimately their apoptotic death, representing pathogenetic hallmarks in DR/DME [
30,
31,
32,
33,
34,
48,
49,
50,
51,
52,
53].
Given the relatively recent trend toward biomarker discovery and the translation to clinical practice, we aimed to explore the cascade of events related to oxidative stress, inflammation, angiogenesis, and apoptosis pathological pathways and the correlation of data obtained from blood and vitreous humor samples from PDR and DME patients and surrogate controls.
Therefore, the present study aimed to extend current knowledge on the biochemical and molecular mechanisms involved in DR and DME by exploring the cascade of events related to the oxidative stress, inflammation, angiogenesis, and apoptosis pathological pathways, in addition to the correlation of data obtained from blood and vitreous humor samples from DM2 patients, thereby validating previous results as well as addressing potential issues for precision medicine in DR/DME diagnostic and therapy, based on hallmark mechanisms of actions. The identification of more specific and sensitive biomarkers is relevant for facilitating the earlier detection of DR/DME toward reducing the prevalence of visual disability.
According to our viewpoint and based on the above statements, unraveling the manner in which the molecular mechanisms of the above signaling pathways participate in DR and DME is essential for ensuring better eye and vision care in diabetics.
3. Discussion
In this work, we intended to address potential issues for precision medicine in PDR/DME diagnostics and therapy based on the hallmark mechanisms of actions. The identification of more specific and sensitive biomarkers that have a known relationship with a specific clinical endpoint is relevant for facilitating the earlier detection of PDR/DME and reducing the prevalence of visual disability. By using plasma and vitreous body samples, we found significantly higher loads of the LPO byproducts MDA and 4HNE, as well as pro-inflammatory CPR and IL6 and pro-angiogenic VEGF. Significantly lower activity of SOD, CAT, and TAC was observed in the T2DM patients with PDR (after excluding other DM types and/or patients with NPDR) and the DME patients compared with the surrogate controls.
The pathophysiology of DM and DR has been widely investigated. Epidemiological and experimental studies have demonstrated a powerful connection between chronic hyperglycemia and poor metabolic control with the onset and/or progression of DR [
3,
5,
6,
7,
8,
9,
10,
11,
12,
15,
17,
19,
20]. The first clinical manifestations of DR are present when BRB rupture occurs and triggers hyperpermeability of the retinal vessels [
22,
37,
54,
55,
56]. Liu et al. [
57] reported the important role of claudins (major transmembrane protein constituents of tight junctions in endothelial and epithelial human tissues) in barrier and pore formation, in addition to their influence in tight junctions. Similarly, other components critical to the development of DR involve OS and antioxidant status in the PLS and VIT of PDR/DME patients [
30,
31,
32,
33,
34,
35,
36,
37,
38,
48,
52,
53,
54,
55,
56,
57,
58,
59,
60,
61,
62]. Xia et al. [
63] recently reviewed the intravitreal molecules involved in DR, the increasing role of oxidative stress (lipid peroxides, SOD), inflammation-related actors (IL1β, IL6, IL13, IL37, interferon-γ), angiogenesis (VEGF), and the kallikrein system (bradykinin, PLS kallikrein, coagulation factor XII), as well as the introduction of new factors such as adiponectin, non-coding RNAs, and renin (pro) receptor. In fact, increased ROS formation leads to a significant repression of mitochondrial biogenesis, inducing decreased antioxidant defenses (SOD), resulting in mitochondrial dysfunction and thus altering the mitochondrial outer membrane, which in turn provokes the release of cytochrome C, leading to apoptotic cell death [
32,
38,
45]. In addition, excessive ROS can trigger the immune response with the release of inflammatory factors (NF-κB), PKC, MAPK, etc., with the intensification and chronification of the inflammatory process [
63,
64,
65,
66]. Antioxidant defenses include enzymatic systems, with SOD being the main chain-breaking antioxidant, acting in the aqueous phase by trapping superoxide anions via the dismutation reaction [
58]. In the present work, significant differences were detected in SOD activity in the PVR and DME groups in comparison with the surrogate controls. It has to be said that we did not discriminate between the Cu-Zn and Mn SOD isoforms, but an important reduction was observed in the total SOD activity in the VIT samples from PDRG compared with SCG, which is in accordance with previous related reports [
58,
60]. CAT is an antioxidant enzyme which plays a pivotal role in protecting cells and tissues against the harmful effects of hydrogen peroxide [
59,
60]. Moreover, it is important to point out that significantly lower CAT activity in PDR and DME eyes was also demonstrated in a previous report of our research group [
48,
60], although others have described a significant increase in the CAT levels in diabetics, probably to adaptive mechanisms in response to pro-oxidants in diabetics [
33,
34,
36,
61]. It is well established that antioxidant activity undergoes significant age-related reduction in the body [
31], which could explain, in part, the differences in the above study results.
The mean age of our study participants was 60 ± 11 years, without significant differences between groups. However, in the comparison between the cases and surrogate controls, a significant reduction in the endogenous antioxidant systems was observed in both groups of diabetics, which is consistent with previous reports [
48,
49,
50,
51,
52,
53,
62].
On the basis of the results mentioned above, OS-related molecules have recently been a point of focus for DR/DME researchers, with the conclusion that biomarkers of oxidative stress are significantly higher in the PLS and VIT of PDR patients compared with controls. In fact, the SOD and LPO levels were found to be significantly higher (with a positive correlation between them), whereas the MDA did not reflect significant differences between groups. Conversely, the present work demonstrates that the MDA and the 4HNE were significantly elevated whilst the antioxidant load significantly decreased in the PLS and VIT of PDR/DME patients. Our data suggest that the combination of increased MDA/4HNE and decreased SOD/CAT/TAC can serve as a potential biomarker of DR progression. Moreover, we conducted correlation analysis between the PLS and VIT variables in PDRG/DMEG and a positive correlation between the PLS-CAT and the VIT-SOD levels (rho = 0.5; p < 0.01) in PDRG, and a negative correlation between the PSD-4HNE and VIT-TAC levels were detected (rho = 0.5; p < 0.01) in DMEG. To summarize, the above molecules can be considered potential biomarkers for discerning the risk of PDR/DME in T2DM patients.
It is well known that cellular interactions in the context of biochemical and metabolic dysregulation (polyol pathway, PKC activation, AGI upregulation, and renin angiotensin system activation) occur in the diabetic retina. Therefore, the described biochemical changes result in the induction of a series of events, such as oxidative stress, inflammation, angiogenesis, and apoptosis, which injury the retina. Cellular damage, loss of vascular endothelial cells and pericytes, and basement membrane thinning are important initiators of DR pathology. Cytokine (IL1β, IL6, TNF-α) increases and loss of neuroprotective and neurotrophic molecules also occur in a hyperglycemic environment [
38,
39,
40,
41,
45,
65,
66]. From a molecular viewpoint, persistent hyperglycemia facilitates the formation of ROS and pro-inflammatory mediators. Increased ROS activates inflammatory factors, and in addition, the immune response increases ROS formation in a stepwise fashion, strongly suggesting there is crosstalk between these pathologic pathways [
38,
42]. Then, hypoxia triggers the expression of pro-angiogenic factors, of which VEGF is the most representative [
41,
67,
68,
69].
Hereafter and for practical purposes, we summarize the pathogenesis of DR in three components: (1) vaso-fibro-proliferative; (2) neuroinflammatory; and (3) neurovascular.
First, the vaso-fibro-proliferative component can be explained through ischemia–reperfusion mechanisms, leading to an appropriate environment for ROS generation and the activation of signaling pathways, such as the angiogenic, inflammatory, and apoptotic routes [
33,
34,
35,
36,
37,
65,
66,
67,
68,
69]. Chronic hyperglycemia induces high levels of VEGF, a core molecule that disrupts the balance between pro-/anti-angiogenic factors, favoring the pro-angiogenic atmosphere [
41,
45]. As a consequence of this, VEGF becomes engaged in destructive action against vascular endothelial cells, stimulating the generation of angiogenic neovessels, which marks a milestone of disease progression to more severe stages, PDR [
67,
68,
69].
In the PLS and VIT samples of our study participants, we detected a differential expression profile of VEGF between PDRG/DMEG and CG (see
Figure 3 and
Figure 6). In fact, other researchers also reported a significant increase in VEGF expression levels in the PLS and VIT samples of PDR/DME patients compared with the controls [
67,
68,
69]. Indeed, Wang et al. [
70] studied 50 patients with PDR who underwent pars plana vitrectomy and 56 healthy controls. The VEGF levels were assayed in PLS and VIT samples by enzyme-linked immunosorbent assays (ELISA), and the data showed significantly higher values in both samples of the PDR patients, and, interestingly, the VIT VEGF concentrations were positively associated with the PLS VEGF levels in these patients. The abovementioned results are in agreement with ours, and we found a correlation of the VEGF expression in samples of both the PDR/DME study groups (see
Table 4 and
Figure 7).
Next, we comment on another critical component of PDR/DME: inflammation. Chronic hyperglycemia induces inflammation and polynuclear neutrophil activation. Cytokines/chemokines are also implicated in the mechanisms of modulating the immune response, acting as chemotactic stimuli for inflammatory cells and fibroblasts. The resident immune cells change their phenotype, becoming the primary source of a variety of molecules, including collagen [
71]. Because of this, a more conducive environment has been created for the formation of membranes and tractional bands between the retina and vitreous, commonly leading to retinal tears and detachments. Hence, it is worth mentioning the elevated levels of CRP and IL6 in PLS samples, as well as of IL6 in VIT samples, of our diabetic participants (see
Table 3 and
Figure 3 and
Figure 5). As published in other reports, the expression levels of cytokines have been correlated with the progression of retinopathy to advanced stages and the appearance of DME, the leading cause of vision loss in diabetics [
26,
27,
65,
71], which are supported in our work. A hydroelectrolytic imbalance between the intracellular and extracellular space in the diabetic retina results in increased water diffusion and inner BRB breakdown [
44,
63,
70]. In this process, the altered metabolism of neuroglial cells has a leading role [
66]. Subsequent cellular swelling and the extravasation of liquid to the extracellular space (which mainly accumulates in the external plexiform membrane and the inner and outer nuclear retinal layers), results in the appearance of cyst spaces [
72,
73,
74]. To sum up, the cascade of processes that we present above induces retinal hypoxia with BRB breakdown, the increased expression of VEGF, activation of the immune response, and the appearance of DME [
70,
72,
73,
74]. As a result of the correlation analyses of the present work, considering biochemical and molecular factors in the T2DM patients, we demonstrated that PLS 4HNE, VEGF, and IL6 and VIT TAC were the most significant molecules for DME. We speculate that those molecules are the best predictors for DME in our diabetic study population.
Recently, the concept of DR as a neurovascular disease has gained many followers. It is well recognized that neurons, neuroglia, and vascular cells intimately interact with each other to maintain a healthy retinal environment, maintaining their well-being, and to perform all physiological functions. In fact, DR is a complex neurovascular disorder in which sustained hyperglycemia influences the retinal vasculature and neural tissue [
39]. Accordingly, the NVC approach was introduced from the CNS to the retina in the early years of the 21st century [
4,
5]. With respect to the NVC, the dysfunctional interrelationship between neurons, glial, immune, and vascular retinal cell phenotypes results in a failure to maintain homeostasis and inner BBR integrity and to harmonize blood flow responses to the high metabolic retinal demand [
44]. In the PLS and VIT samples of our study participants, we assayed molecules involved in OS, inflammation, angiogenesis, and apoptosis to improve our knowledge of the physiopathology of PDR/DME. Our results regarding CAS3 are unexpected and require further attention. In fact, CAS3 is a cysteine protease with aspartic acid specificity involved in apoptosis. It has been reported that CAS3-targeted isatin analogs could be imaged (by positron emission tomography) in addition to the activation of CAS3 in response to anticancer therapy based on the induction of apoptosis [
75]. Furthermore, CAS3 has been linked to glaucoma neurodegeneration because of its role in apoptosis [
76]. No significant differences in the CAS3 expression levels of the PLS and VIT samples were detected between PDRG and DMEG compared with SCG. However, Tian et al. [
77] studied 20 NPDR patients, 20 PDR patients, and 20 patients with idiopathic macular hole as the control group that underwent vitrectomy, to collect vitreous samples. Venous blood was also collected. The concentration of CAS3, among other molecules, was assayed by ELISA. The authors concluded that DR severity is positively correlated with CAS3. Taking into consideration that apoptosis is an important step in the pathogenesis of advanced DR, further research is needed to understand our CAS3 results in the PDR and DME patients.
There have also been many reports on the correlation between DR and local and systemic risk factors and biochemical and molecular genetics data, and the results of these research studies are promising [
3,
6,
12,
15,
17,
19,
20,
78,
79]. However, due to the heterogeneity of the studies (ethnic, age range, gender, work design, molecular assays, etc.), the assessment of PDR and DME risk in T2DM patients is biased and not easily transferrable to the global use of specific biomarkers in diabetics. Because of this, the key objective of the present study was to identify clinical, biochemical, and molecular biomarkers to reduce the risk of worsening the DR/DME course and diabetic blindness.
We first presented physiopathological knowledge of DR/DME, including the risk factors that cause retinopathy and the clinical and imaging indicators of disease progression. Then, we showed data from the classic biochemical parameters. Finally, we presented the results from the molecules involved in the most relevant pathogenic mechanisms, such as oxidative stress, inflammation, angiogenesis, and apoptosis in addition to the differences between groups. We also conducted correlation analysis between PDRG and DMEG on the basis of specific controlled variables.
The strengths of this study include the homogeneous population-based sampling. This work provides an opportunity to identify new biomarkers for the preclinical diagnosis and better therapeutic management of PDR/DME. With objective assessment of PDR/DME, the diagnostic error can be reduced, and the precision of estimates can be improved. This work will be continued by increasing the power to detect associations with risk factors, comorbidities, and PDR/DME therapy. All of these aspects may help to improve knowledge and to solve uncertainties that may emerge in the course of the research.
The study limitations have been considered and are as follows: Participants may have provided inaccurate answers to our questions on the issues concerning the characteristics of the disease, comorbidities, and treatments. We did not enclose the treatments for the eyes and/or systemic diseases. With the study database and statistical processing, a large amount of information was set up. In this context, we mainly focused on the study objectives. Because of this, some of the information and data have been omitted from the final data in processing. In trying to diminish the above study limitations, some specific actions were taken, among them the revision of the patient’s clinical charts with the patient themself and an accompanying person. We also conversed among ourselves regarding any discrepancies arising from the selection of suitable participants, data screening, and the results. To ensure maximum coherence in the registered information, data scrubbing and normalization were independently performed by two researchers. Moreover, we solicited special help from an experienced retina specialist for better estimation of contradictions. With the above interventions, we intended to improve the power of our data.
In summary, key research in PDR/DME focuses on the molecular genetic mechanisms (biomarkers, gene editing), advanced diagnostic techniques (deep learning automated algorithms for imaging, robotics), and application of stem cell appliances. This work aimed to revisit current knowledge and to recognize the most pressing problems in DR/DME, such as preventing and treating DR/DME, which are major concerning challenges in this field. New strategies are urgently needed for preclinically detecting potential vision-threatening retinopathy and maculopathy and prevent their progression in diabetics.
We demonstrated that the MDA, 4HNE, VEGF, and IL6 concentrations increased whilst SOD, CAT, and TAC decreased in the PLS and VIT samples from PDR and DME patients versus the surrogate controls. We observed a positive correlation between the PLS-CAT and the VIT-SOD levels in PDRG, and a negative correlation between the PSD-4HNE and the VIT-TAC levels in DMEG. When the retinal imaging variables were integrated, data showed a positive correlation between the CSFT and the VIT-SOD levels, and a negative correlation between the CSFT and the VIT-4HNE levels in PDRG. In DMEG, the CSFT displayed a negative correlation with VIT-CAT.
We suggest that OS, angiogenesis, and inflammation play important roles in the pathogenesis of PDR and DME, with the altered immune response critically contributing to the development and progression of macular edema.
As the formation of ROS and their harmful effects on biomolecules can be reduced/avoided by blockage and pro-oxidants removed by means of antioxidant enzymes and scavengers, further research on a possible coadjunctive therapeutic approach to PVR and DME is needed. This will allow important adjuvant intervention in the current anti-inflammatory and anti-angiogenic therapy of the diabetic retina, aiming to counteract visual impairment and blindness in the affected patients.