ESTABLISHMENT AND EQUIPPING OF A  
CONNECTICUT LIONS VASCULAR EYE CENTER  
AT THE UCONN HEALTH CENTER  
TO PROMOTE PREVENTION OF EYE DISEASE BY  
ADVANCED RETINAL IMAGING AND COMMUNITY PROGRAMS.

INTRODUCTION

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Vision like other biological functions depends on the free flow of blood through ten billion microvessels that serve all body regions. Diabetes and glaucoma specifically damage microvessels in the retina and the optic nerve. However, relatively little research is currently done to clarify the specifics of microvessel functions and damage within the eye. This proposal addresses that need.
The Importance of a University Vascular Eye Center

The UCONN Medical Center serves as a necessary bridge between eye microvessel research and actual contact with patients. Based on our experience, a serious and unnecessary gap exists between patients having diabetes or glaucoma and obtaining adequate retinal examinations at a local level. Consider the following:

i)   Fewer than half of Connecticut insured diabetic patients seek recommended annual retinal examinations. This lapse occurs each year in a state with a population of 3 million well served by one ophthalmologist for each 10,000 persons.
ii)   Damage to the optic nerve microvessels is not directly evaluated in glaucoma patients due to limited access to advanced vessel imaging facilities.
iii)   Diabetic and glaucoma patients screened by our Lions-affiliated Fidelco Guide Dog Foundation and other Connecticut rehabilitation agencies show a high incidence of preventable diabetic and glaucoma blindness, based on failure to obtain regular retinal examinations.
iv)   It is especially distressing that juvenile-onset type I diabetes, a disease running a longer course, shows the highest incidence of vision loss after five years (20 percent) and of legal blindness after 20 years.

PHASE I

Operational Strategy

In Phase I we propose a new Connecticut Lions Vascular Eye Center at the UCONN Health Center equipped with state-of-the-art clinical imaging equipment to intensify studies of human eye blood vessels. (Phase II will upgrade research capabilities in concert with a 21st Century $300 million dollar expansion at UCONN Health Center). The existing collaboration among seven outstanding scientists and physicians at work on studies of eye microvessels will be enhanced by the training of a postdoctoral fellow in this new field. Clinical microvascular imaging will emphasize better visualizations of eye microvessels in the diabetic retina and the glaucomatous optic nerve. The Phase II center laboratory research will continue to emphasize the structure and function of animal and human microvessels.

The clinical imaging program will also undertake year-round screening and education of diabetic and glaucoma patients at our university hospital base, using free color image copies and instructional materials. In a kickoff program Connecticut Lions and family members having diabetes will be provided complementary images. (Patients who see early blood spots in their own image copies are quickly motivated to comply with all diabetic self-care recommendations). Similarly, patients suspected of having familial glaucoma will be offered genetic screening in the UCONN Ophthalmic Molecular Genetics laboratories.

Funding Strategy

With a goal of $200,000 needed for Phase I start-up of the Vascular Eye Center, CLERF has committed to raise $75,000 through solicitations of Lions Clubs in Multiple District 23 and apply to LCIF for a standard grant in the amount of $75,000. UCONN has set aside $100,000 in a Vascular Eye account. One half ($50,000) will be committed to Phase I start-up and UCONN will continue to fund eight scientists and staff salaries at $1.4 million. The UCONN Vision Center will also solicit additional private donors and foundations with pledges payable over the next five years.

Recognizing the many years of continuing support by the Connecticut Lions, the new center will be designated "The Connecticut Lions Vascular Eye Center at UConn." Appropriate plaques and signs will display the Lions, and the International Foundation's logos. All publications and scientific presentations at national and international meetings will acknowledge Lions organization support, and periodic tours and conferences arranged for Connecticut Lions officers.

PHASE I PROJECT BUDGET PROSPECTUS

To move the project forward, a grant from Lions Club International Foundation of ($75,000) is requested to assist in the purchase of critical patient imaging equipment and the recruitment of new fellows in vascular eye studies.

Project Income      
  Connecticut Lions Eye Research Foundation      
    Multiple District 23 Club Pledges     75,000
  LCIF Grant     75,000
  UCONN Lions Vision Center         50,000
Total Project Income     $200,000
 
Project Expenses      
  A. Upgraded Imaging Capabilities      
    1. High Resolution System 55,000    
    2. 50EX Retinal Camera 25,000    
    3. Fluorescein Slit Lamp 25,000    
    4. Non Mydriatic Camera  25,000    
    Retinal and Slit Lamp Cameras   130,000  
  B. Imaging Services and Supplies      
    1. Kodak Printer 7,000    
    2. Supplies and Maintenance 8,000    
    3. Postdoctoral Fellow Support (2 years) 55,000    
            70,000  
Total Project Expenses     $200,000

Expense Narrative

A first priority in the new center will be to link laboratory and clinical studies of the eye microvessels. For this, we must first equip clinical spaces with state-of-the-art instruments that will increase accuracy and efficiency and enable us to recruit an additional young postdoctoral fellow investigator in eye vascular research. The following equipment list is therefore arranged under four headings: Retinal Microvascular Imaging; Anterior Segment Microvessels; Community Screening Outreach and Imaging Services and Supplies.

A.  Retinal Microvascular Imaging Equipment ($55,000)
  Our initial investigations of retinal imaging began in 1995, funded by Connecticut Lions dollars. Recent improvements in the optics and resolution of available cameras make it essential to update this equipment as soon as possible.

Highly magnified images of individual microvessels in the retina and optic nerve can now be obtained by replacing the retinal camera and computer software. The current 624 x 624 image pixel density will increase nearly five-fold to 3000 x 2000. With this technology, the fine details of individual microvessels can be visualized in color, fluorescein dye angiography or high contrast red-free black and white images.

This upgrade will be especially important in studies of new retinal blood vessel formation in diabetes (angiogenesis), and in evaluations of vessels in optic nerve pallor or cupping. For example, during fluorescein dye injection studies, the blood flow in the optic nerve microvessels can be verified in a greatly magnified nerve head. The equipment will also detect fine retinal vessel changes in numerous other diseases such as hypertension and macular edema.

Parallel laboratory studies of vessels in the optic nerve and retinas of diabetic and aging rats will be visualized by electron microscopy at 75-100,000 X magnifications. In this way the damage observed in patient microvessels can be interpreted in terms of microscopic changes in individual vessel cells.

B.  Anterior Segment Microvessels ($50,000)
  Microvessels of the iris and ciliary body show fluorescein dye leakage in diabetic and glaucomatous eyes. This microvascular change is not evaluated in current patient studies. Dye fluorescence in the adjacent aqueous humor fluid can now be measured using a late model fluorescein slit lamp and digital camera ($50,000). This can be done in dilated eyes following the completion of routine retinal angiograms without additional dye injection. The results will be compared to electron microscopic images of diabetic rat microvessels in the iris.
C.  Community Screening Outreach ($25,000)
  A new retinal imaging program will utilize the services of an experienced imaging technician and a vascular biology postdoctoral fellow.

Since 1999, UCONN collaborative studies with the Connecticut Lions LEHP program have assisted the development of a new imaging approach to screening for retinal diabetes using portable units. Aided by a grant from Lions Clubs International Foundation in partnership with Eli Lilly Inc, LEHP volunteers have begun this effort in Connecticut communities. The intent is to better educate persons having diabetes, and to determine why more than half are reluctant to obtain annual retinal examinations. This problem is the main barrier in our efforts to prevent diabetic blindness.

In further support of this effort, the Vascular Eye Center will establish a year-round university hospital retinal imaging screening service for diabetic and glaucoma patients. This will be staffed by an imaging technician. These undilated retinal images will utilize a Topcon non-mydriatic retinal camera with computer and color printer ($25,000). The intent is to better educate patients about their own microvessels by giving free instruction, copies of their own retinas and informative booklets. Our recent surveys have confirmed that conventional patient education programs about diabetes self-care do not provide the detailed information needed to motivate regular retinal examinations. Clear pictures of retinas in our "Know Your Retina" program will do this.

D. Imaging Services and Supplies
  Operation of the upgraded imaging equipment requires a trained technician, now on hand, and a postdoctoral M.D. fellow in training in eye microvascular diseases. Fellowship support in the amount of $55,000 supplemented by research grants will initiate the program over two years after which service revenues will be available. Photographic paper and state of the art color printing ($7,000) are essential to visualize small vessel details and transmit to discs for storage and mail out. Approximately $8,000 will be required for specialized set-up and maintenance of the equipment as well as supplies and patient information booklets.

PHASE II

Operational Strategy

Diabetes: Typical studies of diabetic eye microvessels will examine the course of microvascular changes in young and aging animals. The influence of elevated blood pressure in hypertensive animals on microvessels changes will be correlated to diabetic changes, as will natural aging effects. Density in the outer collagen coat of microvessels associated with nitric oxide deficiency will be related to changes in vessel wall nerve fiver enzyme secretions. Patterns observed will be related to interpretations of microvascular retinal images in patients.

Glaucoma: In typical projects the capacity of optic nerve and iris tissues to release a clot-dissolving enzyme from microvessel and smooth muscle nerve fibers will be measured and compared to ultramicroscopic images of enzyme locations in such vessels. Effects of tobacco and alcohol on these functions must be evaluated. Location of the glaucoma optineuron gene in precise regions of microvessel walls is also necessary.
Macular Retina: Enzyme release functions will be first examined in response to destruction of sympathetic nerve fibers in choroid microvessels by chemical sympathectomy.

Funding Strategy

With a goal of $150,000 needed for laboratory equipment at the Connecticut Lions Vascular Eye Center at UConn, CLERF has committed to raise $50,000 over the next two years through solicitations of Lions Clubs in Multiple District 23. District 23-B will apply to LCIF for a standard grant in the amount of $50,000. The Center at UConn has set aside $50,000 in a Vascular Eye account and will continue to fund eight scientists and staff salaries at $1.4 million. In the UConn 21st Century Building Program, $300 million will support new research laboratory improvements. The Center will also solicit private gifts from individuals and foundations with pledges payable over the next five years.

PHASE II PROJECT BUDGET PROSPECTUS

To move the project forward, a grant from Lions Club International Foundation of ($50,000) is requested to assist in the purchase of critical patient imaging equipment and the recruitment of a vascular eye research postdoctoral fellow.

Project Income      
  Connecticut Lions Eye Research Foundation      
    Multiple District 23 Club Pledges     50,000
  LCIF Grant     50,000
  UCONN Lions Vision Center         50,000
Total Project Income     $150,000
 
Project Expenses      
  A. Microvascular Physiology Laboratory      
      Leiden Microincubators, Perfusion System   50,000  
  B. Micro Vascular Immunohistochemistry      
    1. Cryostat 20,000    
    2. Fluorescent Plate Reader, Gene Scanner 25,000    
          45,000  
  C. Imaging Services and Supplies      
    1.  Electron Scanning, Confocal Microscopy 20,000    
    2. Postdoctoral Fellow Partial Stipend 35,000    
          55,000  
Total Project Expenses     $150,000

Expense Narrative

A first priority in the new center will be to link laboratory and clinical studies of the eye microvessels. For this, we must first equip clinical spaces with state-of-the-art instruments that will increase accuracy and efficiency and enable us to recruit an additional young investigator in eye vascular research. The following equipment list is therefore arranged under three headings: Microvascular Physiology; Micro Vascular Immunohistochemistry; and Electron/Confocal Microscopy Services and Personnel.

A.  Microvascular Physiology ($50,000)
  These laboratory studies examine and culture dissected animal eye microvessels in tissue baths and measure-released products including enzymes, inhibitors and constructing agents from the eye blood vessels and nerve fibers. Similar studies examine the vessels in dissected optic nerves. These methods involve periodic immunochemical assays of the incubation bath fluids for released enzymes and related proteins.

The intent of the studies is to detect changes in the vessel-nerve release levels associated with diabetes, glaucoma and vascular aging of the macula. They also examine the choroid, the accessible network of microvessels that underlies the retina, diffuses vital oxygen and nutrients to the retina. Little is known about the response of choroid microvessels to diabetes, macular diseases or glaucoma. Our laboratory recently discovered that small choroid vessels (15 micron diameter) contain fine nerve fibers that release enzymes into the capillary bloodstream, as shown in Appendix A Figures

The techniques used in these studies where developed in our laboratory ten years ago. They now require a new Leiden Microincubator organ culture, computerized pump and perfusion apparatus and dissecting microscope ($50,000). A full time postdoctoral fellow will be recruited in vascular biology to conduct these experiments.

B.  Micro Vascular Immunohistochemistry ($45,000)
  The preparation and analysis of gene expression in eye blood vessel cells requires the use of fluorescent dyes tagged to antibodies. An important example is localization of the glaucoma gene (Optineuron) in eye microvessels. The gene and its prominent presence in eye blood vessel cells were discovered in our Ophthalmology Molecular Genetics Laboratory last year. Continuation of this work requires access to a fluorescence microplate reader (25,000). In addition to conventional fluorescent microscopy in intact tissues, this equipment allows us to rapidly image the traffic of dye-labeled proteins within large numbers of isolated cells.

The preparation of ultrathin (0.5 micron) sections of frozen eye tissues requires the use of an improved cryostat machine ($20,000). These sections are cut at minus 50 degrees centigrade temperatures and require delicate handling while immunostained with antibodies.

C.  Electron/Confocal Microscopy Services and Personnel ($55,000)
  Major research equipment is available to us in the present Vision Center and an adjacent laboratory on a fee-for-service basis.

Scanning electron microscopy (SEM) enables one to visualize in 3/D the outer surface of tiny eye blood vessels in animal tissues. This surface contains the network of nerve fibers that contract vessels, and also releases a clot-dissolving enzyme into the blood, as discovered in our laboratory. The outer surface also contains membrane protein receptors that trigger these processes, as noted.

The Center will produce new SEM three-dimensional images of nerve fibers and receptors on the retinal and optic nerve microvessels. The surfaces will be immunostained with antibodies tagged on micron gold particles that bind to these receptors and enzymes. The process is labor intensive and requires long-term access to a scanning microscope. The benefit to retinal diabetes and glaucoma research is a clearer understanding of the vessel processed that are damaged by these diseases.

These services will cost $20,000 over two years. Until funded by new federal grants partial stipend support of a vascular biology fellow required to conduct these studies is $35,000.

More Information - At the University of Connecticut: Lions Vision Center: Retinal Diagnostic Imaging Service

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