Reviewer #1 (Public Review):
Summary of what the authors were trying to achieve
Background: Myopia (short- or near-sightedness) is an ocular disorder of increasing concern to human individuals and health-care systems; these days one speaks of a "myopia epidemic" in developed countries. Usually it is due to excessive elongation of the optic axis of the eye during the ages of most rapid growth (ca. 5-16 years in humans), causing images of distant objects to be blurred at the retinal photoreceptors. The optical error can be corrected with lenses or corneal surgeries, but this does not reduce the risk of continued progression and vision loss. Despite extensive epidemiological and animal studies in the past several decades, the underlying causal mechanisms remain poorly known, and therapeutic options are limited. Therefore, further discovery of new candidate mechanisms, drug targets and drugs for inhibiting the onset and progression of myopia is urgently needed.
Rationale: The axial length of the eye is regulated mainly by qualities of the visual environment, including light intensity, spectrum, and spatiotemporal characteristics of images on the retina. Thus the retina encodes and integrates visual information over time, and ultimately sends regulatory "grow" or "stop" signals via the choroid - a vascular plexus behind the retina - to the sclera, the fibrous outer coat of the eye. Changes in size (area) of the sclera are responsible for changes in axial length, and thereby, refraction. The choroid is in a critical position, not only to relay "stop" or "go" messages to the sclera, but also potentially to critically modify those signals (or generate signals of its own) and further modulate ocular elongation and refraction. Importantly, very little is known about how the choroid fulfills either of these roles.
Aims of the Study: The authors' purpose was to test, in juvenile chicken models, whether the 'pro-inflammatory' cytokine, interleukin-6 (IL-6) - synthesized and released in the choroid - might play a key role in the developmental regulation of axial elongation and refraction of the eye.
Major strengths and weaknesses of the methods and results
Strengths:
1. The studies are focused on the choroid, which must be important in regulating ocular growth and refraction, but whose role is still not well understood
2. Expert use of front-line tools for quantifying mRNA and protein (microarray, RT-PCR, ELISA)
3. Immunohistochemistry: Good choice of antibody (raised to chicken IL-6), appropriate specificity control (preabsorption with chicken antigen)
4. IL-6 mRNA in choroid was impressively increased during recovery from form-deprivation myopia (FDM) (preliminary results, Fig. 2) - i.e., during strong positive (myopic) defocus - a defocus-dependent effect confirmed by a similar effect of lens-induced myopic defocus (Fig. 5).
5. Good data for the time-course of IL-6 mRNA content in choroid, with some confirmation of protein levels (though at only 2 treatment intervals) (Fig. 3)
6. Choroidal IL-6 mRNA also shown convincingly to increase, going from darkness to light (Fig. 4).
7. It's clever to compare the growth- and myopia-inhibiting effects of positive defocus, with those of other treatments known to do the same - in this case, atropine and nitric oxide (NO). The evidence shows that the effects of these agents on choroidal IL-6 mRNA are similar to the effect of positive defocus, with an NO-donor increasing the amounts of IL-6 mRNA and protein in isolated choroid (Fig. 7), and a NOS-inhibitor decreasing the mRNA levels at an intravitreal dose that inhibits scleral growth (Fig. 6).
8. If my calculations are correct, 0.1% atropine sulfate solution has a molarity of something like
1.3 mM. Since alpha-2A adrenoreceptors are present in the choroid, of mammals at least (e.g., Wikberg-Matsson et al., 1996, Exp Eye Res, 63(1):57-66), it might be interesting to explore the possibility that atropine is stimulating IL-6 production in the choroid by acting as agonist via these receptors (cf. Carr et al., 2018, IOVS, 59m2778-2791). The isolated choroid, with IL-6 mRNA and protein synthesis as read-outs, should be an exceptional (and novel) model for testing this and other possible signalling pathways in the choroid.
Weaknesses:
1. Immunolocalization of IL-6: The images (Fig. 1) are not good enough to identify cellular localization of immunoreactive structures; identification of RPE is questionable (no DAPI+ nuclei in labeled 'RPE'); nucleated erythrocytes should be visible in vessel lumina.
2. Many important details of methods have been left out. Spectral peaks of LED light-sources need to be given, lines 409-412; that's just one of many examples.
3. Intensity (illuminance) of "red" and "blue" lights seems unnecessarily low (58 and 111 lux, respectively, far below the "medium" and "high" intensities of white lights that were used; Fig. 4).
4. Also, given that red and blue lights have been found to have opposite effects on FDM in chicks (e.g., Wang et al., 2018, IOVS, 59(11):4413-4424), the similarity of IL-6 responses to red and blue in the present study strikes me as a point against a role for IL-6 in regulation of eye growth.
5. I admire the thoroughness of confirming that some of the treatments did in fact have the predicted effects on ocular enlargement, by performing assays for scleral proteoglycan synthesis. This might not be essential to this work, although it is well done, and the scleral data won't detract from the value of the paper if retained. But the induction of opposite effects on eye (scleral) growth by such manipulations is well established, and much simpler (cheaper and faster) refraction and/or caliper measurements would have served the same purpose.
6. I don't buy the argument that the source of NO is not in the choroid (lines 337-340), based on the failure of L-Arg to change significantly the amount of choroidal IL-6 mRNA (Fig. S1). Several thoughts come to mind here: (a) It is solidly established that the choroid is richly innervated with NO-synthesizing nerve fibres, and that its content of NOS is very high [e.g.: "NOS activity is widely distributed in the eye, (choroid > retina > CP > TM) ..."; Geyer et al., 1997, Graefes Arch, 235(12):786-93; also (among others): Wu et al., 2007, Brain Res., 1186m155-63; Hashitani et al., 1998, J Physiol, 510(1):209-223; Fischer & Stell, 1999, cited in the present MS.]. So, there clearly are sources of NO within the choroid, in chicks as in mammals. (b) It's extremely unlikely that "NO, released from the retina ... diffuses to the choroid to stimulate IL-6 synthesis", because NO is highly reactive and has a short half-life, restricting its diffusion. But yes, NO generated by iNOS in the RPE certainly could reach choroidal targets; is there anything in the literature to indicate that iNOS mRNA and protein are increased in the RPE, under conditions or treatments that inhibit axial elongation? (c) The critical experiment to test this idea - treating the isolated choroid with a NOS-inhibitor, to block synthesis of NO by cells in the choroid - was not performed here.
That would be a complicated and difficult exercise, however, requiring the invention of a way to stimulate NOS activity to a new base-level, and then being able to detect effects due to the inhibition of NO-synthesis. It would be good to discuss the issues raised in this point, but acceptable to suggest this as another of the questions that would be suitable to address by further experimentation beyond the scope of this paper.
7. Since it's overwhelmingly likely that NO is synthesized and released locally in the choroid, alternative explanations must be considered for why the NO-donor, PAPA-NONOate, caused increases in IL-6, while L-Arg didn't. Might it have been the case, for example, that the NOS- containing choroidal cells already were fully loaded with L-Arg, under these particular experimental conditions? or that the administered concentration of L-Arg was sub-optimal? or that the proportions of cellular mass to fluid volume in the choroidal samples were highly variable, causing high variance of the individual values? or that the parent compound PAPA- NONOate, however attractive 'his' name, had destinations in mind (molecular targets, actions) in addition to or other than sGC? Any one of these hypotheses might account for the fact that
L-Arg reduced the mean level of IL-6 mRNA by almost 50%, but with p=0.14 despite the sample size n=16.
8. The results of the bulk assays - of whole choroids - are a good beginning, starting to build a map of largely uncharted territory; but they will never be completely satisfactory for constructing signalling pathways or networks for visual regulation of scleral expansion, and will leave one struggling to make sense of it all (cf. lines 345-347). Better immunolabeling, with better image definition and resolution, the addition of single-label images and bright-field images (to locate the RPE securely), and possibly FISH would be helpful for this. If you're rich, have great local resources, and/or are well connected with others who do, scRNA-seq of dissociated choroidal tissue (with RPE and sclera as controls) would have great potential here. If the tissue has been perfused intravascularly or well washed and drained, to get rid of blood cells, there shouldn't be very many cell types to characterize (but, my, wouldn't it be exciting and illuminating if there were!)
9. The relationships between the studies and outcomes reported in this manuscript, and the possible role of choroidal IL-6 and other inflammation-signalling molecules in myopia, is hardly touched upon at all - just a short, very general statement near the end of the Conclusions (lines 368-374).
Whether the authors achieved their aims, and whether the results support their conclusions:
The authors have made a very convincing case that myopic defocus stimulates the synthesis of IL-6 mRNA and protein in the chick choroid. The effects of atropine and NO-related drugs further support the association between this action and the inhibition of excessive axial elongation and myopia.
Likely impact of the work on the field, and the utility of the methods and data to the community: This work - and in particular the use of assays for IL-6 in choroidal explants to assess the actions of candidate signalling molecules in the choroid - should be seen as an important step forward. The methods are up-to-date, but well established and straightforward, and could be easily duplicated by most workers in the field. The chick models for myopia induction and recovery have been used and refined for decades, so they are easy and almost foolproof (used successfully by many undergraduates in my lab). Once the foundations have been laid by studies in chicks, they can be translated rather easily for making similar studies in mammalian models such as guinea pigs and NHPs