Oxygen-induced retinopathy (OIR) is a well-characterized model for retinopathy of prematurity, a disorder that results from rapid microvascular proliferation after exposure of the retina to high oxygen levels. Here, we report that the proliferative phase of OIR requires transcriptional induction of the annexin A2 (A2) gene through the direct action of the hypoxiainducible factor-1 complex. We show, in addition, that A2 stabilizes its binding partner, p11, and promotes OIR-related angiogenesis by enabling clearance of perivascular fibrin. Adenoviral-mediated restoration of A2 expression restores neovascularization in the oxygen-primed Anxa2 ؊/؊ retina and reinstates plasmin generation and directed migration in cultured Anxa2 ؊/؊ endothelial cells. Systemic depletion of fibrin repairs the neovascular response to high oxygen treatment in the Anxa2 ؊/؊ retina, whereas inhibition of plasminogen activation dampens angiogenesis under the same conditions. These findings show that the A2 system enables retinal neoangiogenesis in OIR by enhancing perivascular activation of plasmin and remodeling of fibrin. These data suggest new potential approaches to retinal angiogenic disorders on the basis of modulation of perivascular fibrinolysis. (Blood. 2011;118(10): 2918-2929)
IntroductionRetinopathy of prematurity (ROP) is the main cause of severe visual impairment in children in the developed world. 1 A vascular proliferative disorder that affects preterm and low-birth weight infants on exposure to supraphysiologic oxygen tension, ROP is increasing in incidence with the greater availability of neonatal intensive care, and more frequent survival of very-low-birth weight infants. In the initial, vaso-obliterative phase of ROP, high oxygen exposure provokes endothelial cell death because of oxidative injury, nitrative stress, and suppression of oxygen-related growth factors. 2 In the second phase, the resulting retinal ischemia leads to neovascularization characterized by excessive proliferation and vitreal invasion of blood vessels. This pathologic response arises when neurons and supporting astrocytes become severely metabolically deprived because of vaso-obliteration and produce exaggerated amounts of oxygen-regulated angiogenic factors, such as VEGF and erythropoietin. These agents stimulate the regrowth of abnormal vessels that proliferate toward the vitreous, can form a fibrous scar, and, on contraction, can apply tractional forces that ultimately may detach the retina from its underlying pigment epithelium. Scarring and retinal detachment can lead to vision loss and blindness. Current preventive measures for ROP include restriction of tissue oxygenation and the use of antioxidants, whereas standard treatment for established disease requires ablative laser photocoagulation or cryotherapy. Newer therapies with VEGF-neutralizing antibodies appear promising, but their effects on retinal ganglion cell integrity, the developing cerebral vasculature, and long-term visual acuity and visual fields are unknown. 2 Annexin A2 is a cell...