Defective cone photoreceptor cytoskeleton, alignment, feedback, and energetics can lead to energy depletion in macular degeneration.

Macular degeneration (MD) is a puzzling disease characterized by disturbance, and then complete loss, of fine detailed vision in the central macular region of the human retina, as a result of disturbed function and then death of photoreceptor cells. This review describes a possible pathomechanism for MD that involves a causal relationship between mutated genes, altered photoreceptor cytoskeletal proteins, defective cone photoreceptor alignment, and disturbed visual feedback mechanisms that leads to energy depletion and apoptosis of macular cone photoreceptors. MD may be associated with mutations in genes encoding certain photoreceptor proteins (ATP-binding cassette transporter retina, retinitis pigmentosa GTPase regulator, retinal degeneration slow/peripherin) that are components of, or interact with, microtubule-containing cytoskeletal systems at the connecting cilium of rods and cones and at the multiple incisures of rod outer segments (OSs). Vertebrate photoreceptors are directionally sensitive: the longitudinal axis of each cell is actively aligned towards the entrance pupil of the eye, and the cells are most sensitive to light travelling along this axis (as in the Stiles-Crawford effect). The mechanisms responsible for photoreceptor alignment involve movements made by photoreceptors in response to the direction of incident light, using their cytoskeletons. A model is proposed for photoreceptor alignment whereby light absorption in the OS causes fast membrane and slower cytoplasmic changes that spread from the OS to the inner segment myoid, where they activate feedback-controlled motor functions by cytoskeletal elements (microtubules and microfilaments) to produce a differential local bending that adjusts photoreceptor orientation. The fovea at the center of the human macula has specialized features that enable it to provide uniquely high visual acuity, if its cones are accurately aligned. Accordingly, it is proposed that some gene defects in MD cause disturbances at photoreceptor connecting cilia that lead to gradual defects in photoreceptor alignment; misalignment of central macular cones will be initially perceived as blurring, distortions, and decreased acuity of central vision. Although photoreceptors throughout the retina use their cytoskeletons for alignment, the accurate alignment of foveal cones is particularly important because their signals contain fine resolution information that is used in visual feedback systems, e.g., for adjusting accommodation and eye movements. Vision involves multiple feedback loops that are interdependent, e.g., the accuracy of alignment of foveal cones influences how effectively changes in accommodation bring images into focus, and the state of accommodation in turn influences how light entering the eye is projected onto foveal cones. It is proposed that in MD gene defects that disturb the cytoskeleton and alignment of photoreceptors lead to a disturbance in the normal signalling within these feedback systems, causing the mechanisms controlling the alignment of cones in the center of the macula to become progressively more disturbed and the cells to unnecessarily expend energy. These disturbances can lead to local energy depletion within the metabolically fragile central macular cones that trigger them to die, producing central areas of blindness. If this line of reasoning is correct, it may be possible to treat the local energy depletion within macular cones in MD by energy supplementation. Copyright 2004 Elsevier Ltd.