Symptoms and management of cow's milk allergy: perception and evidence.

Introduction: The diagnosis and management of cow's milk allergy (CMA) is a topic of debate and controversy. Our aim was to compare the opinions of expert groups from the Middle East (n = 14) and the European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) (n = 13). Methods: These Expert groups voted on statements that were developed by the ESPGHAN group and published in a recent position paper. The voting outcome was compared. Results: Overall, there was consensus amongst both groups of experts. Experts agreed that symptoms of crying, irritability and colic, as single manifestation, are not suggestive of CMA. They agreed that amino-acid based formula (AAF) should be reserved for severe cases (e.g., malnutrition and anaphylaxis) and that there is insufficient evidence to recommend a step-down approach. There was no unanimous consensus on the statement that a cow's milk based extensively hydrolysed formula (eHF) should be the first choice as a diagnostic elimination diet in mild/moderate cases. Although the statements regarding the role for hydrolysed rice formula as a diagnostic and therapeutic elimination diet were accepted, 3/27 disagreed. The votes regarding soy formula highlight the differences in opinion in the role of soy protein in CMA dietary treatment. Generally, soy-based formula is seldom available in the Middle-East region. All ESPGHAN experts agreed that there is insufficient evidence that the addition of probiotics, prebiotics and synbiotics increase the efficacy of elimination diets regarding CMA symptoms (despite other benefits such as decrease of infections and antibiotic intake), whereas 3/14 of the Middle East group thought there was sufficient evidence. Discussion: Differences in voting are related to geographical, cultural and other conditions, such as cost and availability. This emphasizes the need to develop region-specific guidelines considering social and cultural conditions, and to perform further research in this area.

A guide to COVID-19 antiviral therapeutics: a summary and perspective of the antiviral weapons against SARS-CoV-2 infection.

Antiviral therapies are integral in the fight against SARS-CoV-2 (i.e. severe acute respiratory syndrome coronavirus 2), the causative agent of COVID-19. Antiviral therapeutics can be divided into categories based on how they combat the virus, including viral entry into the host cell, viral replication, protein trafficking, post-translational processing, and immune response regulation. Drugs that target how the virus enters the cell include: Evusheld, REGEN-COV, bamlanivimab and etesevimab, bebtelovimab, sotrovimab, Arbidol, nitazoxanide, and chloroquine. Drugs that prevent the virus from replicating include: Paxlovid, remdesivir, molnupiravir, favipiravir, ribavirin, and Kaletra. Drugs that interfere with protein trafficking and post-translational processing include nitazoxanide and ivermectin. Lastly, drugs that target immune response regulation include interferons and the use of anti-inflammatory drugs such as dexamethasone. Antiviral therapies offer an alternative solution for those unable or unwilling to be vaccinated and are a vital weapon in the battle against the global pandemic. Learning more about these therapies helps raise awareness in the general population about the options available to them with respect to aiding in the reduction of the severity of COVID-19 infection. In this 'A Guide To' article, we provide an in-depth insight into the development of antiviral therapeutics against SARS-CoV-2 and their ability to help fight COVID-19.

Understanding the complexity of the matrix metalloproteinase system and its relevance to age-related diseases: Age-related macular degeneration and Alzheimer's disease.

Extracellular matrices (ECMs) are maintained by tightly coupled processes of continuous synthesis and degradation. The degradative arm is mediated by a family of proteolytic enzymes called the matrix metalloproteinases (MMPs). These enzymes are released as latent proteins (pro-MMPs) and on activation are capable of degrading most components of an ECM. Activity of these enzymes is checked by the presence of tissue inhibitors of MMPs (TIMPs) and current opinion holds that the ratio of TIMPs/MMPs determines the relative rate of degradation. Thus, elevated ratios are thought to compromise degradation leading to the accumulation of abnormal ECM material, whilst diminished ratios are thought to lead to excessive ECM degradation (facilitating angiogenesis and the spread of cancer cells). Our recent work has shown this system to be far more complex. MMP species tend to undergo covalent modification leading to homo- and hetero-dimerization and aggregation resulting in the formation of very large macromolecular weight MMP complexes (LMMCs). In addition, the various MMP species also show a bound-free compartmentalisation. The net result of these changes is to reduce the availability of the latent forms of MMPs for the activation process. An assessment of the degradation potential of the MMP system in any tissue must therefore take into account the degree of sequestration of the latent MMP species, a protocol that has not previously been addressed. Taking into consideration the complexities already described, we will present an analysis of the MMP system in two common neurodegenerative disorders, namely age-related macular degeneration (AMD) and Alzheimer's disease (AD).

Modulating the Transport Characteristics of Bruch's Membrane With Steroidal Glycosides and its Relevance to Age-Related Macular Degeneration (AMD).

PURPOSE: Beneficial expectations of supplement therapies to increase the transport of nutrients, vitamins, and antioxidants across Bruch's membrane in AMD, by mass action alone, remain inconclusive. Therefore, the potential for targeting the transport pathways themselves to improve bidirectional exchange using amphipathic steroidal glycosides (ginsenosides) has been investigated. METHODS: Bruch's choroid preparations were mounted in modified Ussing chambers and basal levels of hydraulic conductivity (23 donors, age range, 12-89 years) and diffusional transport of FITC-albumin (21 donors, age range, 12-92 years) quantified. Then, following a 24-hour incubation with ginsenoside preparations, the transport parameters were re-evaluated and the resulting data analyzed with respect to aging and modulation by ginsenosides. RESULTS: Basal hydraulic conductivity of Bruch's showed an age-related exponential decline with a half-life of 19 years. Incubation with ginsenosides improved hydraulic conductivity with levels equivalent to donors 19 years younger. Across the age range examined, hydraulic conductivities were increased to 2.05-fold ± 0.38 (P < 0.001) of basal values. Diffusional transport of albumin across Bruch's also showed an age-related exponential decline with a half-life of 18 years. The decay curves were elevated on incubation with ginsenosides and diffusional rates were equivalent to donors 15 years younger. Diffusional rates were elevated 2.01-fold ± 0.49 over basal values (P < 0.001). CONCLUSIONS: Transport characteristics of human Bruch's can be improved by ginsenosides, facilitating the bidirectional exchange of nutrients and waste products across the membrane. With improved transport pathways, the need for supplement therapies becomes redundant. Slowed aging of Bruch's is expected to delay the onset and/or progression of AMD.

Characterization of the gelatinase system of the laminar human optic nerve, and surrounding annulus of Bruch's membrane, choroid, and sclera.

PURPOSE: We determined the presence and levels of gelatinase matrix metalloproteinases (MMPs) in the optic nerve and surrounding rim region of the human fundus. METHODS: Samples of optic nerve, rim region, and Bruch's membrane-choroid from macular and peripheral regions were isolated from 9 pairs of human donor eyes. The MMPs were extracted and separated by gelatin zymography. Individual gelatinase species were identified by their respective molecular weights and levels quantified by standard densitometric techniques. Ratios of active/latent MMPs were calculated as representative indicators of the degree of proteolytic activity at each of the locations examined. RESULTS: All of the gelatinase species normally found in Bruch's membrane also were present in the optic nerve region. The presence of the high molecular weight MMP species (HMW1 and HMW2) was indicative of the age-related accumulation of polymerized MMPs 2 and 9. Level of activated MMPs was considerably raised in comparison with their latent forms at the optic nerve and surrounding region indicative of greater ongoing turnover of the matrix (P < 0.005). CONCLUSIONS: The components of the gelatinase pathway mediating matrix turnover in Bruch's membrane also were present in the optic nerve region. The presence of high levels of active MMPs 2 and 9 in comparison with the latent forms in the optic nerve and rim area is indicative of a high rate of matrix remodeling in these regions. Enhanced matrix turnover within the optic nerve region may represent an important mechanism for maintaining the plasticity of the lamina cribrosa.

Laser-mediated activation of human retinal pigment epithelial cells and concomitant release of matrix metalloproteinases.

PURPOSE: To investigate cellular dynamics and associated matrix metalloproteinase (MMP) release patterns of human retinal pigment epithelium (RPE) cells subsequent to irradiation by nanosecond pulsed laser at energy levels below visual threshold. METHODS: Following a stabilization period, human RPE-Bruch's-choroid explants were irradiated with a nanosecond laser system (Q-switched, frequency doubled YAG laser, 532 nm), using a 400 µm spot size with a discontinuous energy distribution and total irradiance of 240 mJ/cm², and returned to the incubator for a further 14 days. RPE cellular dynamics were assessed using confocal laser scanning, conventional microscopy, cell viability, and proliferation assays. MMPs were quantified by gelatine zymography and densitometry. RESULTS: Within 4 hours of laser intervention, 47% ± 8% (mean ± SEM, n = 6) of the RPE cells within the treatment zone showed clear signs of injury. By posttreatment days 10 to 14, most of the injured beds were repopulated by migrating RPE cells from regions surrounding the lesion. Release of inactive MMP-2 was little altered over the 2-week experimental period, whereas levels of inactive MMP-9 increased 1.3-fold by day 1 to reach a 2.8-fold threshold by day 7 (n = 4; P < 0.05). However, changes in activated MMP-2 and MMP-9 were much more profound with levels increasing 6.7 ± 2.6-fold (mean ± SEM, n = 6; P < 0.001) and 4.4 ± 1.1-fold (mean ± SEM, n = 5; P < 0.01), respectively, above controls at day 7 post laser. CONCLUSIONS: The nanosecond laser pulse modality provides an avenue for transiently increasing the RPE-mediated release of active MMP enzymes. The likely impact of this enzymatic release on the structural and functional aspects of aging Bruch's membrane requires further evaluation.

Disturbed matrix metalloproteinase activity of Bruch's membrane in age-related macular degeneration.

PURPOSE: To evaluate the potential role of the matrix metalloproteinase (MMP) system of Bruch's membrane in the pathology of age-related macular degeneration. METHODS: Free and bound pools of gelatinase activity in Bruch's membrane-choroid preparations were isolated by phosphate-buffered saline (PBS) and sodium dodecyl sulfate (SDS) extraction, respectively. Individual MMP species were separated by gelatin-substrate zymography and the levels were quantified by densitometric techniques. Altogether, 13 control (age range, 71-99 years) and 6 AMD (age range, 71-95 years) donor eyes were used. RESULTS: All the gelatinase components normally present in control samples were also present in AMD tissue without any significant differences in their molecular masses. Total levels (bound plus free) of active MMP2 and -9 were significantly reduced in AMD donors (P < 0.05). The decrease in active MMP2 may be attributable to a similar reduction in the level of free pro-MMP2, the precursor to the active form. Reduction in active MMP9 occurred despite a nearly 3.5-fold increase in free pro-MMP9. The high-molecular-mass gelatinases denoted by HMW1 and -2 and comprising homo- and heteropolymers of pro-MMP2 and -9 were also raised in AMD (P < 0.05). The sequestration of free pro-MMP2 and -9 by these high-molecular-mass complexes may further contribute to reduced rates of activation of MMPs. CONCLUSIONS: The reduction in the levels of activated MMP2 and -9 may be responsible for impaired matrix degradation of Bruch's membrane, leading to the pathology associated with AMD. The degradation pathway is therefore a viable therapeutic target for future intervention.

Increased sequestration of matrix metalloproteinases in ageing human Bruch's membrane: implications for ECM turnover.

PURPOSE: The ageing of Bruch's membrane is associated with progressive reduction in the degradation of the capacity for ECM turnover mediated by the matrix metalloproteinase (MMP) system. In this study, the free and bound pools of all gelatinase species were quantified to aid in assessing the likelihood of reduced availability of pro-MMPs for activation in ageing Bruch's membrane. METHODS: Bruch's membrane from macular locations (10 eyes; donor age range, 21-84 years) was mounted in Ussing chambers and eluted with phosphate-buffered saline to release the free pool of MMPs. Free and bound pools of MMPs were subjected to gelatin zymography, and individual gelatinase species were quantified by densitometric scans. RESULTS: The zymograms displayed six gelatinase species: four corresponding to the pro- and active forms of MMP-2 and -9 and two high-molecular-weight polymeric forms designated HMW1 and -2, corresponding to approximate molecular masses of 195 and 391 kDa, respectively. The ageing of Bruch's membrane was associated with an exponential increase in the percentage of pro-MMPs bound to the membrane (pro-MMP-2: %age bound = 0.54 exp(0.04 x age), r = 0.87, P < 0.01; and pro-MMP-9: %age bound = 5.0 exp(0.03 x age), r = 0.8, P < 0.01). A similar exponential increase was seen in the percentage of bound HMW1 species (%bound = 11.7 exp(0.018 x age; P < 0.05). The HMW2 species was virtually all bound to the membrane, but some release was observed in the very elderly. CONCLUSIONS: The ageing of Bruch's membrane was associated with progressive sequestration of MMPs reducing the free concentration and potential for activation. These changes may underlie the reduction in degradation that leads to the age-related increase in the thickness of the membrane.

High molecular-weight gelatinase species of human Bruch's membrane: compositional analyses and age-related changes.

PURPOSE: The structural and functional demise of aging Bruch's membrane is associated with a reduction in the activity of the matrix metalloproteinase (MMP) degradation system. The gelatinase component of the MMP system consists of MMP2 and MMP9 and two high molecular-weight (HMW1, HMW2) species that are yet to be characterized and whose roles in the aging process are yet to be elucidated. The purpose of this study was to determine the age-related changes in levels of expression and subunit characterization of the HMW gelatinase species of Bruch's membrane. METHODS: Gelatin zymography followed by densitometric scanning was used to quantify the level of the HMW species present. Gel-filtration chromatography allowed the fractionation of the gelatinases according to their molecular weight, and subsequent degradation of the HMW species with a mino-phenyl acetate activation, reduction, and alkylation produced subunit fragments for analysis. RESULTS: Most of the HMW1 and HMW2 pool (80% and 87%, respectively) were tightly bound to the matrix. Aging was associated with significant increases in the levels of HMW1 and HMW2 (P < 0.005 and P < 0.05 respectively). On gel filtration, a single large macromolecular complex (LMMC) was observed containing HMW1, HMW2, MMP9, and some MMP2. Activation-mediated fragmentation of HMW1 and HMW2 showed them to be composed of heteropolymers of MMP2 and MMP9. CONCLUSIONS: The age-related increase of HMW1 and HMW2, together with the formation of LMMC, resulted in the sequestration of MMP2 and MMP9, thereby reducing the free pool for activation. This is likely to contribute to reduced matrix degradation and turnover of Bruch's membrane in both normal aging and age-related macular degeneration.

Human transscleral albumin permeability and the effect of topographical location and donor age.

PURPOSE: To quantify the permeability coefficient of albumin across human sclera and to assess topographical and age-related variation. METHODS: Equatorial superotemporal scleral tissue from 15 donor eyes (mean age 60 years; range 39-84) was mounted in a modified Ussing chamber. Additional tissue was taken from the anterior and posterior superotemporal regions of six eyes, and equatorial superonasal, and inferotemporal regions of a further six eyes. Fluorescein isothiocyanate (FITC)-labeled, 0.412 mM, bovine albumin was placed in one hemichamber facing the internal scleral surface, and the rate of transscleral flux was determined over 24 hours, at 25 degrees C, with a spectrophotometer. RESULTS: Permeability coefficient for equatorial superotemporal scleral tissue at 25 degrees C (+/-SD) was 0.83 +/- 0.50 x 10(-6) cm . s(-1). The permeability coefficient adjusted for 37 degrees C (+/-SD) was 1.43 +/- 0.86 x 10(-6) cm . s(-1). The effect of donor age was assessed for the 15 equatorial superotemporal samples. Regression analysis showed a significant decline in scleral diffusion of albumin with increasing donor age (P = 0.0166). There was no significant difference in diffusion over the different topographical regions tested. The partition coefficient of permeability to albumin also showed a decline with increasing donor age (P = 0.001). CONCLUSIONS: The permeability and partition coefficients of human sclera both significantly decline with increasing donor age. Permeability coefficient shows no significant variation over the different topographical regions tested. The decrease in albumin permeability with increasing donor age may have pharmacokinetic implications when considering transscleral diffusion of high-molecular-weight compounds.

Effect of taurine and apical potassium concentration on electrophysiologic parameters of bovine retinal pigment epithelium.

The purpose of this study was to assess the effect of taurine and apical potassium concentration modelling in vivo light evoked changes on the transepithelial potential (TEP) and the transepithelial resistance (TER) of isolated bovine retinal pigment epithelium (RPE). Isolated specimens of bovine non-tapetal RPE-Bruch's-choroid (RPE-BC) were mounted in modified Ussing chambers. The apical and the basolateral side of the preparations were exposed to 10 mm and 10 microm concentrations of taurine in Krebs' medium with either 6.04 or 2.2 mm potassium in the apical compartment. TEP and TER were recorded over 140 min. TEP and TER decreased with exposure to taurine over the course of 1 hr followed by a stabilisation. The degree of this response did not depend on the concentration of taurine but was more pronounced when taurine was added to the apical compartment. Lowering apical potassium from 6.04 to 2.2 mm further pronounced the decrease of TEP and TER. The data show that light-induced release of taurine from the outer retina and light-induced decrease of the potassium concentration in the subretinal space synergistically lead to a temporary decrease in TEP and TER. Thereby, taurine uptake into the RPE is reduced probably by a reduction of the activity of the electrogenic Na+/taurine co-transporter of the apical RPE cell membrane. The findings suggest a mechanism whereby the sustained presence of taurine in the interphotoreceptor matrix following exposure to light may protect photoreceptor outer segments from light-induced oxidative stress.

Taurine uptake by human retinal pigment epithelium: implications for the transport of small solutes between the choroid and the outer retina.

PURPOSE: To characterize the Michaelis-Menten kinetics of the taurine transporter (TT) in retinal pigment epithelium (RPE) freshly isolated from human donor eyes. To identify the rate limiting compartment in the pathway of taurine delivery from the choroidal blood supply to the outer retina composed by Bruch's-choroid (BC) and the RPE in the human older age group. METHODS: In human donor samples (4 melanoma-affected eyes, and 14 control eyes; age range, 62-93 years), radiochemical techniques were used to determine the RPE taurine accumulation at various exogenous concentrations. The transport capability of human RPE was obtained from a kinetic analysis of the high-affinity carrier over a substrate concentration of 1 to 60 microM taurine. RESULTS: Uptake of taurine into human RPE at a taurine concentration of 1 microM was independent of donor age (P > 0.05) and averaged at 2.83 +/- 0.27 (SEM) pmol/10 minutes per 6-mm trephine. Taurine transport by human RPE was mediated by a high-affinity carrier of K(m) 50 microM and V(max) of 267 pmol/10 minutes per 5-mm disc. CONCLUSIONS: In human donor RPE, uptake of taurine remained viable in the age range 62 to 93 years. Taurine transport rates in the RPE were lower than across the isolated BC complex, and thus the data suggest that the former compartment houses the rate-limiting step in the delivery of taurine to the outer retina.

Compartmental analysis of taurine transport to the outer retina in the bovine eye.

PURPOSE: To assess the relative resistance presented individually by Bruch's membrane-choroid (BC) and the retinal pigment epithelium (RPE) to movement of taurine between the choroidal circulation and the outer retina. To quantify the effect of light-evoked changes in subretinal potassium concentration on the transepithelial transport of taurine across bovine RPE. METHODS: Transport studies were performed in Ussing chambers with intact and RPE-denuded specimens of BC. RPE viability was monitored by recording transepithelial potential (TEP) and transepithelial resistance (TER). Taurine transport with substrate concentrations in the micro- and millimolar range, reflecting physiological taurine concentrations in plasma, retina, and subretinal space was quantified by high-performance liquid chromatography (HPLC) and radiotracer techniques. Taurine transport was also assessed after apical potassium concentration was lowered from 6.0 to 2.2 mM to mimic the effects of light. RESULTS: Transport of taurine across RPE-BC at a 10-mM substrate concentration increased from 32.92 before to 111.72 nanomoles/4 mm per hour after removal of the RPE. Similarly, at 50 microM taurine, transport rates increased from 0.158 to 0.439 nanomoles/4 mm per hour after removal of the RPE. At both high (10 mM) and low (50 microM) substrate concentrations, lowering of apical potassium was associated with decreased transport of taurine across the RPE. For taurine concentrations greater than 42 microM, the rate-limiting compartment for transport of taurine to the outer retina was the RPE monolayer. Similar rates were observed across each compartment for concentrations <42 microM. CONCLUSIONS: The magnitude and directionality of taurine transport across the RPE is determined solely by the driving taurine concentration gradient and is modulated by subretinal levels of potassium. Such modulation may provide a mechanism for conserving retinal taurine. Processes that increase the resistance to diffusion across Bruch's membrane such as human ageing and increased thickening and deposition of debris associated with age-related macular degeneration (AMD) are likely to affect transport across the RPE, culminating in a secondary retinal taurine deficiency.

The influence of path length and matrix components on ageing characteristics of transport between the choroid and the outer retina.

PURPOSE: To determine the relative influence of path length and matrix components on the movement of small solutes and water between the choroid and the outer retina. METHODS: Human and bovine Bruch's membrane-choroid (BC) tissue samples were mounted in modified Ussing chambers, and the diffusion of taurine and hydraulic conductivity (Lp) was determined. In humans, diffusion of taurine was determined as a function of age of the donor. The relative contribution of Bruch's membrane in the BC complex to transport processes was measured after its removal by laser ablation. Similarly, the effect of choroidal path length was determined. In humans, tracking the trend of age-related thinning provided samples of various path lengths. In young bovine animals (< or =2 years old), choroidal thickness was adjusted by laser ablation. RESULTS: Diffusion of taurine across human BC decreased linearly from 162.7 to 105.9 nanomoles/h per 3 mm between 10 and 90 years of age (P < 0.05). Ablation of Bruch's membrane increased diffusion of taurine from 129 to 287.9 nanomoles/h per 4 mm in human (donor age 55, 74, and 82 years; P < 0.005) but caused no statistically significant change in bovine BC. Diffusion of taurine across bovine BC was greater in samples with partially ablated choroid (218 nanomoles/h per 4 mm) than in normal control samples (128.75 nanomoles/h per 4 mm). Lp was not measurable in bovine samples after complete ablation of Bruch's membrane, but did not change significantly as the choroid thinned. CONCLUSIONS: The data suggest that both path length and matrix components contribute to the decline of diffusion of small solutes across BC with age. The importance of matrix components was also demonstrated in restricting the movement of water while choroidal thickness played little if any role.

Age-related alterations in the diffusional transport of amino acids across the human Bruch's-choroid complex.

Photoreceptor maintenance is dependent on effective delivery of nutrients from the choroidal circulation by way of the acellular Bruch's membrane and the retinal pigment epithelium. Aging of Bruch's membrane is associated with thickening, increased cross linking of fibers, and deposition of debris culminating in reduced porosity. The present study has investigated the effects of aging on the diffusional transport of eight amino acids across Bruch's membrane in 19 human donors. Diffusion studies were carried out in Ussing chambers, and the amount of time-dependent transfer of amino acids across the preparation was quantified by reverse-phase high-performance liquid chromatography. Diffusion rates for all amino acids showed a significant linear decline with aging of donor. The importance of this reduction in delivery of amino acids is discussed with reference to both normal physiology and age-related macular degeneration.

Expression of metalloproteinases from human retinal pigment epithelial cells and their effects on the hydraulic conductivity of Bruch's membrane.

PURPOSE: To evaluate the expression pattern of matrix metalloproteinases (MMPs) from retinal pigment epithelial (RPE) cells in culture, and to determine their ability to alter the transport properties of human Bruch's membrane. METHODS: Human RPE cells from either primary cultures or a cell line were maintained under culture conditions. At different time intervals after subculturing of cells the presence of MMPs in the bathing medium was determined by zymography. Cellular MMP activity was determined in a similar series of experiments where serum was omitted from the culture medium. Cultured cells were introduced onto Bruch's membrane, mounted in a modified Ussing chamber, to assess entry of MMPs into the membrane. Fluid flow across Bruch's membrane was determined by hydraulic conductivity for different ages of donor tissue, before and after 24 hours' incubation with active MMPs from the RPE-conditioned medium or after incubation with purified activated MMPs. Latent (inactive) MMPs from medium containing serum were used in control experiments. RESULTS: Cultured RPE cells expressed both MMP-2 and -9, with active MMP-2 becoming detectable from 4 days after subculture through to confluence and activated MMP-9 becoming abundant up to 24 hours after subculture. Both active MMPs significantly increased hydraulic conductivity of Bruch's membrane, with the increase after MMP-9 incubation being far greater than that for MMP-2. Both enzymes showed a trend in hydraulic conductivity change with age such that, MMP-2 produced a relatively constant change, whereas MMP-9 showed a greater increase in older eyes. CONCLUSIONS: Activation of both MMP-2 and -9 by cultured RPE cells appeared to show a temporal relationship with the growth cycle of the cells. The activated enzymes increased fluid flow of Bruch's membrane, and the marked effect observed with MMP-9 in older eyes suggests a mechanism that may allow debris removal.