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The Role of Epigenetics in Accelerated Aging: A Reconsideration of Later-Life

Visual Loss After Early Optic Neuropathy

Article in Journal of Neuro-Ophthalmology · November 2023

DOI: 10.1097/WNO.0000000000002041

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 State-of-the-Art Review
The Role of Epigenetics in Accelerated Aging: A
Reconsideration of Later-Life Visual Loss After Early
Optic Neuropathy
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Joseph F. Rizzo III, MD, Madhura P. Shah, BS, Drenushe Krasniqi, BA,
Yuancheng Ryan Lu, PhD, David A. Sinclair, PhD, Bruce R. Ksander, PhD
Background: In 2005, we reported 3 patients with bilateral
optic nerve damage early in life. These patients had stable
vision for decades but then experienced significant bilateral
vision loss with no obvious cause. Our hypothesis, novel at
that time, was that the late decline of vision was due to age-
related attrition of retinal ganglion cells superimposed on a
reduced neuronal population due to the earlier injury.
Evidence Acquisition: The field of epigenetics provides a
new paradigm with which to consider the normal aging
process and the impact of neuronal injury, which has been
shown to accelerate aging. Late-in-life decline in function
after early neuronal injury occurs in multiple sclerosis due to
dysregulated inflammation and postpolio syndrome. Recent
studies by our group in mice have also demonstrated the
possibility of partial reversal of cellular aging and the
potential to mitigate anatomical damage after injury and
even improve visual function.
Results: The results in mice and nonhuman primates
published elsewhere have shown enhanced neuronal survival
and visual function after partial epigenetic reprogramming.
Conclusions: Injury promotes epigenetic aging, and this find-
ing can be observed in several clinically relevant scenarios.
An understanding of the epigenetic mechanisms at play
opens the opportunity to restore function in the nervous
system and elsewhere with cellular rejuvenation therapies.
Our earlier cases exemplify how reconsideration of previ-
Department of Ophthalmology and the Neuro-Ophthalmology Service
(JFR), Massachusetts Eye and Ear and the Harvard Medical School,
Boston, Massachusetts; Avedisian and Chobanian School of Medicine
(MPS), Boston University, Boston, Massachusetts; Department of
Ophthalmology (MPS, DK, BRK), Harvard Medical School, Schepens
Eye Research Institute of Mass Eye & Ear, Boston, Massachusetts;
Department of Biology (YRL), Whitehead Institute for Biomedical Sci-
ences, MIT, Cambridge, Massachusetts; and Paul F. Glenn Center for
Biology of Aging Research (DAS), Department of Genetics, Blavatnik
Institute, Harvard Medical School, Boston, Massachusetts.
B. R. Ksander receives financial support from Life Biosciences; J. F.
Rizzo is a paid consultant for Life Biosciences; D. A. Sinclair and Y. R.
Lu are inventors of patent applications for Cellular Reprogramming
to Reverse Aging and Promote Organ and Tissue Regeneration (ID
20230048010) and Mutant Reverse Tetracycline Transactivators for
Expression of Genes (ID 20210403923) and hold equity in Life
Biosciences Inc, a company that licensed these patents to develop
epigenetic rejuvenation therapy. M. P. Shah and D. Krasniqi report
no conflicts of interest.
J. F. Rizzo and M. P. Shah contributed equally as first authors.
Address correspondence to Joseph F. Rizzo III, MD, Department of
Ophthalmology and the Neuro-Ophthalmology Service, Mas-
sachusetts Eye and Ear and the Harvard Medical School, 243 Charles
Street, Boston, MA 02114; E-mail: Joseph_Rizzo@meei.harvard.edu
Rizzo et al: J Neuro-Ophthalmol 2023; 00: 1-6
Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited.
Section Editors: Fiona Costello, MD, FRCP(C)
Sashank Prasad, MD
ously established concepts can motivate inquiry of new par-
adigms.
Journal of Neuro-Ophthalmology 2023;00:1–6
doi: 10.1097/WNO.0000000000002041
© 2023 by North American Neuro-Ophthalmology Society
I
n 2005, we (J.F.R.) posited that a significant, later-life
decline in vision occurred in 3 patients due to an aging
effect that caused a small annual but moderate cumulative
attrition of retinal ganglion cells (RGCs).1 These patients
shared an unusual feature in that each had suffered bilateral
optic nerve damage early in life due to a monophasic process
that caused elevated intracranial pressure. After decades of
stable vision, the patients then experienced visual loss with-
out an obvious explanation. This visual decline was meaning-
ful enough to necessitate a change in occupation or lifestyle.
There is a significant age-related decline in the number of
RGC axons of several thousand (perhaps up to 5,600) per
year (of an average population of roughly 1.2 million
axons).2,3 Dohlman et al quantified axonal counts on 300
human optic nerves (from birth to 96 years of age) and found
that “the older population experiences a progressive and often
substantial outfall of axons in the optic nerve.” These authors
assumed that “loss of nerve cells in the eyes contributes con-
siderably to the diminution of visual acuity of old people,”
although a “surprising” number of their patients had “no
recorded ophthalmic complaints and examination,”4 and
thus, the authors could not correlate function with structure.
Although age-related visual decline due to cataract, macular
degeneration, or some other identifiable neural process such as
glaucoma occurs commonly, a significant decline in visual
acuity later in life, as occurred in our patients, is not attribut-
able to the normal aging, although reduced contrast sensitivity
does occur with aging and may be due to neuronal attrition or
reduced neural processing.5 Curiously, the age-related decline
in optic nerve axons may be larger than that which occurs
across most of the neocortex.6,7
The etiological hypothesis that we offered in 2005 was
novel in that it suggested that progressive decline of vision in
later life could be a late residuum of damage to the optic
nerves that had occurred long ago. Our cases suggested us that
1
 State-of-the-Art Review
a superimposed effect of aging with its known RGC attrition
could become clinically significant after an earlier significant
loss of neural substrate. In this context, as individuals enter
their later years, a diminished population of RGCs would
unveil the otherwise concealed effects of aging, potentially
lowering the threshold for clinically significant visual loss.
Although we believe that our earlier assertion of an age effect
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remains valid, new evidence demands a reappraisal of the
mechanism(s) that might underlie this “aging” effect. In our
2005 article, we also suggested that a similar mechanism
might be relevant to other neurological conditions in which
progressive and clinically significant decline in function can
occur decades after an initial injury, especially if neurons
experienced metabolic stress that accelerated their aging.
The assertions in our earlier article perhaps form a basis for
an unfolding story related to epigenetic factors.
EPIGENETICS
The field of epigenetics provides a new conceptualization of
relationships between the normal aging process and cellular
adversity caused by disease. In distinction to the principles of
“genetics” that are defined as heritable traits that can be passed
from one generation to the next through DNA, the field of
“epigenetics” includes a host of molecular mechanisms that
influence the transcription of DNA and the translation of
gene products into proteins. These mechanisms exert control
over which segments of DNA are transcribed and the extent
to which proteins are translated, and thus, epigenetic factors
can alter cellular function and influence heritable traits with-
out modifying DNA nucleotide sequences (Fig. 1).
Although the term epigenetics was first coined by Conrad
Waddington in 1942, the scientific foundation of the
epigenetic field did not take root until the 1960s when
molecular biologists began to appreciate how promoter or
repressor factors influenced the expression of proteins by
bacterial DNA. Histones, which were the first epigenetic
factor found in eukaryotes, provide structural support by way
of their negative charges that keep the very long stretches of
DNA that can extend to .1.5 m, tightly compacted within
the nucleus, and impart regulatory control over DNA by
loosening the DNA structure to facilitate transcription. His-
tones can either facilitate or inhibit transcription depending
on post-translational modifications, including methylation
(which is the most well-studied), acetylation, phosphoryla-
tion, or ubiquitination. Each of these modifications changes
the propensity of DNA to be transcribed or inhibited.
Two other epigenetic factors, noncoding stretches of RNA
and the methylation of DNA, also influence transcription and
collectively these epigenetic factors guide the translation of
proteins that constitute the transcriptome. Genes and epige-
netic factors have metaphorically been referred to, respectively,
as the hardware and software governing protein production.
Epigenetic mechanisms can be influenced by a wide range of
environmental factors, including cellular or molecular stresses
2 Rizzo et al: J Neuro-Ophthalmol 2023; 00: 1-6
Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited.
that can alter the transcription process.8 The influence of
epigenetic factors may play a role in various clinical scenarios,
such as the later-life cases of visual loss discussed above or
other neurological disease discussed below.
The passage of time (i.e., aging) is highly correlated with
reduced global methylation of DNA,8–10 with regions of
increased methylation at densely packed cytosine preceding gua-
nine dinucleotide regions known as “CpG islands” that are
present in roughly 40% of mammalian genes11 and in humans
number approximately 30,000 across the whole genome.12
When located in a promoter region, highly methylated CpG
islands silence transcription at that locus. The degree of DNA
methylation at CpG islands defines a “biological clock” that is
highly linear (with q coefficients .0.98 for some clocks).13 The
age-dependent patterns and degree of DNA methylation at
CpG sites creates a code that varies across different cell types
and organs and guides tissue-specific gene transcription.
RESTORING YOUTHFUL CELLS
Yamanaka was awarded a Nobel prize in 2012 for his
discovery that activation of 4 genes (that code protein
transcription factors that control the propensity for DNA
transcription) could revert adult somatic cells (such as
fibroblasts, which were the first to be studied) into induced
pluripotent stem cells (iPSCs).14
The dedifferentiation of mature cells and loss of cell
identity required the induction of epigenetic modifiers
(known generally as DNA demethylases and specifically in
the case of these 4 genes as ten-eleven translocation
methylcytosine dioxygenases: TET1 and TET2) that
remove DNA methyl groups. In this state and with an
appropriate in vitro (i.e., embryonic) culture medium, the
somatic cells can become iPSCs. The rejuvenated methyl-
ation profile lowers the DNA age of cells, which forms the
basis for the “biological clock.” This approach, therefore,
provides an epigenetic strategy to reverse the age of cells that
can provide survival advantages when cells are injured or
metabolically stressed (as discussed below). The Yamanaka
“reprogramming” approach was effective in vitro, but when
studied in vivo, the newly dedifferentiated cellular pool
generated teratomas.15,16 Our variation on the original tech-
nical methods, described below, provides the hoped-for
metabolic advantages without tumor formation.
INJURY ACCELERATES EPIGENETIC
MARKERS OF AGING
In 1984, Drager and Hofbauer were the first to observe a
rapid change in a major protein class (i.e., heavy neurofila-
ments) within RGCs 3 days after optic nerve axotomy in
mice. The molecular basis for this change in protein
expression was neither known nor even conjectured. In
2010, Pelzel et al16 discovered decreased expression of several
RGC-related genes after optic nerve crush that was associated
 State-of-the-Art Review
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FIG. 1. Epigenetic modifications of DNA methylation and its influence on gene expression. A model for how environmental
factors affect the rate of aging and recovery from injury. Injury and DNA breakage accelerate the loss of epigenetic infor-
mation, leading to altered gene expression due to variation in activity of DNA methyltransferases. Low DNA methyl-
transferase activity (left, red arrow) increases methylation of CpG islands at gene promoter regions, which in turn increases
transcription of genes and translation into proteins (derived from the affected genes). Conversely, high DNA methyl-
transferase activity (right, green arrow) decreases methylation at gene promoter regions, which in turn decreases tran-
scription and translation of proteins.

with decreased histone acetylation, the effect of which may
have silenced apoptotic genes and thus may have improved
survival. Notably, this epigenetic change occurred within one
day of the crush injury, just after the time when decreased
somal volume is typically recognized as a very early event in
the apoptotic cascade. This discovery may have been the first
documentation of epigenetic changes in response to neuronal
injury and subsequent death in the visual system.
Our later experiments (Ksander and Sinclair labs) dem-
onstrated that murine RGCs experience an acceleration of
DNA methylation age (as determined by a ribosomal DNA
methylation clock17) within 4 days of an injury.18 Notably,
even beyond the clock CpG sites, the genome-wide patterns of
DNA methylation postinjury highly resembled the pattern of
change that occurs due to aging. Other laboratories have
found similar outcomes, including changes in DNA methyl-
ation of murine RGCs induced by metabolic stress without
overt injury and in response to ocular hypertension. In these
experiments, the epigenetic changes were more significant in
older mice. In younger mice, the induced DNA patterns
mimicked that found in naturally aged older mice
(i.e., those not exposed to ocular hypertension).19 More
recently, another group demonstrated accelerated DNA aging
in humans undergoing major surgery, or having severe
COVID-19, or even being pregnant. Remarkably, the accel-
erated DNA in these 3 scenarios returned to a normal pattern
after the period of stress,15 which suggests the existence of
some fundamental and dynamic organization of epigenetic
factors that can be reversibly modified by injury or stress.
The overall theme is that at the epigenetic level, injury
promotes epigenetic aging. The biological status of cells as
they age or experience stress or injury can be quantitatively
and reliably correlated with the extent and patterns of DNA
methylation. In general, older cells, partly because of their
hypermethylated DNA, are less able to recover from injury
by inducing protective gene expression, which presumably
makes them less resilient and more vulnerable to injury.
Bolstered by our initial success in reversing the epigenetic
age of fibroblasts without them losing their identity, our
group pioneered an exploration to reverse the epigenetic age
of ocular tissue, specifically RGCs. Our approach differed
from Yamanaka’s seminal work in 2 ways: 1) we induced
expression of only 3 of the 4 “Yamanaka genes” (i.e., Oct4,
Sox2, and Klf4: “OSK”) and 2) the induction was only “par-
tial” (i.e., limited in expression level and time, in distinction to
Yamanaka’s approach that generates induced pluripotent stem

Rizzo et al: J Neuro-Ophthalmol 2023; 00: 1-6 3

Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited.
 State-of-the-Art Review
cells) (Fig. 2).18 With these methods, we were able to induce
in aged mice more youthful patterns of DNA methylation
and transcriptomes in RGCs, and crucially, our technical
modifications did not cause cells to lose their identity or
induce tumors in vivo, even when induced for 15 months.
Next, we explored whether reversing methylation might
enable the now “younger” RGCs to more readily withstand
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stress or injury. With both an optic nerve crush model and a
microbead-induced glaucoma model with transiently raised
intraocular pressure, OSK reprogramming by intravitreal
injection 1) improved RGC survival, as documented by axo-
nal counts in the optic nerve; 2) improved RGC physiology,
documented with pattern electroretinography (pERG); and 3)
restored visual function, documented by the optomotor reflex
response. At the molecular level, treated RGCs has a more
youthful DNA methylation pattern and transcriptome, nota-
bly without erasing the identity of the neurons.18 This ability
to unwind epigenetic features to a pattern essentially matching
that of younger cells implies that these cells retain a coded
record of their youthful epigenetic DNA methylation profile.
If these results turn out to be universal, this concept
could provide a framework to develop a wide range of
therapies across various systems in the body. This possibility
is supported by studies of reprogramming nonocular
tissues.20,21 For example, the Serrano laboratory induced
reprogramming for 1 week and observed reversal toward a
younger methylome, transcriptome, and metabolome in
aged mouse pancreas, liver, spleen, and blood, with
in vivo rejuvenation in the pancreas in particular and
enhanced DNA repair and replication machinery more gen-
FIG. 2. Schematic of the proposed mechanism of partial
epigenetic reprogramming on retinal ganglion cells. The 4 Ya-
manaka factors Oct4, Sox2, Klf4, and c-Myc (OSKM) are used
routinely to make induced pluripotent stem cells. Expression of
3 of the Yamanaka factors, while leaving out c-Myc (OSK),
causes RGCs to revert to a more youthful epigenetic state
through a process that is poorly understood but requires the
DNA methylases TET1 and TET2 (ten-eleven translocation
methylcytosine dioxygenases). The reversal of gene expres-
sion patterns rejuvenates neurons and enhances recovery of
vision after injury. In the upper part of this figure, the red
arrows depict increased methylation of genes that occurs with
aging or injury to neurons. With OSK expression (lower part of
figure, with green arrow), the degree and pattern of methylation
of genes decreases, which enhances rejuvenation and recov-
ery from injury. RGC indicates retinal ganglion cell.
4 Rizzo et al: J Neuro-Ophthalmol 2023; 00: 1-6
Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited.
erally.22 In a pioneering study, the Belmonte laboratory
examined long-term OSKM expression for up to 10 months
using a short, 2 day per week cycle of induction and
observed reversal of epigenetic age and restoration of the
transcriptome and metabolome in aged mice in skin, spleen,
liver, kidney, lung, and skeletal muscle.23 In our work,
whole body viral transduction of mice reversed gene expres-
sion of accelerated aging in mice in both the muscle and
kidney.24 Collectively, these studies support our findings in
the visual system that in vivo partial epigenetic reprogram-
ming can reverse epigenetic age and improve cell function in
old tissues. Our study, however, remains the only documen-
tation of improved visual function after injury.
Regarding the future potential to restore vision to
humans, our group achieved these results in mice even
when OSK expression was induced 24 hours postinjury.
These outcomes motivated us to study whether our meth-
ods conferred a visual restorative effect in an ongoing non-
human primate model of nonarteritic anterior ischemic
optic neuropathy (NAION).25,26 If these tests provide
encouraging results and if future testing suggests that epi-
genetic manipulations could be induced safely in humans,
our approach could potentially mitigate visual loss due to
RGC injury, perhaps independent of the mechanism of
injury, assuming cell structure is maintained.
REFLECTION ON OUR CASES
The epigenetic responses to injury that accelerate aging of cells
led us to reconsider whether the later-life loss of vision
suffered by our 3 patients might have occurred, in part, due to
modified epigenetic profile to a more aged state, rather than
simply being due to aging alone. Based on the emerging body
of information, from an epigenetic perspective, injury early in
life could have accelerated the aging of the RGC, making
those cells less resilient to metabolic stress and more prone to
premature death. In this construct, the later loss of vision may
not have been due to cellular damage and dysfunction, such as
irreversible DNA mutations,27,28 telomere erosion, cell cycle
dysregulation, mitochondrial dysfunction, increased oxidative
stress, or increased inflammation, among others, but also to
epigenetic changes that accelerated aging. Indeed, our work
has recently demonstrated that epigenetic changes resulting
from DNA breaks can accelerate the loss of epigenetic infor-
mation and age-related decline in mice.24 The fact that the
epigenetic information in cells is recoverable in mouse and
human cells highlights the potentially great therapeutic oppor-
tunity that might be attainable.
EXTENDING THE AGING/INJURY CONCEPT
TO OTHER DISORDERS OF THE CENTRAL
NERVOUS SYSTEM
The general decline in function with age-related diseases
seems to be related in part to relatively low grade but more

persistent inflammation (i.e., “inflammaging”).27,29–31
Numerous mechanisms have been offered to explain why
age-related inflammation occurs, but epigenetic influences
are increasingly being considered. Regardless of the mecha-
nisms of age-related inflammation, the cellular stress and
damage caused by the inflammation might reduce a cell’s
viability, especially if the metabolic stress was continual or
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recurrent. Indeed, there are well-known examples of a late
decline in function that might be a consequence of earlier
injury. A particularly glaring example may be the inexorable
decline in neurological function associated with primary or
secondary progressive multiple sclerosis (MS) which is a
disorder caused by dysregulated inflammation.
The fact that older age increases the risk of MS pro-
gression32–36 may be due in part to age-related increase in the
inflammatory state, upregulation of immune-related genes31
and relatively poor repair of myelination later in life.37 These
observations, together with the relatively low concordance rate
in monozygotic twins, strong female sex bias, geographical
effect (increased prevalence as one moves farther from the
equator), the influence of migration (risk changes with migra-
tion to a less prevalent zone), and environmental factors that
increase the risk of MS (including exposure to ultraviolet light,
smoking, diet, level of vitamin D, and exposure to Epstein–
Barr virus)38,39 collectively suggest a prominent role of epige-
netic influences on the course of MS. This supposition is not
inconsistent with the role(s) that exposure to Epstein–Barr virus
or other factors might have. Numerous studies have found
differentially methylated regions in blood cells, including
modified methylation of human leukocyte antigen genes, and
brain tissue from MS patients which could enhance breakdown
of the blood–brain barrier due to hypermethylation of cadherin
and intercellular adhesion molecules. Alteration of the blood–
brain barrier could further contribute to increased inflamma-
tion and resultant demyelination.39 Further evidence of epi-
genetic influences in MS include differences in nucleosomal
histone acetylation or citrullination in normal-appearing white
matter of multiple sclerosis–affected brains,40,41 pathology-free
regions in MS brains having greater DNA methylation with
reduced expression of genes regulating oligodendrocyte survival,
and hypomethylation (and thus potentially increased expres-
sion) of genes related to proteolytic processing.42
Kular and Jagodic43 have recently provided a comprehen-
sive summary of epigenetic factors in the context of MS. The
growing list of epigenetic factors that relates to MS bolster the
notion that metabolic stress and injury accelerate cellular
aging, which may account for some of the functional decline
over time in MS. A natural consequence of this paradigm is
that the more aged cells would die prematurely. The visual
system provides extraordinary insight into dynamics within
the central nervous system, especially regarding the unambig-
uous evidence that the neural substrate (at the level of RGCs)
of patients with MS declines over time even in the absence of
clinical events of optic neuritis.44
Rizzo et al: J Neuro-Ophthalmol 2023; 00: 1-6
Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited.
State-of-the-Art Review
Another example of a late-in-life decline after early injury
is the postpolio syndrome (PPS).45,46 The PPS syndrome is
characterized by progressive muscle atrophy and weakness
that develops at least 15 years after an acute infection in up
to 85% of patients, although the true incidence is difficult
to assess because of varying definitions.47 The cause of PPS
is not known, but a variety of factors including “metabolic
stress,”48 “physiological aging,”45 and persistent inflamma-
tion are believed to increase the risk of progressive weakness.
Viewed through an epigenetic lens, these factors including
the advancing age of late survivors of polio, and perhaps
others, may alter the epigenetic profile and perhaps contrib-
ute to progressive weakness despite the fact that the inciting
event had occurred long ago.
AN EMERGING STORY BRINGING HOPE
FOR NEW THERAPIES
Any relatively new field of scientific study will produce
outcomes that initially can lead researchers astray. Over time,
the hope is that the foundation of knowledge leads to more
clarity. At this point in time, the emerging results in the field
of epigenetics from a wide range of laboratories make clear
that epigenetic factors impose prominent regulatory control
over gene expression. Increasing chronological age alone
modifies the epigenetic profile in highly predictable patterns,
with reduced gene expression being one consequence of those
changes. Similarly, metabolic stress or injury also modifies the
epigenetic profile, producing a more aged state that may
account for progressive decline in neurological function even
in the absence of obvious inciting events. Recent laboratory
techniques have enabled reversion of older epigenetic states,
whether induced by injury, stress, or chronological age alone,
to a more youthful configuration. Beyond OSK-based gene
therapy may lie RNA-based therapies, possibly even small
molecule approaches.24,49 Rejuvenated cells more readily
withstand injury in the visual system, even when epigenetic
changes are induced after the injury. Although it is early days,
gene therapy–based and more recent strategies to dial-back
the epigenetic clock, as we have performed in the visual
system, offer potential opportunities for cellular rejuvenation
and restoration of function in the nervous system and else-
where in the body.
STATEMENT OF AUTHORSHIP
Conception and design: J. F. Rizzo III, M. P. Shah; Acquisition of
data: J. F. Rizzo III, M. P. Shah, D. Krasniqi; Analysis and
interpretation of data: J. F. Rizzo III, M. P. Shah, D. Krasniqi, Y. R.
Lu, D. A. Sinclair, B. R. Ksander. Drafting the manuscript: J. F. Rizzo
III, M. P. Shah, D. Krasniqi, Y. R. Lu, D. A. Sinclair, B. R. Ksander;
Revising the manuscript for intellectual content: J. F. Rizzo III, M. P.
Shah, D. Krasniqi, Y. R. Lu, D. A. Sinclair, B. R. Ksander. Final
approval of the completed manuscript: J. F. Rizzo III, M. P. Shah, D.
Krasniqi, Y. R. Lu, D. A. Sinclair, B. R. Ksander.
5
 State-of-the-Art Review
REFERENCES
1. Kim JW, Rizzo JF, Lessell S. Delayed visual decline in patients
with “stable” optic neuropathy. Arch Ophthalmol.
2005;123:785–788.
2. Balazsi AG, Rootman J, Drance SM, Schulzer M, Douglas GR.
The effect of age on the nerve fiber population of the human
optic nerve. Am J Ophthalmol. 1984;97:760–766.
3. Johnson BM, Miao M, Sadun AA. Age-related decline of human
Downloaded from http://journals.lww.com/jneuro-ophthalmology by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsI
Ho4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 11/08/2023
optic nerve axon populations. AGE. 1987;10:5–9.
4. Dolman CL, McCormick AQ, Drance SM. Aging of the optic
nerve. Arch Ophthalmol. 1980;98:2053–2058.
5. Owsley C, Sekuler R, Siemsen D. Contrast sensitivity
throughout adulthood. Vis Res. 1983;23:689–699.
6. Freeman SH, Kandel R, Cruz L, et al. Preservation of neuronal
number despite age-related cortical brain atrophy in elderly
subjects without Alzheimer disease. J Neuropathol Exp Neurol.
2008;67:1205–1212.
7. Pakkenberg B. Aging and the human neocortex. Exp Gerontol.
2003;38:95–99.
8. Toraño EG, García MG, Fernández-Morera JL, Niño-García P,
Fernández AF. The impact of external factors on the
epigenome: in utero and over lifetime. Biomed Res Int.
2016;2016:2568635.
9. Wilson VL, Jones PA. DNA methylation decreases in aging but
not in immortal cells. Science. 1983;220:1055–1057.
10. Wilson VL, Smith RA, Ma S, Cutler RG. Genomic 5-
methyldeoxycytidine decreases with age. J Biol Chem.
1987;262:9948–9951.
11. Larsen F, Gundersen G, Lopez R, Prydz H. CpG islands as gene
markers in the human genome. Genomics. 1992;13:1095–
1107.
12. Jeziorska DM, Murray RJS, De Gobbi M, et al. DNA methylation
of intragenic CpG islands depends on their transcriptional
activity during differentiation and disease. Proc Natl Acad Sci U
S A. 2017;114:E7526–E7535.
13. Horvath S. DNA methylation age of human tissues and cell
types. Genome Biol. 2013;14:R115.
14. Takahashi K, Yamanaka S. Induction of pluripotent stem cells
from mouse embryonic and adult fibroblast cultures by defined
factors. Cell. 2006;126:663–676.
15. Abad M, Mosteiro L, Pantoja C, et al. Reprogramming in vivo
produces teratomas and iPS cells with totipotency features.
Nature. 2013;502:340–345.
16. Pelzel HR, Schlamp CL, Nickells RW. Histone H4 deacetylation
plays a critical role in early gene silencing during neuronal
apoptosis. BMC Neurosci. 2010;11:62.
17. Wang M, Lemos B. Ribosomal DNA harbors an evolutionarily
conserved clock of biological aging. Genome Res.
2019;29:325–333.
18. Lu Y, Brommer B, Tian X, et al. Reprogramming to recover
youthful epigenetic information and restore vision. Nature.
2020;588:124–129.
19. Xu Q, Rydz C, Nguyen Huu VA, et al. Stress induced aging in
mouse eye. Aging Cell. 2022;21:e13737.
20. Sebastiano V, Zack DJ. We shall see? N Engl J Med.
2021;384:1766–1768.
21. Huberman AD. Sight restored by turning back the epigenetic
clock. Nature. 2020;588:34–36.
22. Chondronasiou D, Gill D, Mosteiro L, et al. Multi-omic
rejuvenation of naturally aged tissues by a single cycle of
transient reprogramming. Aging Cell. 2022;21:e13578.
23. Browder KC, Reddy P, Yamamoto M, et al. In vivo partial
reprogramming alters age-associated molecular changes during
physiological aging in mice. Nat Aging. 2022;2:243–253.
24. Yang JH, Hayano M, Griffin PT, et al. Loss of epigenetic
information as a cause of mammalian aging. Cell.
2023;186:305–326.e27.
25. Ksander B, Shah M, Krasniqi D, et al. Epigenetic
reprogramming—a novel gene therapy that restores vision loss
in a nonhuman primate model of NAION. Invest Ophthalmol Vis
Sci. 2023;64:474.
6 Rizzo et al: J Neuro-Ophthalmol 2023; 00: 1-6
Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited.
View publication stats
26. Shah M, Krasniqi D, Gregory-Ksander MS, et al. Non-human primate
laser-induced NAION model for assessing neuro-rejuvenating gene
therapies. Invest Ophthalmol Vis Sci. 2023;64:5223.
27. Franceschi C, Campisi J. Chronic inflammation (inflammaging)
and its potential contribution to age-associated diseases. J
Gerontol A Biol Sci Med Sci. 2014;69(suppl 1):S4–S9.
28. Lu T, Pan Y, Kao SY, et al. Gene regulation and DNA damage in
the ageing human brain. Nature. 2004;429:883–891.
29. Franceschi C, Zaikin A, Gordleeva S, et al. Inflammaging 2018:
an update and a model. Semin Immunol. 2018;40:1–5.
30. Franceschi C, Bonafè M, Valensin S, et al. Inflamm-aging. An
evolutionary perspective on immunosenescence. Ann N Y Acad
Sci. 2000;908:244–254.
31. Cheng H, Xuan H, Green CD, et al. Repression of human and
mouse brain inflammaging transcriptome by broad gene-body
histone hyperacetylation. Proc Natl Acad Sci U S A.
2018;115:7611–7616.
32. Scalfari A, Neuhaus A, Daumer M, Ebers GC, Muraro PA. Age
and disability accumulation in multiple sclerosis. Neurology.
2011;77:1246–1252.
33. Bonhomme GR, Waldman AT, Balcer LJ, et al. Pediatric optic
neuritis: brain MRI abnormalities and risk of multiple sclerosis.
Neurology. 2009;72:881–885.
34. Confavreux C, Vukusic S. Natural history of multiple sclerosis:
a unifying concept. Brain. 2006;129:606–616.
35. Tutuncu M, Tang J, Zeid NA, et al. Onset of progressive phase
is an age-dependent clinical milestone in multiple sclerosis.
Mult Scler. 2013;19:188–198.
36. Waldman AT, Stull LB, Galetta SL, Balcer LJ, Liu GT. Pediatric
optic neuritis and risk of multiple sclerosis: meta-analysis of
observational studies. J AAPOS. 2011;15:441–446.
37. Nicaise AM, Wagstaff LJ, Willis CM, et al. Cellular senescence
in progenitor cells contributes to diminished remyelination
potential in progressive multiple sclerosis. Proc Natl Acad Sci.
2019;116:9030–9039.
38. Handel AE, Williamson AJ, Disanto G, Handunnetthi L,
Giovannoni G, Ramagopalan SV. An updated meta-analysis of
risk of multiple sclerosis following infectious mononucleosis.
PLoS One. 2010;5:e12496.
39. Celarain N, Tomas-Roig J. Aberrant DNA methylation profile
exacerbates inflammation and neurodegeneration in multiple
sclerosis patients. J Neuroinflammation. 2020;17:21.
40. Pedre X, Mastronardi F, Bruck W, López-Rodas G, Kuhlmann T,
Casaccia P. Changed histone acetylation patterns in normal-
appearing white matter and early multiple sclerosis lesions. J
Neurosci. 2011;31:3435–3445.
41. Mastronardi FG, Wood DD, Mei J, et al. Increased citrullination
of histone H3 in multiple sclerosis brain and animal models of
demyelination: a role for tumor necrosis factor-induced
peptidylarginine deiminase 4 translocation. J Neurosci.
2006;26:11387–11396.
42. Huynh JL, Garg P, Thin TH, et al. Epigenome-wide differences in
pathology-free regions of multiple sclerosis-affected brains.
Nat Neurosci. 2014;17:121–130.
43. Kular L, Jagodic M. Epigenetic insights into multiple sclerosis
disease progression. J Intern Med. 2020;288:82–102.
44. Talman LS, Bisker ER, Sackel DJ, et al. Longitudinal study of
vision and retinal nerve fiber layer thickness in multiple
sclerosis. Ann Neurol. 2010;67:749–760.
45. Trojan DA, Cashman NR. Post-poliomyelitis syndrome. Muscle
Nerve. 2005;31:6–19.
46. Li Hi Shing S, Chipika RH, Finegan E, Murray D, Hardiman O,
Bede P. Post-polio syndrome: more than just a lower motor
neuron disease. Front Neurol. 2019;10:773.
47. Farbu E, Gilhus NE, Barnes MP, et al. EFNS guideline on
diagnosis and management of post-polio syndrome. Report of
an EFNS task force. Eur J Neurol. 2006;13:795–801.
48. Gordon T, Hegedus J, Tam SL. Adaptive and maladaptive motor
axonal sprouting in aging and motoneuron disease. Neurol
Res. 2004;26:174–185.
49. Yang JH, Petty CA, Dixon-McDougall T, et al. Chemically
induced reprogramming to reverse cellular aging. Aging.
2023;15:5966–5989.