Increased Vascular Endothelial Growth Factor Levels in the
Vitreous of Eyes With Proliferative Diabetic Retinopathy
A n t h o n y P. A d a m i s , M.D., Joan W. M i l l e r , M.D., Maria-Teresa Bernai, M.D.,
D o n a l d J. D ' A m i c o , M.D., Judah Folkman, M.D., Tet-Kin Yeo, P h . D . ,
and Kiang-Teck Yeo, P h . D .
The vitreous levels of the angiogenic poly-
peptide vascular endothelial growth factor
(also known as vascular permeability factor)
were measured and compared in eyes with
and without proliferative diabetic retinopa­
thy. Undiluted vitreous samples from 20 eyes
were collected at the time of vitrectomy, and
vascular endothelial growth factor levels were
determined by using a time-resolved immuno-
fluorometric assay. Vitreous vascular endo­
thelial growth factor levels were significantly
higher in eyes with proliferative diabetic reti­
nopathy than in eyes without proliferative
diabetic retinopathy (P = .006; Wilcoxon Rank
Sum Test). The median vitreous concentration
in the eyes with proliferative diabetic reti­
nopathy was 29.1 pM and exceeded the known
concentration required for the maximal pro­
liferation of vascular endothelial cells in vi­
tro. These data are consistent with vascular
endothelial growth factor serving as a physio­
logically relevant angiogenic factor in prolif­
erative diabetic retinopathy.
ANGIOGENESIS is a necessary biologic process
for development, ovulation, placental matura­
tion, and wound healing. 1 Exclusive of these
Accepted for publication April 8, 1994.
From the Department of Ophthalmology, Massachu­
setts Eye and Ear Infirmary (Drs. Adamis, Miller, Bemal,
and D'Amico); the Department of Surgery, Children's
Hospital (Drs. Adamis a n d Folkman); a n d t h e Depart­
ment of Pathology, Beth Israel Hospital (Drs. Yeo a n d
Yeo); Harvard Medical School, Boston, Massachusetts.
This study was supported in part by research grant
EY00325 from the National Institutes of Health (Dr.
Adamis); and by the Beth Israel Pathology Foundation,
Inc. (Drs. T.-K. Yeo a n d K.-T. Yeo). This study was
presented in part at the Annual meeting of the Associa­
tion for Research in Vision and Ophthalmology, Saraso-
ta, Florida, May 4, 1994.
Reprint requests to Anthony P. Adamis, M.D., Massa­
chusetts Eye and Ear Infirmary, 243 Charles St., Boston,
MA 02114.
©AMERICAN JOURNAL OF OPHTHALMOLOGY 118:445-450, OCTOBER, 1994
processes, the vascular endothelial cells that
comprise the network of blood vessels in the
normal adult rarely proliferate and exist in a
differentiated quiescent state. 2 · 3 In angiogenic
diseases such as proliferative diabetic retinopa­
thy, vascular endothelial cell growth control is
lost, resulting in severe intraocular tissue inju­
ry and blindness. Retinal ischemia precedes the
onset of retinal and iris neovascularization, and
ischémie retina has been identified as a poten­
tial source of diffusible angiogenic factors. 46
The search for angiogenic factors has been
extensive, resulting in a growing list of endoge­
nous angiogenic and antiangiogenic factors1·7;
however, the factors necessary for ocular neo­
vascularization remain unknown.
Vascular endothelial growth factor refers to a
family of vascular endothelial cell mitogens
derived through alternative splicing of mRNA
that promote vascular permeability and angi­
ogenesis in vivo. 810 Unlike basic-fibroblast
growth factor, vascular endothelial growth fac­
tor is a secreted angiogenic factor and targets
only vascular endothelial cells and mono-
cytes. 911 Hypoxia in vitro and ischemia in vi­
vo dramatically increase vascular endothelial
growth factor mRNA in certain human tumors
and normal tissues.12·13 In a model of exper­
imental iris neovascularization in the cy-
nomolgus monkey, experimental retinal vein
occlusion is associated with large increases of
inner retinal vascular endothelial growth factor
mRNA, as well as vitreous and aqueous vascu­
lar endothelial growth factor protein. 14 In the
same model, a spatial and temporal association
between increased vascular endothelial growth
factor protein levels and iris neovascularization
has been established, with the degree of vascu­
lar endothelial growth factor increase corre­
lating with the severity of iris neovascular­
ization. 14 In separate studies of vascular
endothelial growth factor-associated tumor an­
giogenesis, neutralizing antibodies to vascular
445
446 AMERICAN JOURNAL OF OPHTHALMOLOGY
endothelial growth factor directly inhibited tu­
mor angiogenesis and indirectly inhibited tu­
mor growth, 13 implicating vascular endothelial
growth factor as a requisite growth factor for
tumor angiogenesis in vivo.
In this study, we sought to determine if in­
creased vascular endothelial growth factor lev­
els were associated with intraocular neovascu­
larization in human eyes. Utilizing a highly
sensitive and specific vascular endothelial
growth factor immunoassay, vitreous vascular
endothelial growth factor levels were measured
in eyes with and without proliferative diabetic
retinopathy. We now show that vitreous vascu­
lar endothelial growth factor protein levels are
increased to physiologically relevant concen­
trations in eyes with proliferative diabetic reti­
nopathy.
Material and Methods
Human vitreous samples from 20 patients
were collected in accordance with the guide­
lines and recommendations of the Massachu­
setts Eye and Ear Infirmary Human Studies
Committee. At the onset of vitrectomy, undilut­
ed vitreous (50 to 100 μΐ) was collected via
vitrectomy probe, transferred to a heparinized,
siliconized 1-ml tube, and frozen ( — 20 C). All
patients were examined preoperatively and in-
traoperatively by one of us (D.J.D. or J.W.M.),
each of whom documented the clinical history
and status of each eye enrolled in the study.
Samples were collected from eyes with either
proliferative diabetic retinopathy (n = 8) or
other conditions requiring vitrectomy (n = 12).
None of the latter samples were from eyes with
intraocular neovascularization. All eyes in the
proliferative diabetic retinopathy group were
categorized according to the modified Airlie
House criteria as having neovascularization of
the disk, neovascularization elsewhere, fibrous
proliferation of the disk, or fibrous proliferation
elsewhere. 15 Fibrous proliferation was defined
as fibrous tissue with or without visible vessels.
All eyes with proliferative diabetic retinopathy
had panretinal photocoagulation, in some cases
incomplete, at some point before vitrectomy
(range, three days to 36 months before vitrec­
tomy). Retinopathy was graded intraoperative-
ly in all eyes because preoperative photographs
were precluded in some eyes by the presence of
vitreous hemorrhage.
The ocular findings were further graded with
October, 1994
regard to presence and degree of vitreous hem­
orrhage and retinal detachment (Table). Vitre­
ous hemorrhage was graded as follows: 0 = no
vitreous hemorrhage; 1 = less than one fourth
of the retina obscured by blood; 2 = one fourth
to three fourths of the retina obscured by blood;
3 = total obstruction of the retina by fresh
blood; 4 = total obstruction of the retina by
organized blood. Retinal detachment was de­
scribed as fractional or rhegmatogenous, and
graded according to the number of quadrants
attached: 0 = retina attached; 1 = less than one
fourth of the retina detached; 2 = one fourth to
one half of the retina detached; 3 = greater than
one half but less than three fourths of the retina
detached; 4 = three fourths to total retinal
detachment.
Patients 1 and 2 underwent extensive panret­
inal photocoagulation for persistent neovascu­
larization including fibrous proliferation pre­
operatively. Patient 2 had a long-standing
history of neovascular glaucoma, controlled at
the time of surgery. Patient 7 underwent endo-
laser panretinal photocoagulation intraopera-
tively but developed iris neovascularization
three months later that was subsequently con­
trolled by supplemental panretinal photocoag­
ulation.
In the nonproliferative group, Patient 9 had
grade C, type 1 proliferative vitreoretinopathy.
Patient 14 had sustained blunt trauma that
subsequently necessitated cataract extraction.
At the time of vitrectomy, the retinal detach­
ment was deemed irreparable secondary to
multiple posterior breaks, a large giant tear,
and grade C, type 2 proliferative vitreoretinop­
athy. Patient 15 had a traumatic cataract re­
moved and a vitrectomy for a traumatic macular
hole. Patient 17 had a vitreous hemorrhage,
subluxed lens, and phacolytic glaucoma after
blunt trauma. At the time of surgery, the retina
was found to be attached but there was evi­
dence of traumatic maculopathy. Patient 19 had
long-standing uveitis and had a large traction
detachment with grade C, type 1 proliferative
vitreoretinopathy.
A two-site, time-resolved immunofluorome-
tric assay was used to measure human vitreous
vascular endothelial growth factor protein lev­
els using antibodies prepared against the N-
and C-terminal peptides of vascular endotheli­
al growth factor.1617 Briefly, rabbit polyclonal
antibodies were raised against synthetic pep­
tides corresponding to the N-terminus of hu­
man vascular endothelial growth factor. Be­
cause the C-terminus is conserved in guinea pig
Vol. 118, No. 4 Increased Vascular Endothelial Growth Factor Levels 447

TABLE
PATIENT DATA

RETINAL VASCULAR
LASER DETACHMENT VITREOUS ENDOTHELIAL
PATIENT (MOS GRADE HEMORRHAGE GROWTH
NO. DIAGNOSIS NEOVASCULARIZATION PRIOR) AND TYPE GRADE FACTOR (pM)

1 Proliferative diabetic Neovascularization disk, elsewhere 6 1, Tractional 0 25.0

retinopathy Fibrous proliferation disk, elsewhere
2 Proliferative diabetic Neovascularization disk, elsewhere 0.2 1, Tractional 2 16.9
retinopathy Fibrous proliferation disk, elsewhere
3 Proliferative diabetic Neovascularization disk, elsewhere 4 1, Tractional 2 5.0
retinopathy Fibrous proliferation disk, elsewhere
4 Proliferative diabetic Neovascularization disk, elsewhere 2 1, Tractional 2 38.4
retinopathy Fibrous proliferation disk, elsewhere
5 Proliferative diabetic Neovascularization, elsewhere ? 1, Tractional 2 31.3
retinopathy Fibrous proliferation disk
6 Proliferative diabetic Fibrous proliferation disk, elsewhere 9 0 4 26.8
retinopathy
7 Proliferative diabetic Neovascularization disk, elsewhere 36 1, Tractional 2 67.0
retinopathy Fibrous proliferation disk, elsewhere
8 Proliferative diabetic Neovascularization disk 10 0 4 72.9
retinopathy Fibrous proliferation disk
9 Retinal detachment None 2, Rhegmatogenous 0 11.1
10 Background diabetic None 0 0 5.0
retinopathy; epiretinal
membrane
11 Terson's syndrome None — 0 4 8.9
12 Epiretinal membrane None — 0 0 5.0
13 Epiretinal membrane None — 0 0 7.2
14 Trauma None 2, Rhegmatogenous 3 25.6
15 Trauma None — 1, Rhegmatogenous 1 12.5
16 Dislocated implant None 0 0 5.0
17 Terson's syndrome None — 0 2 5.0
18 Trauma None — 0 1 22.1
19 Recurrent uveitis None — 2, Tractional 0 9.7
20 Macular hole None — 0 0 5.0

and human vascular endothelial growth factor,
a rabbit polyclonal antibody corresponding to
the C-terminus of guinea pig vascular endothe­
lial growth factor was used. C-IgG was affinity-
purified and used to coat Maxisorp microtiter
wells (Nunc, Inc., Naperville, Illinois). Sepa­
rately, affinity-purified antibodies (IgG) direct­
ed against the N-terminus of human vascular
endothelial growth factor were labeled with
Eu 3+ -chelate and used as second antibodies.
After binding and washing, Eu3+ was dissociat­
ed from the second antibodies with an enhance­
ment buffer containing ß-diketone (Pharmacia
LKB Nuclear, Gaithersburg, Maryland) to yield
a highly fluorescent chelate that was measured
in a time-resolved fluorimeter. The antibodies
recognized all four forms of human vascular
endothelial growth factor, and standardized
controls containing known concentrations of
human vascular endothelial growth factor were
used for calibration. The lower limit of detec­
tion was 5 pM vascular endothelial growth
factor (200 pg/ml).
The two groups were compared by using the
Wilcoxon Rank Sum Test. Samples with con­
centrations below the detection threshold of
448 AMERICAN JOURNAL OF OPHTHALMOLOGY
the immunoassay (<5 pM) were entered as
5 pM for all statistical calculations. No vitreous
samples were excluded in the analysis.
Results
In the proliferative diabetic retinopathy cate­
gory (n = 8), the range of vascular endothelial
growth factor measurements was from < 5.0 to
72.9 pM (Table). The median was 29.1 pM. In
the nonproliferative diabetic retinopathy cate­
gory (n = 12), the range of measurements was
from <5.0 to 25.6 pM. The median was 8.1 pM.
Analysis of these data demonstrated a statisti­
cally significant increase in the vitreous vascu­
lar endothelial growth factor levels in the eyes
with proliferative diabetic retinopathy com­
pared to the eyes without proliferative diabetic
retinopathy (P = .006).
The median level in eyes with vitreous hem­
orrhage was 23.9 pM (range, 5.0 to 72.9 pM) as
compared to 6.1 pM (range, 2.0 to 25.0 pM) in
eyes without vitreous hemorrhage. This differ­
ence was statistically significant (P = .02).
There was a trend toward increase in the medi­
an vascular endothelial growth factor levels in
eyes with traction retinal detachments; howev­
er, the difference was not statistically signifi­
cant (P = .07).
Discussion
Vascular endothelial growth factor was orig­
inally characterized as a vascular permeabil­
ity factor which is 50,000 times more potent
than histamine. 8 In 1989, vascular endothelial
growth factor was sequenced and found to be a
potent and specific angiogenic factor.9·10 It is
present in a variety of tissues, including normal
human retina and human retinal pigment epi­
thelium in vitro. 1819 After laser retinal vein
occlusion, ischémie cynomolgus monkey inner
retina expresses high levels of vascular endo­
thelial growth factor mRNA, whereas it is bare­
ly detectable in nonischemic retina. 14 Similarly,
hypoxic human retinal pigment epithelial cells
in vitro upregulate vascular endothelial growth
factor mRNA and secreted protein. 20 Secreted
vascular endothelial growth factor levels in
both experimental systems are increased to
concentrations above those necessary for the
October, 1994
stimulation of vascular endothelial prolifera­
tion in vitro.14·20·21
By demonstrating increased vascular endo­
thelial growth factor levels in the vitreous of
eyes with neovascularization secondary to pro­
liferative diabetic retinopathy, our results are
in agreement with the experimental data re­
viewed previously. The median levels mea­
sured in our patients with diabetic retinopathy
are above the known concentration necessary
for the maximal proliferation of vascular endo­
thelial cells in vitro (22 pM)21 and are similar to
those reported by others. 22 The vitreous con­
centrations in the eyes with proliferative dia­
betic retinopathy are therefore likely to be
physiologically relevant.
The source of the increased vitreous vascular
endothelial growth factor is presumably isché­
mie retina; however, the possibility exists that
the increased levels are derived from the blood,
serum, or elsewhere within the eye. Monocytes
are capable of synthesizing vascular endotheli­
al growth factor and could conceivably contrib­
ute to the levels measured. Moreover, analysis
of the data disclosed a statistically significant
association between vitreous hemorrhage and
increased vascular endothelial growth factor.
However, this is not surprising since vitreous
hemorrhage is frequently associated with reti­
nal neovascularization and is not an indepen­
dent variable. Although simultaneous blood
levels were not obtained, serum measurements
in normal humans 17 and in cynomolgus mon­
keys both with and without intraocular neovas­
cularization are consistently below detection
(5 pM).14 These data are consistent with the
increased vitreous vascular endothelial growth
factor levels not being serum-derived. Finally,
in situ hybridization of whole cynomolgus
monkey eyes with ischémie retinas and iris
neovascularization localized high vascular en­
dothelial growth factor mRNA transcript levels
to the inner retina and not elsewhere within the
eye.14 Although not direct proof, these data are
consistent with ischémie retina being the pri­
mary source of intraocular vascular endothelial
growth factor protein.
One eye with proliferative diabetic retinopa­
thy had no detectable vascular endothelial
growth factor in the vitreous. This may repre­
sent protein degradation during collection and
processing, or vitreous sampling outside the
time period of maximal vascular endothelial
growth factor production. Vitreous sampling
outside the time period is a distinct possibility,
Vol. 118, No. 4 Increased Vascular Endothelial Growth Factor Levels
as our sampling represented only a single time
point in the disease. In the monkey model of iris
neovascularization, aqueous levels decreased
before the regression of the new vessels. Never­
theless, the possibility remains that vascular
endothelial growth factor is not increased
above the detection threshold in some eyes
with diabetic retinopathy and that other growth
factors (for example, basic fibroblast growth
factor) are the primary angiogenic growth fac­
tors driving neovascularization.
The eyes with proliferative diabetic retinopa­
thy all had panretinal photocoagulation before
vitrectomy, whereas none of the control eyes
had any laser photocoagulation. It is possible
that laser photocoagulation resulted in the in­
creased vascular endothelial growth factor lev­
els. This is unlikely, however, because animal
studies have demonstrated that laser photoco­
agulation of monkey retina (without retinal
vein closure) does not result in any appreciable
increase in the vitreous or aqueous vascular
endothelial growth factor levels for 15 days, the
longest time point measured. 14 Furthermore,
the vascular endothelial growth factor levels in
the lasered human eyes in this study do not
correlate with the timing (Table) or extent of
photocoagulation. The best way to address this
concern is to measure vitreous levels in diabetic
human eyes without prior panretinal photoco­
agulation; however, this is problematic, as al­
most none of these eyes initially progress to
vitrectomy.
Although the median vascular endothelial
growth factor levels were significantly lower in
eyes without diabetic retinopathy, there were
several notable exceptions. All four nonprolif-
erative diabetic eyes with retinal detachments
had increased levels. Similarly, most of the eyes
with proliferative diabetic retinopathy had reti­
nal detachments, a condition that results in
outer retinal ischemia and potentially in­
creased vascular endothelial growth factor ex­
pression. Formal comparison disclosed a trend
toward higher levels in the eyes with retinal
detachments (P = .07). Additional measure­
ments may uncover a true association.
In a similar study of human diabetics, in­
creased levels of the angiogenic peptide basic-
fibroblast growth factor were demonstrated
in the vitreous of eyes with proliferative dia­
betic retinopathy, implicating basic-fibroblast
growth factor as a potential ocular angiogenic
growth factor in vivo.23 This is notable because
vascular endothelial growth factor and basic-
449
fibroblast growth factor may be a potent angio­
genic combination in vivo. We and others have
demonstrated marked synergism between vas­
cular endothelial growth factor and basic-fibro­
blast growth factor in their ability to stimulate
angiogenesis in vitro.24,25
Although this study demonstrates a strong
association between increased vascular endo­
thelial growth factor levels and proliferative
diabetic retinopathy, and identifies vascular
endothelial growth factor as a potentially im­
portant ocular angiogenic factor in diabetic
retinopathy, its confirmation as a physiologi­
cally relevant and requisite ocular angiogenic
factor awaits the results of in vivo intraocular
vascular endothelial growth factor neutraliza­
tion experiments.
ACKNOWLEDGMENT
Elizabeth N. Allred, M.S., Neuroepidemi-
ology Unit, Children's Hospital, Boston, Mas­
sachusetts, provided statistical analysis.
References
1. Folkman, J., and Klagsburn, M.: Angiogenic
factors. Science 235:442, 1987.
2. Hobson, B., and Denekamp, J.: Endothelial pro­
liferation in tumours and normal tissues. Continuous
labelling studies. Br. J. Cancer 49:405, 1984.
3. Engerman, R. L., Pfaffenbach, D., and Davis,
M. D.: Cell turnover of capillaries. Lab. Invest.
17:738, 1967.
4. Michaelson, I. C: The mode of development of
the vascular system of the retina, with some observa­
tions on its significance for certain retinal disease.
Trans. Ophthalmol. Soc. U. K. 68:137, 1948.
5. Ashton, N.: Retinal vascularization in health
and disease. Am. J. Ophthalmol. 44:7, 1957.
6. Wise, G. N.: Retinal neovascularization. Trans.
Am. Ophthalmol. Soc. 54:729, 1956.
7. Folkman, J., and Shing, Y.: Angiogenesis. J. Biol.
Chem. 267:10931, 1992.
8. Senger, D. R., Van De Water, L., Brown, L. F.,
Nagy, J. A., Yeo, K.-T., Yeo, T.-T., Berse, B., Jackman,
R. W., Dvorak, A. M., and Dvorak, H. F.: Vascular
permeability factor (VPF, VEGF) in tumor biology.
Cancer Metastasis Rev. 12:303, 1993.
9. Keck, P. J., Häuser, S. D., Krivi, G., Sanzo, K.,
Warren, T., Feder, J., and Connolly, D. T.: Vascular
permeability factor, an endothelial mitogen related
to PDGF. Science 246:1309, 1989.
10. Leung, D. W., Cachianes, G., Kuang, W. J.,
Goeddel, D. V., and Ferrara, N.: Vascular endothelial
450 AMERICAN JOURNAL OF OPHTHALMOLOGY
growth factor is a secreted angiogenic mitogen. Sci­
ence 246:1306, 1989.
11. Clauss, M., Gerlach, M., Gerlach, H., Brett, J.,
Wang, F., Familletti, P. C , Pan, Y. C , Olander, J. V.,
Connolly, D. T., and Stern, D.: Vascular permeability
factor. A tumor derived polypeptide that induces
endothelial cell and monocyte procoagulant activity,
and promotes monocyte migration. J. Exp. Med.
172:1535, 1990.
12. Shweiki, D., Itin, A., Soffer, D., and Keshet, E.:
Vascular endothelial growth factor induced by hy-
poxia may mediate hypoxia-initiated angiogenesis.
Nature 359:843, 1992.
13. Kim, K. J., Li, B., Winer, J., Armanini, M.,
Gillett, N., Phillips, H. S., and Ferrara, N.: Inhibition
of vascular endothelial growth factor-induced angio­
genesis suppresses tumour growth in vivo. Nature
362:841, 1993.
14. Miller, J. W., Adamis, A. P., Shima, D. T.,
D'Amore, P. A., Moulton, R. S., O'Reilly, M. S.,
Folkman, J., Dvorak, H. F., Brown, L. F., Berse, B.,
Yeo, T.-K., and Yeo, K.-T.: Vascular endothelial
growth factor/vascular permeability factor is tem­
porally and spatially correlated with ocular angio­
genesis in a primate model. Am. J. Pathol. In press.
15. Diabetic Retinopathy Study: Report number 6.
Design, methods, and baseline results. Report num­
ber 7. A modification of the Airlie House classifica­
tion of diabetic retinopathy. Invest. Ophthalmol. Vis.
Sei. 21:1, 1981.
16. Yeo, K.-T., Sioussat, T. M., Faix, J. D., Senger,
D. R., and Yeo, T.-K.: Development of time-resolved
immunofluorometric assay of vascular permeability
factor. Clin. Chem. 38:71, 1992.
17. Yeo, K.-T., Wang, H. H., Nagy, J. A., Sioussat,
T. M , Ledbetter, S. R., Hoogewerf, A.-J., Zhou, Y.,
Masse, E. M., Senger, D. R., Dvorak, H. F., and Yeo,
T.-K.: Vascular permeability factor (vascular endo­
thelial growth factor) in guinea pig and human tumor
inflammatory effusions. Cancer Res. 53:2912, 1993.
18. McGookin, E. D., Stopa, E. G., Kuo-LeBlanc,
V., Baird, A., Gonzalez, A., Hanneken, A., and
Streeten, B.: Vascular endothelial growth factor
October, 1994
(VEGF) has a different distribution than basic fibro-
blast growth factor (bFGF) in the adult human retina.
ARVO abstracts. Supplement to Invest. Ophthalmol.
Vis. Sei. Philadelphia, J. B. Lippincott, 1992, p. 651.
19. Adamis, A. P., Shima, D. T., Yeo, K.-T., Yeo,
T.-K., Brown, L. F., Berse, B., D'Amore, P. A., and
Folkman, J.: Synthesis and secretion of vascular per­
meability factor/vascular endothelial growth factor
by human retinal pigment epithelial cells. Biochem.
Biophys. Res. Commun. 193:631, 1993.
20. Shima, D., Adamis, A. P., Yeo, K.-T., Yeo,
T.-K., Berse, B., and Brown, L.: Hypoxie regulation of
vascular permeability factor (vascular endothelial
growth factor) mRNA and protein secretion by hu­
man retinal pigment epithelial cells. ARVO abstracts.
Supplement to Invest. Ophthalmol. Vis. Sei. Phila­
delphia, J. B. Lippincott, 1993, p. 990.
21. Ferrara, N., Houck, K. A., Jakeman, L. B.,
Winer, J., and Leung, D. W.: The vascular endothelial
growth factor family of polypeptides. J. Cell Bio­
chem. 47:211, 1991.
22. Plouet, J., Chollet, P., Pagot, V., Chauvaud, D.,
Korobelnik, J., Favard, C , Mathis, A., and Malecaze,
F.: Vasculotropin/VEGF levels in the vitreous of
patients with proliferative diabetic retinopathy.
ARVO abstracts. Supplement to Invest. Ophthalmol.
Vis. Sei. Philadelphia, J. B. Lippincott, 1992, p. 1363.
23. Sivalingam, A., Kenney, J., Brown, G. C , Ben­
son, W. E., and Donoso, L.: Basic fibroblast growth
factor levels in the vitreous of patients with prolif­
erative diabetic retinopathy. Arch. Ophthalmol.
108:869, 1990.
24. Goto, F., Goto, K., Weindel, K., and Folkman,
J.: Synergistic effects of vascular endothelial growth
factor and basic fibroblast growth factor on the prolif­
eration and cord formation of bovine capillary endo­
thelial cells within collagen gels. Lab. Invest. 69:508,
1993.
25. Pepper, M. S., Ferrara, N., Orci, L., and Monte-
sano, R.: Potent synergism between vascular endo­
thelial growth factor and basic fibroblast growth
factor in the induction of angiogenesis in vitro.
Biochem. Biophys. Res. Commun. 189:824, 1992.