RPE cells produce and secrete their own complement inhibitors, such as complement factor H, complement factor I, membrane cofactor protein, vitronectin, and clusterin.11, 42, 43, 44, 45 and 46 The production of these complement inhibitors is upregulated in patients with AMD.42 Selleck Bcl-2 inhibitor Furthermore, vitronectin and membrane cofactor protein are upregulated in the RPE cells that flank or overlie drusen.11 and 42 This production of complement inhibitors by ocular tissues, like the RPE cell, plays an important role not only in protecting the eye against complement-mediated damage but also in maintaining the immune-privileged state of the eye.47 Disturbance of the aforementioned factors

that induce and sustain chronic local inflammation at the level of the RPE–Bruch membrane interface, and those that attenuate it, can explain the association of a decreased reflectivity of the overlying RPE and concomitant photoreceptor layer with drusen regression. A loss of RPE cells will result in a decreased generation of extracellular debris that makes up a druse, whereas macrophage recruitment

and the upregulation of complement inhibitors by RPE cells flanking the druse will start a process of druse volume regression. It is this process of drusen remodeling that points to a high biochemical activity and suggests that future treatments targeting these biochemical processes in an early stage of the disease may have a significant role in prophylactic and therapeutic interventions in basal laminar drusen. The Paclitaxel supplier finding that drusen progression and drusen regression occurred in all the study eyes within a very short period may have implications for clinical studies on patients with basal laminar drusen. Because number and size of drusen are important for disease staging, longitudinal changes in drusen morphology can be a potential all source of misclassification and needs attention in epidemiologic studies investigating the natural history of basal laminar drusen as well in clinical trials evaluating the efficacy of possible therapies. Our study has some limitations. First

of all, the limited number of eyes restricts the general use of our data. However, because drusen remodeling was observed in all study eyes, those changes are very likely to occur commonly in eyes with basal laminar drusen. Secondly, slight variations of SD-OCT scan positions during follow-up visits cannot be excluded. However, eye movements were automatically registered and corrected for “eye tracking,” resulting in high repeatability and reproducibility of the SD-OCT scans; therefore, small shifts of only a few microns could have influenced the appearance of these very small drusen in basal laminar drusen.29 and 32 On the other hand, it is unlikely that random shifts may lead to nonrandom, continuous changes during the study period.