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Major review

Iron, zinc, and copper in retinal physiology and disease

Marta Ugarte, DPhil, FRCOphtha,*, Neville N. Osborne, PhDb,c, Laurence A. Brown, PhDc,
Paul N. Bishop, FRCOphth, PhDa
a
Centre for Advanced Discovery and Experimental Therapeutics, Institute of Human Development, University of Manchester and Manchester
Royal Eye Hospital, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre,
Manchester M13 9PT, UK
b
Fundación de Investigación Oftalmológica, Instituto Oftalmológico Fernández-Vega, Oviedo, Asturias, Spain
c
The Nuffield Laboratory of Ophthalmology (NDCN), John Radcliffe Hospital, University of Oxford, Oxford OX3 9DU, UK

article info abstract

Article history: The essential trace metals iron, zinc, and copper play important roles both in retinal
Received 27 January 2012 physiology and disease. They are involved in various retinal functions such as photo-
Received in revised form transduction, the visual cycle, and the process of neurotransmission, being tightly bound
9 December 2012 to proteins and other molecules to regulate their structure and/or function or as unbound
Accepted 11 December 2012 free metal ions. Elevated levels of “free” or loosely bound metal ions can exert toxic effects,
and in order to maintain homeostatic levels to protect retinal cells from their toxicity,
appropriate mechanisms exist such as metal transporters, chaperones, and the presence of
Keywords: certain storage molecules that tightly bind metals to form nontoxic products. The path-
iron ways to maintain homeostatic levels of metals are closely interlinked, with various
zinc metabolic pathways directly and/or indirectly affecting their concentrations, compart-
copper mentalization, and oxidation/reduction states. Retinal deficiency or excess of these metals
retina can result from systemic depletion and/or overload or from mutations in genes involved in
metal homeostasis interactions maintaining retinal metal homeostasis, and this is associated with retinal dysfunction and
trace metal deficiency and overload pathology. Iron accumulation in the retina, a characteristic of aging, may be involved in the
trace metal toxicity pathogenesis of retinal diseases such as age-related macular degeneration (AMD). Zinc
age-related macular degeneration deficiency is associated with poor dark adaptation. Zinc levels in the human retina and RPE
iron chelators decrease with age in AMD. Copper deficiency is associated with optic neuropathy, but
zinc supplements retinal function is maintained. The changes in iron and zinc homeostasis in AMD have led
to the speculation that iron chelation and/or zinc supplements may help in its treatment.
ª 2013 Elsevier Inc. All rights reserved.

1. Introduction visual loss. Iron accumulation in the retina of patients with

Iron, zinc, and copper are essential trace elements playing
key roles in retinal structure and physiology.117,144,145,151,
230,232,244,322,331,347,352,362
Inherited disorders of their metabo-
lism are associated with retinal dysfunction and significant
aceruloplasminaemia,88,383,391 hemochromatosis,137 and Frie-
drich’s ataxia26,33 results in yellow deposits. Poor dark adap-
tation is a common manifestation of systemic zinc depletion
(i.e., acrodermatitis enteropathica).46,312 The peripheral
retinal appears hypopigmented in patients with inherited

* Corresponding author: Marta Ugarte, DPhil, FRCOphth, AV Hill Building, Oxford Road, Oxford M13 9PT, UK.
E-mail address: mugarte@doctors.org.uk (M. Ugarte).
0039-6257/$ e see front matter ª 2013 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.survophthal.2012.12.002
586 s u r v e y o f o p h t h a l m o l o g y 5 8 ( 2 0 1 3 ) 5 8 5 e6 0 9

Table 1 e Previously reported measurements of iron, zinc, and copper in mammalian RPE/choroid and neuroretina
A. Iron

Sample Age Sex Method Iron Authors

RPE/choroid
Rat Long-Evans 2e8 weeks N/A PIXE 178.4a Yefimova et al395
Rat
Brown- 4 months Male ICP-OES 65.0 þ 8a Chen et al49
Norway 30 months Male 195.4 þ 33a
Mouse
c57BL/6 3e6 months Male þ Female GF AAS 103 þ 9b Hahn et al127
16e19 months Male þ Female 147 þ 8b Hadziahmetovic et al123
Neuroretina
Human N/A N/A GF AAS 117.63 þ 14.58a Eckhert91
Human
white 17.8 years (4e32) Female AAS 96.1 þ 14.8b Hahn et al128
73.1 years (65e88) Female 137 þ 13.8b
Human
white 24.8 years (17e35) Male 57.2 þ 8.06b
74.1 (65e83) Male 95.4 þ 13.6b
Mouse
c57BL/6 3 weeks N/A N/A 41.1 þ 6.5b Deleon et al79
3e6 months Male þ Female GF AAS 47 þ 4b Hahn et al127
12e19 months Male þ Female 29 þ 2b Hadziahmetovic et al123
B. Zinc

Sample Age Sex Method Zinc (mg/g dry weight) Authors

RPE/choroid
Human
No AMD 73  12 years Men þ Women ICPMS 292.1 þ 98.5 Erie et al92
AMD-MGS 2e4 78  10 years Men þ Women 223.7 þ 94.0
Human
Caucasian 15e87 years N/A ICPMS Wills et al378,377
Rat
Sprague-Dawley N/A N/A ICPMS 75.8 þ 7.4 Fabe et al94
Neuroretina
Human N/A N/A AAS 3.8 þ 0.9 Eckhert91
Human
No AMD 73  12 years Men þ Women ICPMS 123.1 þ 62.2 Erie et al92
AMD-MGS 2e4 78  10 years Men þ Women 98.6 þ 27.9
Human
Caucasian No AMD 15e87 years Men þ Women ICPMS 9.8 Wills et al378
Rat
Sprague-Dawley N/A N/A ICPMS w72 Fabe et al94
C. Copper

Sample Age Sex Method Copper (mg/g dry weight) Authors

RPE/choroid
Human
No AMD 73  12 years Men þ Wom ICPMS 6.6 þ 1.4 Erie et al92
AMD-MGS 2e4 78  10 years Men þ Wom 5.1 þ 1.1
Human
white 15  87 years N/A ICPMS estimated w2 Wills et al378
Neuroretina
Human N/A N/A AAS 61 Eckhert91
Human
No AMD 73  12 years Men þ Wom ICPMS 9.0 þ 5.0 Erie et al92
AMD-MGS 2e4 78  10 years Men þ Wom 8.3 þ 3.0
Human
white 15e87 years Men þ Wom ICPMS estimated w2 Wills et al378

AAS ¼ atomic absorption spectrometry; GF ¼ graphite furnace; ICPMS ¼ inductively coupled plasma mass spectrometry; ICPOES ¼ inductively
coupled plasmaeoptical emission spectrometer; MGS ¼ Minnesota grading system; N/A ¼ not available.
a
mg/g dry weight.
b
ng/retina.
 s u r v e y o f o p h t h a l m o l o g y 5 8 ( 2 0 1 3 ) 5 8 5 e6 0 9
systemic copper depletion (Menkes disease)97,107 and retinal
function is impaired. This also occurs with copper overload in
Wilson disease. Furthermore, impairment of retinal iron
homeostasis is thought to be involved in aging and the path-
ogenesis of conditions such as age-related macular degener-
ation (AMD).137 In order to understand the mechanisms
underlying these retinal diseases, one must first become
familiar with the role, regulation, and dynamic interactions of
these three trace elements. Breakdown in the homeostatic
mechanisms regulating the bioavailability, compartmentali-
zation, and/or redox reactivity of one trace element within the
retina can directly and/or indirectly affect the balance of the
other two.
Iron, zinc, and copper are present in the body in the form of
ions through donation of electrons from their outer orbitals.181
Zinc always exists as a bivalent cation, Zn(II). Iron and copper,
on the other hand, have the ability to yield and absorb
electrons reversibly and can be found in reduced [Fe(II),
Cu(I)] or oxidized [Fe(III), Cu(II)] states. The great majority of
iron, zinc, and copper is tightly bound to ligands rich in
sulphur, nitrogen, and oxygen by accepting pairs of
electrons in their unfilled outer orbitals. They also exist as
“free’’ or loosely bound, labile ions that can be highly
toxic16,37,53,82,216,254,255,374 because of the formation of reactive
oxygen species.83,89,159,160,255,315 Experimental studies have
shown that both decreased87,93,144 and elevated37,88,89,265
levels can cause retinal cell dysfunction. Their relevance in
retinal physiology and pathophysiology, however, depends
not only on their concentrations, but also on their distribution
and oxidation/reduction states, which are under tight regu-
lation by interrelated metabolic pathways.
We review the biological basis of the link between endog-
enous retinal trace element homeostasis and retinal disease,
from inherited defects in their metabolic pathways to the
cellular and molecular mechanisms specific to metal-induced
retinal toxicity. We conclude with a discussion on the poten-
tial use of iron chelators and zinc supplements in AMD.
2. Endogenous iron, zinc, and copper in the
retina
We begin by describing the localization and known functions
of endogenous iron, zinc, and copper in the normal retina,
followed by an outline of key homeostatic molecules medi-
ating their entry, storage, delivery, and exit. Their closely
interlinked homeostases need to be appropriately balanced to
prevent visual impairment.
2.1. Localization
The concentration (Table 1) and distribution of
iron,91,125,128,137,317,318,361,395 zinc,7,36,91,92,141,225,277,357e359,361,
378,379 36,91,92,141,225,361,378,379
and copper in the mammalian
retina are analyzed using various techniques. Inductively
coupled plasma mass spectrometry (ICP-MS),92,128,361,378,379
atomic absorption spectrophotometry (AAS),91 and colori-
metric analytical methods (e.g., diphenylthiocarbazone,
dithizone)36 allow bulk quantification of total (tightly and
loosely bound) trace elements. Beam-based X-ray
587
microanalysis with high energy protons (proton-induced X-
ray emission, PIXE)276,317,318,359,361,396 or X rays (synchrotron X-
ray fluorescence, XRF)361 (Fig. 1) localize and quantify total
trace elements in individual retinal layers. Histological
stains125,137,141,357e359 and fluorescent probes,222,357e359 have
allowed the visualization of pools of loosely bound, chemi-
cally reactive (“free”) metals in retinal sections.
2.1.1. Concentrations
The iron concentration in the human neuroretina is estimated
to be 117.63  14.58 mg/g dry weight (dw) using graphite
furnace AAS91 and around 100 mg/g dw using ICP-MS.128 Erie
et al92 measured zinc at a concentration of 292.1  98.5 mg/g dw
in the retinal pigment epithelium (RPE)/choroid and 123.1 
62.2 mg/g dw in the neuroretina using ICP-MS. In contrast,
using the same technique, Wills et al378,379 reported approxi-
mately 9.8 mg/g dw in the neuroretina, and by graphite furnace
AAS, Eckhert91 calculated 3.8  0.9 mg zinc/g neuroretina dw.
These differences could be a consequence of the tissue prep-
aration and/or the dilutions necessary for the techniques
used; the values derived by Erie et al92 most closely approxi-
mate those found in other mammals (Table 1), however. ICP-
MS analysis quantified total copper in the human retina at
a concentration of 6.6  1.4 mg/g of dw in the RPE/choroid (with
higher levels in men than women)378,379 and 9.0  5.0 mg/g of
dw in the neuroretina.378 The finding that zinc, the second
most common metal in the body (total amount, 2.5 g)12,38,374
after iron (3.5 g),40 is the most abundant in the mammalian
retina implies natural accumulation and and an important
Fig. 1 e Trace element distribution maps (2 3 4 mm
resolution) of 30-mmethick freeze-dried cryosections of rat
retina were obtained with synchrotron X-ray fluorescence
microscopy at the I18 beamline Diamond Light Source
(www.diamond.ac.uk). A: Overlay map of the distributions
of zinc (red), copper (green), and iron (white). With this
technique it was difficult to establish the boundary
between RPE and choroid and in this region the intense
signal for iron, zinc, and copper may be derived from blood
in the choriocapillaris. Heat maps (BeD) showing that
within the neuroretina, zinc (B) was mainly localized in the
RIS/OLM, OPL, and INL. C: Copper was primarily found in
RIS/OLM and both plexiform layers (OPL and IPL). D: Iron
was mainly localized to the RIS/OLM (Scale bar, 20 mm.).
588 s u r v e y o f o p h t h a l m o l o g y 5 8 ( 2 0 1 3 ) 5 8 5 e6 0 9

physiological role. Evidence that the retina requires zinc to
function comes from studies showing that body zinc depletion
results in poor dark adaptation and reduced scotopic and
photopic electroretinogram (ERG) amplitudes169,193,231,236 (see
subsequent discussion).
the phototransduction process (rhodopsin,78,87,110,270,324,329,330,
339,346,354,366
phosphodiesterase,136,393 recoverin274), visual
144,231,232
cycle, retinal neurotransmission,48,292 and production
of the neurotransmitter glutamate394 has been shown, both
in vitro and in vivo, to be affected by iron, zinc, or copper (Fig. 2).

2.1.2. Distribution 2.2.1. Iron

The distribution of total iron, zinc, and copper in the retina is
non-uniform as demonstrated by PIXE276,317,318,358,361,396 and
synchrotron XRF imaging361 (Fig. 1). Zinc is found at high
levels in the RPE/choroid, photoreceptor inner segments (RIS)/
outer limiting membrane (OLM) layer, outer plexiform layer
(OPL), and inner nuclear layer (INL). Iron is primarily localized
in the RPE/choroid and RIS/OLM layers. Copper shares two
regions of high concentration with iron, the RPE/choroid and
RIS/OLM. High amounts of copper are also found in the OPL
and inner plexiform layer (IPL). The presence of high
concentrations of iron, zinc, and copper in certain retinal
regions is likely to be related to the particular physiology of
these layers and their demand for metal-dependent functions.
2.2. Retinal functions of iron, zinc, and copper
The high concentration of iron in the RPE is consistent with its
involvement in the catalytic activity of RPE65,232 the con-
verting enzyme of all trans-retinyl ester to 11-cis retinol
during the visual cycle (Fig. 2). In the RPE, as well as in the
RIS, iron is likely to be within the mitochondrial matrix, either
as loosely bound ions or forming part of heme groups and iron
sulphur clusters (2Fe-2S, 3Fe-4S, and 4Fe-4S) in proteins of
the respiratory chain (cytochromes a, b, c) and oxidative
phosphorylation.293,300 Iron is also required for the activity of
guanylate cyclase,393 the heme-containing enzyme involved
in the phototransduction process;95 of aconitase,394 necessary
for the synthesis of glutamate; and of fatty acid desaturase,
involved in the generation of disc membranes of
photoreceptors.

Iron,232 zinc,29,38,42,62,65,142,173,295,361,397 and copper42,132,166,212,

304,335,397
play important catalytic, structural, and regulatory
roles in proteins and enzymes of general cell metabolism (e.g.,
mitochondrial function, gene expression, antioxidant defense)
(Table 2). As free ions, they participate in angiogenesis, nerve
myelination, endorphin action, and synaptic transmission.
Cells with high energy demands, such as some retinal
cells,262,402,403 will have high levels of these metals. In addition,
iron, zinc, and copper are considered to have specialized retinal
functions. The function of several compounds involved in

Table 2 e Functions of iron, zinc, and copper in general

cell metabolism
Function Metalloprotein Fig. 2 e Iron-, zinc-, and copper-dependent proteins found
Iron
in the RPE and photoreceptors. The photopigment,
Oxygen transport Hemoglobin rhodopsin (Rho), possesses two zinc coordination motifs,
Cellular respiration Cytochromes a, b, c which mediate dose-dependent changes in rhodopsin
Respiratory chain units stability and function in the physiological range. Copper
Lipid synthesis Fatty acid desaturase ions can also modify the function of rhodopsin. The
Glutamate synthesis Ribonuclease reductase
enzyme 30 ,50 -cGMP phosphodiesterase (PDE), which
Aconitase
catalyzes the hydrolysis of cGMP and leads to closure of the
Zinc
DNA replication, repair, and More than 300 enzymes and cGMP-gated channel and blockade of the dark influx of
transcription proteins, and zinc fingers extracellular cations (NaD and Ca2D) into the outer
Protein metabolism transcription factors segments (OS), requires zinc for the stability of its structure
Cell growth and catalytic functions. Zinc binding increases the affinity
Cell division for rod outer segment membrane of recoverin (Recov), the
Antioxidant defense
protein that is involved in deactivation of rhodopsin after
Apoptosis
light stimulation. Zinc is necessary for the function of the
Copper
Cellular respiration Cytochrome C oxidase RPE enzyme retinol dehydrogenase (RD). RPE65, the protein
Iron oxidation Ceruloplasmin and hephaestin expressed in RPE responsible for the conversion of all
Melanin synthesis Tyrosinase trans-retinyl ester to 11-cis retinol, requires Fe(II) for its
Antioxidant defense Superoxide dismutase 1 catalytic activity. Iron is a cofactor for the enzyme
Peptide amidation Copper amine oxidases guanylate cyclase (GC), the enzyme that returns cyclic GMP
Vascular adhesion protein 1
concentration to the original dark levels following light
Connective tissue formation Lysyl oxidase
stimulation.
 s u r v e y o f o p h t h a l m o l o g y 5 8 ( 2 0 1 3 ) 5 8 5 e6 0 9
2.2.2. Zinc
In the RPE, zinc is required for antioxidant defense227 and the
function of retinol dehydrogenase,144,398 the enzyme involved
in retinol processing in the visual cycle (Fig. 2). In the RIS/OLM,
loosely bound zinc is within subcellular organelles in the
myoid part of the inner segments (Golgi apparatus, endo-
plasmic reticulum)7 and in Müller cell end feet.291 Many zinc-
dependent proteins reside in the endoplasmic reticulum and
Golgi apparatus (e.g., calreticulin, calnexin, peptidases,
glycosylphosphatidylinositol, phosphoethanolamine trans-
ferases), where they participate in modifying, sorting, and/or
packaging protein or other cellular materials.386 The endo-
plasmic reticulum may also be the source of zinc that acts
as an intracellular second messenger.392 In Müller cell end
feet, a zinc finger protein, Zbed4, is involved in retinal
morphogenesis and other Müller cell functions.302 In the
plexiform layers, ‘’free’’ zinc is believed to act as a neuro-
modulator48,133,134,167,206,286,290,292,342,343,406 by influencing the
activity of various membrane receptors, voltage- and ligand-
gated channels, and hemi-gap junction channels on bipolar
and horizontal cells.359 The high levels and wide distribution
of zinc across the INL suggest the possibility that multiple
neuron types, such as horizontal, amacrine, and interplexi-
form cells and Müller cells, are the source and that these cells
can handle zinc without signs of toxicity. The vast majority of
the zinc detected in this layer is likely to be tightly bound in
complexes (e.g., zinc-finger transcription factors), as the
fraction of histochemically reactive zinc is small (Fig. 3).358,359
Several zinc finger transcription factors have been shown to
play critical roles in the retina28,266,302,322 (e.g., develop-
ment18,309,375,407 and RPE epithelial to mesenchymal
transition200).
Fig. 3 e Localization of histochemically reactive (i.e., “free”)
zinc in the dark- and light-adapted rat retina by the zinc-
sulphide method. In the dark-adapted retina (A),
histochemically reactive zinc is primarily associated with
photoreceptor perikarya in the outer nuclear layer (ONL),
and to a lesser extent with the retinal pigment epithelial
cells (open arrow heads), both plexiform layers (P), and
some perikarya (arrows) in the inner nuclear layer (INL) and
ganglion cell layer (G). Following light excitation (B),
chelatable (visualized) zinc in the photoreceptors is
associated in particular with the inner segments (closed
arrow heads) of the photoreceptors. This variation in
location suggests a role for zinc in phototransduction. The
localization of free zinc in other parts of the neuroretina
and retinal pigment epithelial cells is similar in the dark-
and light-adapted retinas. (Scale bar, 30 mm.)
589
2.2.3. Copper
The abundant copper co-localizing with iron in the RIS/OLM
could be within the mitochondria. Copper is part of COX1 and
COX2 subunits of the respiratory enzyme, cytochrome c
oxidase (CCO),132 which are essential to its function and
stability.400 In the plexiform layers, “free” copper could
participate in neurotransmission as in some areas of the
brain.222,310,311 In addition, copper might have a unique role in
ganglion cells. A specific copper amine oxidase, with as yet
undetermined function, has recently been identified in their
plasma membranes.408
2.3. Retinal homeostasis of iron, zinc, and copper
The retinal ability to acquire and supply iron, zinc, and copper
ions safely to their final biological destination (e.g., metal-
loproteins, membrane receptors, channels) while preventing
accumulation of potentially toxic, uncommitted ions is coor-
dinated by closely interlinked homeostatic mechanisms. The
key handling proteins mediating entry, storage, delivery, and
exit (i.e., transporters, regulatory sensors, chaperones, and
storage molecules) (Fig. 4) are present in the retina (Fig. 5). At
the beginning of each of the following sections, the general
cellular homeostasis will be summarized briefly to provide the
context for the ensuing discussion on retinal metabolism.
2.3.1. Iron
Iron is actively transported across plasma membranes by
transferrin receptor-mediated endocytosis of Fe(III) bound to
transferrin.4,59,152 Iron can also be transported along a proton
gradient by the divalent metal transporter 1 (DMT-1)211
(Fig. 4A). Following endocytosis, Fe(III) is reduced within the
endosome and Fe (II) transported across the endosomal
membrane by DMT-1. Cytosolic Fe(II) would then be supplied
to proteins (e.g., ferritin),13 taken up by the mitochondria293 or
released from cells by the plasma membrane transporter,
ferroportin,86 with assistance from the cuproenzymes, ceru-
loplasmin and hephaestin.59,71,264 Ferritin binds iron in
a nontoxic form and is necessary to protect the retina in
situations of stress (i.e., light-induced retinal degeneration278).
“Free” intracellular Fe(II) is thought to be transported bound to
intermediate proteins (chaperones)66,247,258,327,341 to prevent
cytotoxic redox chemistry of Fe(II) via the Haber-Weiss cycle/
Fenton reaction (Fig. 6).
Cellular iron uptake and release and the intracellular labile
pool size are tightly controlled. Transcriptional, post-
transcriptional, and post-translational processes regulate
certain homeostatic molecules (e.g., transferrin receptor,
ferritin).66,119,140 There are RNA binding proteins that modu-
late the synthesis of other proteins by binding to a nucleotide
motif in its mRNA called the iron regulatory element, and
their activity is regulated by intracellular “free” iron. The
membrane-bound human hemochromatosis protein
(HFE)112e114,217 controls iron uptake by regulating the inter-
action between transferrin receptor and transferrin. Iron
export by ferroportin is modulated by the iron hormone,
hepcidin,57,81,102,114 whose expression is, in turn, regulated by
hemojuvelin,111,113,288 the co-receptor for bone morphogenetic
protein 6.124
590 s u r v e y o f o p h t h a l m o l o g y 5 8 ( 2 0 1 3 ) 5 8 5 e6 0 9

Fig. 4 e Cellular metabolism of iron (A), zinc (B), and copper (C). A: Iron is transported across cell plasma membranes by
transferrin receptor (TfR)-mediated endocytosis of transferrin (Tf)-Fe(III). Within the endosome, Fe(II) is released from Tf,
reduced to Fe(II) and transported across the endosomal membrane by the divalent metal transporter 1 (DMT-1). Once Fe(II) is
transported out of the endosome, it enters the chelatable iron pool and is supplied to cytosolic proteins for storage (e.g.,
ferritin, Ft), taken up by the mitochondria or released from the cell by the plasma membrane transporter, ferroportin (Fo),
with the assistance of the cuproenzymes ceruloplasmin (Cp) and hephaestin, which convert Fe(II) to Fe(III). B: Zinc cellular
homeostasis is coordinated by three systems involved in uptake/extrusion zinc transporters of the Zip and ZnT families,
buffering by metallothioneins (MTs) and sequestration by organelles (e.g., mitochondrion). C: Copper entry into cells, as
Cu(I), is thought to be mediated by integral membrane protein Cu transporter 1 (CtR1). Once inside the cell, copper is bound
to MT for storage and/or detoxification, and to metallochaperones (CCS, COX17, ATOX1) for Cu(I) allocation to specific targets
(SOD-1, CCO, ATP7A/B, respectively) with virtually no free copper ions intracellularly. COX17 delivers Cu(I) to CCO with help
from the mitochondrial inner membrane accessory proteins, Sco1, COX11. ATP7A delivers copper to tyrosinase and ATP7B
to lysyl oxidase and Cp. In addition to their biosynthetic role, ATP7A and B have key functions in cellular copper secretion.

Iron uptake by retinal tissue and individual retinal cells is
via transferrin receptor and DMT-1.146,328 Transferrin receptor
has been detected in mammalian RPE cells, capillary endo-
thelial cells, and in RIS, OPL, INL, and ganglion cell
layers146,217,395 (Fig. 5A). In cultured human RPE cells,146
transferrin receptor is located both on the basolateral and
apical surfaces, suggesting a possible bidirectional flow across
the RPE and perhaps iron recycling between the RPE and
neuroretina (Fig. 7), with contribution from the locally
synthesized transferrin.75 Transferrin-Fe(III) uptake from
choroidal blood may be regulated by HFE, which has been
shown in the basolateral membrane of c57BL/6 mouse
RPE.112,113,217 DMT-1 is expressed in RIS, horizontal cells, as
well as bodies and axon terminals of rod bipolar cells. The iron
storage protein, ferritin,126,39 has been demonstrated immu-
nocytochemically in rodents in layers with a relatively high
iron content (i.e., RPE, RIS).317,318,395 In adult c57BL/6 mice, 65%
of the total retina iron is estimated to be bound to ferritin.79
Additionally, ferritin localizes to the INL, ganglion cell layer
(GCL), and IPL.126,395 In the IPL, ferritin may play a role in
presynaptic terminals. Export of Fe(II) from the retina147 may
be facilitated by ferroportin, which exists in mouse RPE
(basolaterally), RIS, IPL, OPL, and GCL.126 Ceruloplasmin and
hephaestin are expressed in RPE and Müller cells.127,177,199
Ferroportin104,137 together with ceruloplasmin and hephaes-
tin127,177,271,382 are localized in Müller cell end feet. It is
 s u r v e y o f o p h t h a l m o l o g y 5 8 ( 2 0 1 3 ) 5 8 5 e6 0 9
therefore possible that iron is transported through the retina
into the vitreous. Ceruloplasmin and hephaestin are also
expressed in photoreceptors.382 Hepcidin, the regulator of
ferroportin, is detectable in all mouse retinal cells57,111,113,123
and the protein necessary for its expression, hemojuvelin, is
expressed in murine RPE (apical membrane), Müller, photo-
receptor, and ganglion cells.111,115 Hepcidin co-receptor, bone
morphometric protein 6, in turn, is present in the RPE.124
2.3.2. Zinc
Zinc crosses cellular membranes through transporters of the
Zip [Zrt- and Irt-like proteins (SLC39A)] and ZnT [solute-linked
carrier 30 (SLC30A)] families68,103,333 (Fig. 4B). Zip proteins
promote zinc transport from the extracellular fluid or from
intracellular vesicles into the cytoplasm along a concentration
gradient. Within the cytoplasm, zinc binds to metal-
lothioneins (MTs) for storage.51,90,214,215,267,350,376,387
Zip1, Zip2, Zip3, Zip4, Zip12, ZnT3, ZnT6, and ZnT7 have all
been identified in human RPE cells in culture (Fig. 5B).196,197 The
basolaterally localized Zip2 and Zip4 have been shown to
participate actively in zinc uptake in vitro and could mediate
transport from choroidal blood into the retina in vivo.197,249
ZnT3289 and ZnT7372 have also been found in mouse neuro-
retina, where they play a role in neuromodulation of dopa-
minergic pathways. ZnT3 is present in RIS/OLM, INL, GCL, OPL,
and IPL layers. In isolated rodent Müller cells, ZnT3 is localized
in the apical villi, soma, and end feet,289 suggesting these cells
may provide a system for zinc homeostasis, similar to iron,
throughout the neuroretina. ZnT7 is expressed on photore-
ceptor outer segments (ROS), amacrine and ganglion cells, and
both plexiform layers in mouse retina.372 Semenogelin I and II,
the high-capacity zinc-binding proteins,162 which are also
likely to be involved in zinc cellular homeostasis, have been
detected in photoreceptor and ganglion cells.34,35
2.3.3. Copper
Copper cell entry is mediated by the integral membrane
protein, copper transporter 1 (CtR1), as Cu(I).201,208,235,256 Once
inside the cell, copper binds to glutathione and MT267 for
storage and to metallochaperones132,208,284,296 for delivery to
specific proteins, with virtually no intracellular “free” ions.
Three copper chaperones have been identified to date, CCS
(copper chaperone for the antioxidant enzyme, superoxide
dismutase 1), COX17 (chaperone for the respiratory enzyme,
CCO), and ATOX1 (chaperone for ATPases, ATP7A and B). MTs,
in addition to copper storage, serve a major role in cellular
copper usage and targeting by delivering copper to CCS and
COX17 but not ATOX1.344 ATP7A and B, located at the trans
Golgi network, mediate copper translocation for incorporation
into cuproenzymes.187,207,208 ATP7A delivers copper to tyrosi-
nase319 and ATP7B to lysyl oxidase and ceruloplasmin.284 In
situations where intracellular copper levels are high, ATP7A
and B migrate from the trans Golgi network to peripheral
vesicular compartments to facilitate copper excre-
tion.207,208,364 The intracellular movement of ATP7B seems to
be regulated in a copper-dependent manner by the ubiqui-
tously expressed cytoplasmic protein, Commd1.176,221,238,307
Similar to the situation in the bloodebrain barrier,55 copper
could cross the blooderetinal barrier, as Cu(I) released from
the plasma protein albumin, by CtR1, which is expressed in
591
the RPE, OLM, and OPL (Fig. 5C).186 The lack of CtR1 regulation
in the RPE following dietary copper restriction/loading in
rats,186 however, suggests other unknown copper transporters
may be important in the RPE. The proteins involved in copper
transport into the biosynthetic and secretory pathways,
ATP7A and B, are both localised to the Golgi apparatus in RPE
cells.183 Studies with ARPE19 cells incubated with increased
copper levels led to the redistribution of ATP7B from the trans
Golgi network to a diffuse cytoplasmic compartment sug-
gesting it may be involved in copper export from the RPE
in vivo.183 No redistribution of ATP7A was reported. Within
the neuroretina, ATP7A has been localized to the OPL and
GCL.183 In the OPL, it could release copper at synapses as it
does in the brain.222,310,311
2.3.4. Mitochondrial role in iron, zinc, and copper
homeostases
Mitochondria play critical roles in iron, zinc, and copper
cellular metabolism.44,63,64,69,73,101,143,190,239 Mitochondrial
matrices contain dynamic pools of biochemically reactive
ions, which regulate the overall cellular concentration and
affect metal-dependent functions by controlling the incorpo-
ration of metals into metalloproteins.6,21,98 One pool of labile
zinc in the mitochondria of neurones is thought to be involved
in ischemic neuronal injury by activating divalent sensitive
channels in the inner membrane.165,314,315 Movement of iron,
zinc, and copper across the mitochondrial inner and outer
membranes is thought to occur via various channels, pores,
and/or transporters.63,64,98,293 Mitoferrin 1 and 2 transport iron
from the cytosol269 and hematopoietic cells lacking them have
reduced mitochondrial iron incorporation.323 Another trans-
membrane protein involved in iron mitochondrial metabo-
lism in this organelle is sideroflexin 1,401 which transports
molecules essential for iron use. Once inside the mitochon-
dria, Fe(II) is thought to be transported by frataxin,195
a ferritin-like protein acting as an iron chaperone.
2.3.5. Interactions between iron, zinc, and copper cellular
homeostases
The cellular homeostases of iron, zinc, and copper are closely
interlinked. The physical and chemical properties of these
three trace elements are very similar. They can compete for the
same ligands11,109,139,148,210,220 and displace each other
directly.20,139,220,242,281 In addition, their metabolic pathways
have several positive (synergistic) and negative (antagonistic)
interactions39,131,154,245,257,259 (Fig. 8). If one of these metals
becomes deficient, another metal may accumulate. A positive
interaction exists between copper and iron homeostasis.
Copper is necessary for the activity of ceruloplasmin264 and
hephaestin275,368 and facilitates iron excretion by ferroportin.71
Ceruloplasmin and hephaestin, acting as ferroxidases, convert
Fe(II) to Fe(III), generate an iron gradient, and facilitate export of
iron and uptake by proteins. The absence of ceruloplasmin
results in retinal iron accumulation.121,127,381 Copper is also
necessary for the activity of tyrosinase and synthesis of
melanin,223 a storage protein14,180 for iron, zinc, and copper in
the RPE and melanocytes.14,30,31,36 The amount of melanin
present in the RPE determines the zinc uptake and storage by
these cells.180 Zinc-deficient animals accumulate iron in
several organs.170,298 Numerous genes respond to alterations in
592 s u r v e y o f o p h t h a l m o l o g y 5 8 ( 2 0 1 3 ) 5 8 5 e6 0 9

Fig. 5 e Schematic representation of the retinal distribution of iron (A), zinc (B), and copper (C), and proteins involved in their
homeostases. A: Transferrin receptor (TfR), which can mediate endocytosis of transferrin(Tf)-bound Fe(III), is expressed in
the RPE, photoreceptor inner segments (IS), outer plexiform layer (OPL), inner nuclear layer (INL), and ganglion cell layer
(GCL). In RPE cells, TfR is located both on the basolateral and apical surfaces suggesting a possible bidirectional flow of iron
through the RPE, perhaps involved in retinal iron recycling between the RPE and neuroretina. The divalent metal transporter
1 (DMT1), which can transport Fe(II) along a proton gradient, has been shown in photoreceptor IS, rod bipolar cell bodies and
 s u r v e y o f o p h t h a l m o l o g y 5 8 ( 2 0 1 3 ) 5 8 5 e6 0 9 593

cellular zinc levels with changes in mRNA levels.253 An in vitro
study has shown that zinc deficiency results in increased levels
of iron regulatory proteins and enhanced transferrin receptor
expression. An increase in transferrin receptor could raise
cellular iron uptake and hence intracellular levels.253
3. The effect of light on retinal zinc
homeostasis
the adequate expression and function of their homeostatic
molecules. Alterations in the systemic homeostasis can
increase or decrease their availability in the circulation. In
situations when the retinal regulatory mechanisms are over-
whelmed, tissue levels may be disturbed. Decreased
bioavailability can result in insufficient metal-dependent
functions. On the other hand, excessive levels can be associ-
ated with harmful amounts of loosely bound ions and metal-
induced retinotoxicity.

The retinal distribution of biochemically reactive zinc (Fig. 3 in 4.1. Iron

Ugarte and Osborne358) and the gene expression of metal-
loproteins and metal homeostatic proteins (unpublished data)
change with light exposure.
In the light-adapted retina, photoreceptors stain positively
for zinc, with the greatest concentration in the RIS. In the
dark-adapted retina, histochemically reactive zinc is
primarily associated with RPE cells and photoreceptor peri-
karya and to a lesser extent with both plexiform layers and
some perikarya in the inner part of the INL and GCL.358,359 The
change in the localization of visualized zinc in the photore-
ceptors with light stimulation might be a result of the trans-
location of total zinc from the perikarya to the RIS and ROS
and in the process binding to certain molecule(s) (e.g.,
rhodopsin, cGMP phosphodiesterase) in the ROS (rendering it
non-histochemically reactive), but remaining free in the RIS.
Alternatively, a shift in the distribution of zinc in the inter-
photoreceptor matrix might occur, similar to changes of other
components.356 It is also possible that free zinc binds to form
a complex following light exposure without changing its
localisation. Similar changes in the binding and/or compart-
mentalization of iron and copper upon light stimulation may
occur, and this needs further investigation.
These changes are likely to reflect alterations in the
requirement for metal dependent functions (e.g., energy
metabolism, respiration, phototransduction, visual cycle,
neurotransmission) and the demand for metal ions in
different retinal regions upon light stimulation.
4. Retinal pathology associated with
changes in iron, zinc, and copper homeostases
The metabolism of the three essential trace elements iron,
zinc, and copper depends on their dietary intake, as well as
A key feature of systemic iron homeostasis is that body
requirements far exceed the gastrointestinal absorption
capacity. Iron is continuously recycled with only small
amounts (1e2 mg) lost daily.209 The greatest amount of iron is
found within hemoglobin in red blood cells (2.5 g of the body
total of 3.5 g). Stores are found in the liver (200 mg), macro-
phages of the reticuloendothelial system (500 mg), and bone
marrow (150 mg).213,241 Commonly used biomarkers of
systemic iron status include serum levels of iron (normal
range, 50e180 mg/dl),241 ferritin (normal values, 30e300 ng/
ml),23,27,370,371 transferrin receptor,188 transferrin saturation
(normal values, 20e50%),27 transferrin receptor:ferritin
ratio27,285 and red blood cell zinc protoporphyrin.188,380,410
Serum iron represents the concentration of iron bound to
transferrin. Serum ferritin provides information on body iron
store size (1 ng/ml corresponding to approximately 8 mg of
stored iron). Transferrin saturation reflects iron availability
for peripheral supply.
4.1.1. Systemic iron deficiency and visual problems
Iron deficiency remains a highly prevalent problem with
approximately 2 billion people affected worldwide.241,409
Increased requirements (e.g., pregnancy), limited external
supply (malnutrition),353 and blood loss are well-known risk
factors.209 Systemic features include microcytic, hypochromic
anemia, fatigue (as the result of deficient function of iron-
enzymes involved in oxidative phosphorylation), headaches,
vertigo, tachycardia, dyspnoea, restless legs syndrome,
impaired thermoregulation, hair loss, glossitis, and villous
atrophy.105,241,272
An adverse impact of iron deficiency on retinal function is
not well established. Adult individuals with iron deficiency
anemia suffer from retinal vein164,174 and artery224 occlusions,

=axon terminals, and horizontal cell bodies. The plasma membrane transporter, ferroportin (Fo), exists in mouse RPE,
photoreceptor IS, inner plexiform layer (IPL), OPL, and GCL. In the RPE, the immunoreactivity is primarily basolateral.
Ceruloplasmin (Cp) expression has been reported in RPE and Müller cells. The iron storage protein, ferritin (Ft), has been
demonstrated in rat RPE, photoreceptor OS, IS, INL, and GCL. In mouse retina, rod bipolar cells have been found to express
ferritin in the cell bodies in the INL, as well as axon terminals in the IPL. The iron regulatory molecule HFE is expressed in
the basolateral membrane of the RPE. Hepcidin is detectable in all retinal cell types. Hemojuvelin (Hjo) is expressed in the
RPE (apical membrane), Müller cells, photoreceptors, and ganglion cells. B: Zinc importers (Zip1, Zip2, and Zip12) have been
identified in RPE cells. ZnT3 has been shown in Müller cells, RPE cells, OLM, IS, OPL, INL, IPL, and GCL. ZnT6 and ZnT7 have
been identified in RPE cells. ZnT7 has also been found in photoreceptors, amacrine, and ganglion cells. Metal binding
proteins, metallothioneins 1 and 2 (MT1/2), are expressed in the RPE and throughout the retina. C: The high affinity Cu(I)
transporter, CtR1, is known to be expressed in the RPE, OLM, and OPL. Both copper transporters, ATP7A and B proteins, are
expressed within RPE. ATP7A is also present in the neuroretina in the OPL and GCL. MTs are present throughout the retina
and Cp and hephaestin (Heph) are found in RPE and Müller cells.
594 s u r v e y o f o p h t h a l m o l o g y 5 8 ( 2 0 1 3 ) 5 8 5 e6 0 9
Fig. 6 e Haber-Weiss cycle/Fenton reaction. Fe(II) can act as
a catalyst for the Fenton reaction (represented within
dotted box, A) reacting with hydrogen peroxide (H2O2) or
superoxide anion (OL 2 ∙) to form Fe(III), hydroxide anion
(OHL), and hydroxyl radical (∙ ∙OH), a highly toxic species
that is proposed to initiate lipid peroxidation and other
damaging reactions. If the hydroxyl radical is not
quenched (by an antioxidant) another Fe(II) atom will react
with it to form a second Fe(III) and hydroxyl ion. The
Haber-Weiss cycle regenerates Fe(II) by oxidation with
a peroxyl radical to give oxygen gas as a byproduct. Similar
to iron, copper can also act as a catalyst in these reactions.
and papilledema.99,153,178,205,303,338,355 There are, however, no
adults with retinal dysfunction associated with iron defi-
ciency without anemia.
In children, however, iron deficiency is associated with
dysfunction of the visual pathways.9,233,306 Twenty-five chil-
dren aged 6e24 months with iron deficiency (serum levels of
iron, ferritin, and transferrin saturation: 27.09  12.62 mg/dl,
5.32  2.92 ng/ml, 5.41  2.78%, respectively) were shown to
have significantly delayed latencies on visual evoked poten-
tials (VEP) compared with controls.233 Iron deficiency might
have hindered the function of oligodendrocytes and myeli-
nation of the visual pathways.19,234 The delayed latencies may
have been to the result of iron-deficiency anemia and hypoxia
as 21 of these children had moderate, and the remaining
severe, anemia. A correlation found between serum ferritin
levels and the delay of one of the VEP waves suggested that
iron deficiency per se was a key player in the pathogenesis.
Consistent with this view, in a separate study,306 the latency
of one of the VEP improved after treatment of the iron defi-
ciency. In another similar study correction of the iron-
deficiency anemia did not produce this effect.9
4.1.2. The retina in systemic iron overload status
Systemic iron overload can develop with increased absorp-
tion (i.e, hereditary hemochromatosis) or iron administra-
tion, especially transfusions (i.e., thalassemia major, sickle
cell disease, aplastic or refractory anemia, or myelodysplastic
Fig. 7 e Schematic representation showing possible
bidirectional flow of iron through the RPE. Iron is likely to be
recycled between the RPE and neuroretina with contribution
from transferrin (Tf) in a process that might be regulated by
light. Tf produced by the RPE and photoreceptors could bind
to Fe(III) extracellularly and the complex is endocytosed by
transferrin receptor (TfR) expressed in the RPE,
photoreceptor inner segments (IS), and outer segments (OS).
The second potential route of iron entry into the
photoreceptors is the divalent metal transporter 1 (DMT1),
which transports Fe(II) along a proton gradient and has been
shown to be expressed in photoreceptor IS. Iron from
photoreceptor OS could also gain access to the RPE during
phagocytosis of the OS. Once inside the RPE or
photoreceptor cell, iron would be supplied to cytosolic
ferritin (Ft) for storage, taken up by the mitochondria, or
released from the cell by the plasma membrane transporter,
ferroportin (Fo), with the assistance of the cuproenzymes
ceruloplasmin (Cp) and hephaestin. Dysregulation of
photoreceptor OS phagocytosis in the Royal College of
Surgeons rats leads to retinal iron overload in the layer of
undigested OS tips in the subretinal space. Alterations in
retinal iron homeostasis have also been demonstrated in
rd10 mice (with a mutation in the photoreceptor
phosphodiesterase). These mice accumulate iron and
ferritin-bound iron in the photoreceptor IS and OS
supporting the view that a normal phototransduction
process in the photoreceptors is necessary for iron to be
released from these cells. The increased TfR expression,
which was demonstrated in rd10 mice at 6 weeks of age,
may contribute to increased retinal iron uptake.
syndrome)313 and presents with fatigue, dark skin, arthralgia,
hepatomegaly, cardiomyopathy, and endocrine disorders.
Testing reveals elevated serum levels of iron, ferritin (>200
ng/ml in women, >300 ng/ml in men), transferrin, and
transferrin saturation (>45%).
Some serially transfused thalassemia patients106,157,294,
337,348
develop RPE mottling that correlate with high serum
iron and ferritin levels. The fundus changes are thought to
reflect retinal iron overload; some of those included in these
studies,157,294 however, had been treated with the iron chelator
 s u r v e y o f o p h t h a l m o l o g y 5 8 ( 2 0 1 3 ) 5 8 5 e6 0 9 595

Fig. 8 e Diagramatic representation of interactions between cellular iron, zinc, and copper homeostases. The effects and
functions of iron, zinc, and copper in the cell are likely to be heavily dependent on one another. Intracellular “free” zinc is
involved in the regulation of iron regulatory proteins (IRP). Optimal levels of copper are essential for the synthesis of melanin
(binding molecule for iron, zinc, and copper) and ceruloplasmin (Cp) (ferroxidase involved in iron export). Intracellular zinc
ions will also influence the expression of MT (copper and zinc storage). Decreased copper levels might cause reduced Cp and
retinal iron accumulation. Reduced intracellular zinc could potentially influence the regulation of molecules involved in iron
homeostasis (i.e., transporters, storage, regulatory proteins) causing intracellular iron accumulation.

deferoxamine, which could have contributed to the retinal
features (see subsequent discussion).
4.1.3. Retinal iron overload in hereditary disorders of iron
homeostasis
Iron can accumulate in the retina in inherited diseases with
mutations in genes encoding homeostatic proteins (e.g.,
ceruloplasmin,88,137,381 frataxin,89,137 and HFE137). These
molecules are expressed in the retina, therefore the retinal
features may be due to a combination of changes in the
abundance and/or activity of these proteins at the retinal level
and alterations in iron availability in the circulation.
4.1.3.1. Aceruloplasminemia. This rare autosomal recessive
disease caused by mutations in the ceruloplasmin gene387
results in the impaired export of iron from the retina,
brain, and pancreas and the triad of adult onset retinal
degeneration, dementia, and diabetes.177,321 Ophthalmolog-
ical features include drusen-like subretinal lesions and
yellow discoluration of the fundus with gray areas of RPE
atrophy.88,381,390 Although visual acuity is maintained, the
function of the RPE and neuroretina is affected, as shown by
ERG. Retinal histopathology of one patient with acer-
uloplasminemia381 revealed RPE atrophy and hypertrophy
with accumulation of iron, lipofuscin, and melanolipo-
fuscin. Elevated iron levels were also found in the
neuroretina.
Similarly, mice lacking both ceruloplasmin and hephaestin
develop retinal iron accumulation, subretinal neo-
vascularisation, and photoreceptor loss as they get older.127 By
the age of 6e9 months, up to 75% of RPE cells are severely
hypertrophic with an accumulation of iron, phagosomes, and
lysosomes (probably containing undigested ROS).127
4.1.3.2. Friedreich’s ataxia. This autosomal recessive neuro-
degenerative disorder is usually associated with a mutation in
the gene encoding frataxin leading to progressive accumula-
tion of iron in the mitochondria.179,268 Ocular manifestations26
include autofluorescent yellow deposits throughout the
macula (presumed to contain iron and lipofuscin) and late-
onset optic neuropathy.10,100
4.1.3.3. Hemochromatosis. The iron-overload genetic disorder
hereditary hemochromatosis results from loss-of-function
mutations in genes coding for the iron-regulatory proteins
HFE (human leucocyte antigen-like protein involved in iron
homoeostasis), transferrin receptor, ferroportin, hepcidin or
hemojuvelin, and/or disruption of the bone morphometric
protein signaling pathway controlling hepcidin. Iron overload
in the peripapillary RPE and drusen formation can develop in
these patients.137,299 Hemojuvelin,115 HFE,112 hepcidin,122 or
bone morphometric protein 6124 knockout mice have also
been shown to accumulate retinal iron in an age-dependent
manner.
596 s u r v e y o f o p h t h a l m o l o g y 5 8 ( 2 0 1 3 ) 5 8 5 e6 0 9
4.1.4. Changes in retinal iron balance in experimental animal
models of retinal disease
Alterations in retinal iron metabolism can also occur as
a consequence of retinal disease. The Royal College of Surgeons
rats carry a mutation that disrupts the gene encoding the
tyrosine kinase receptor, MertK, in the RPE.76,367 This makes
these cells unable to phagocytose ROS leading to undigested
ROS tips in the subretinal space. Iron builds up in the subretinal
debris in a time-dependent manner and is thought to be
a contributing factor in photoreceptor degeneration.396
Mice with a mutation in the rod phosphodiesterase, rd10,
also show age-dependent retinal iron accumulation.79 At 6
weeks of age, the retinal expression of transferrin receptor,
transferrin, and ceruloplasmin is elevated. The increased
expression of transferrin receptor might contribute to
increased retinal iron uptake. The enhanced expression of
transferrin and ceruloplasmin might reflect an attempt by
the retina to cope with the iron excess. Intraperitoneal
injections of exogenous human transferrin and cross-
breeding of rd10 mice with mice expressing human trans-
ferrin protected photoreceptors and second-order neurons
from degeneration.277 Human transferrin produced by Müller
and RPE cells in transgenic mice protects Müller cells in
culture against iron excess.276 The protective effect might
result from Fe(III) binding and/or other potential biological
functions of transferrin.75,149,191 The retina of 2-month-old
hypotransferrinemic mice shows abnormal function and
expression of genes encoding iron homeostatic molecules
despite normal iron levels.191 Treatment with the iron
chelator deferoxamine also prevents retinal degeneration in
rd10 mice and this protective effect is potentiated by
concomitant use of zinc.261 The protective effect of zinc-
deferoxamine complex is thought to be mediated through
modulation of iron availability and antioxidant mechanisms.
Reduced levels of retinal ferritin and iron content within
ferritin were found in the zinc-desferoxamine treated
retinas.
4.1.5. Iron-induced retinal toxicity
Histology from humans60 and rabbits43 with iron intraocular
foreign bodies (ocular siderosis) has demonstrated retinal
degeneration. Intravitreal injections of iron particles in
mice,297 rats,373 rabbits43,77,365 and monkeys218 result in RPE
and neuroretinal dysfunction with decreased amplitude of the
a- and b-waves of scotopic and photopic ERG. In mice, damage
to photoreceptors was greater in cones than rods.297 The
mechanism of iron-induced retinal toxicity is thought to
include the formation of reactive oxygen species, lipid per-
oxidation, and impairment of phagocytosis and ROS digestion
by RPE cells.8,50
4.2. Zinc
Unlike iron, there is no body storage of zinc. Approximately
1% of the total body zinc (2.5 g)12,373 needs to be replenished
daily with the diet, and long periods of zinc deficiency
cannot be compensated for. Zinc is found in most animal
products, legumes, whole grains, and dairy products. The
most commonly used biomarkers of zinc status are plasma/
serum zinc concentration (normal range, 70e250 mg/dl),
measurements of the activity of zinc-dependent enzymes
(e.g., alkaline phosphatase), and 24-hour urinary zinc excre-
tion.170,173,203 Serum/plasma zinc levels reflect intake and
respond to alterations over short periods of time.
4.2.1. Retinal dysfunction associated with zinc depletion
Systemic zinc depletion can result from mutations in the gene
encoding the Zip4-transporter (i.e., acrodermatitis enter-
opathica),312 which is important in intestinal uptake, or can be
acquired in cases of decreased dietary intake (alcoholism,
total parenteral nutrition, low meat diet), decreased absorp-
tion (diets high in cereal grains, gastric bypass surgery,
inflammatory bowel disease, celiac disease, chronic diarrhea),
increased elimination (from alcoholism, malignancy, burns,
infections, pregnancy, renal and liver disease, or stress), or use
of certain medications (penicillamine, diuretics, antimetabo-
lites, valproate, and iron salts).93,172,204,280,320 Premature
infants, children, and pregnant and lactating women are at
increased risk. Children and adolescents present with growth
retardation, male hypogonadism, and dysgeusia. Psoriasiform
dermatitis, immune system dysfunction, poor wound healing,
and iron overload may also occur. Ocular manifestations
include poor dark adaptation.1,87,155,169,182,231,236
Mochizuki et al231 reported the case of a 46-year-old Japanese
man with liver dysfunction, low serum zinc levels (44 mg/dl), and
vitamin A deficiency (10 IU/dl; normal range, 9e316 IU/dl) with
markedly reduced scotopic and phototopic ERG b-waves.
Normalization of night vision and scotopic ERG responses fol-
lowed improvement of liver function and recovery of blood zinc
levels, despite persistent vitamin A deficiency and abnormal
photopic ERGs. This suggested that rod function is more
susceptible to zinc deficiency than cone function. Morrison
et al236 also demonstrated a patient with liver disease and low
serum zinc and vitamin A levels, whose impaired dark adapta-
tion improved by zinc supplementation alone.
The rapid response of retinal zinc bioavailability to alter-
ations in serum may result from a fast turnover and the retinal
uptake mediated by concentration gradients via Zip trans-
porters. Pigs305 and pigmented rats182 fed zinc-deficient diets
show reduced zinc concentration in RPE melanosomes after
6 months and 12 weeks, respectively. In the early stages of
zinc deficiency, specific retinal regulatory mechanism of zinc
homeostasis might be in place. Albino rats on a zinc-deficient
diet for 6 weeks developed depressed plasma zinc levels, but
did not show alterations in the total amount of zinc in the RPE
or neuroretina.94 At 7 weeks, however, ultrastructural
changes and vesiculation of RPE cells develop in association
with degeneration of photoreceptor ROS.198
The mechanisms of zinc deficiencyeinduced retinal
dysfunction, similarly to iron overload, probably include
oxidative stress,227 lipofuscin accumulation163 in the RPE, and
photoreceptor disruption. In RPE cells in culture, zinc deple-
tion results in reduced protein synthesis,349 disruption of
growth factor signalling molecules,150,151,351 and cell death.62
4.2.2. Retinal effect of zinc excess
High zinc intake, either intentional or inadvertent (e.g.,
ingestion of denture adhesive),85 occupational exposure (e.g.,
welding), high intestinal absorption, or diminished intestinal
excretion may result in hyperzincemia and elevated 24-hour
 s u r v e y o f o p h t h a l m o l o g y 5 8 ( 2 0 1 3 ) 5 8 5 e6 0 9
urinary zinc excretion. Systemic features of zinc overload
include dysfunction of the immune system, fever, headaches,
cramps, nausea, vomiting, diarrhea, loss of appetite, and
demyelination, which seem to be secondary to the zinc-
induced copper deficiency.85,118,138,282,301,377
No retinal abnormalities have been described in patients
with zinc overload. This suggests that in vivo homeostatic
mechanisms may prevent zinc accumulating in the healthy
retina beyond physiological levels. Both the RPE and retinal
neurones are highly sensitive to excess “free” zinc. Intraocular
injections of 150 mM zinc265 and brief exposure (15 min) of
retinal cells in culture to high levels of zinc (300e600 mM)5,53
lead to retinal cell degeneration and apoptosis of photore-
ceptors and RPE.
The mechanisms of zinc-induced cell toxicity involve
oxidative stress,160,314,316 apoptosis,53,265 and mitochondrial
injury.41,83,84,158,184,202,226,316 Zn(II) opens mitochondrial pores
and initiates membrane hyperpolarisation and the release of
pro-apoptotic proteins.158,226 An endogenous zinc-based
cytotoxic mechanism is thought to operate in the retina, as
in other parts of the CNS.5,56,161 Retinal ischemia induced by
high intraocular pressure399 and light-induced injury326
caused intracellular accumulation of chelatable zinc in the
INL and GCL. The origin of this chelatable zinc is unclear. It
could be zinc released from presynaptic terminals of the
photoreceptors and bipolar cells during synaptic trans-
mission, from metallothionein, or from intracellular organ-
elles (mitochondria, nuclei, endoplasmic reticulum).
4.3. Copper
The total body content of copper is approximately 110 mg.
Under normal circumstances, the amount of copper absorbed
by the body is equivalent to the amount excreted. The main
dietary sources are organ meat (liver), seafood (oysters), cocoa,
nuts (particularly cashews), seeds, and drinking water. The
most frequently used markers of systemic status are serum
copper (normal levels, 70e150 mg/dl) and ceruloplasmin
concentrations.135 They are useful in diagnosing moderate to
severe copper deficiency or excess but not sensitive enough to
detect small changes. Alternative markers include measure-
ments of the activity of copper-dependent enzymes (e.g.,
erythrocyte superoxide dismutase or platelet CCO).135
4.3.1. Copper deficiency and visual dysfunction
Copper deficiency can result from malnutrition, poor absorp-
tion after surgical removal or bypass of a large part of the
intestine,185 excessive losses (e.g., in nephrotic syndrome,273
skin burns), or pharmacological treatment with copper
chelators, zinc, or iron supplements.404 Systemic features
include anemia (copper-containing CCO and ceruloplasmin
are required for blood hemoglobin formation), dysregulation
of lipid metabolism, increased blood cholesterol levels, elec-
trocardiogram abnormalities, hypotension, glucose intoler-
ance, myelopathy, impaired melanin synthesis, poor immune
response, and secondary iron deficiency.283
There are a few reports of optic neuropathy in patients
with low copper levels243,279 presenting with reduced visual
acuity and color vision, constricted visual fields, optic atrophy,
and retinal nerve fiber thinning. The scotopic and photopic
597
ERG were normal, suggesting that the retinal function was
preserved. Copper deficiency in rats fed diets with insufficient
copper content results in optic nerve demyelination and
damaged vacuole-containing myelin.70 These effects are
thought to be the result of reduced activity of cupro-enzymes
or free copper ions involved in the synthesis of phospholipids.
4.3.2. Copper excess and visual function
Ingestion of large doses of copper may cause nausea, sickness,
and diarrhea. Extreme cases may be fatal. No cases have been
reported with associated retinal symptoms or signs in the
absence of an underlying genetic disorder; the retina is known
to have high affinity for copper, however, and be sensitive to
copper-induced toxicity. Ten days after intravitreal injection
of 25 mg copper sulphate in rabbits, 20% of the injected copper
still remained within retinal cells.32 Copper-containing intra-
ocular foreign bodies are extremely toxic to the retina. “Free”
or loosely bound copper ions are highly toxic as they are
potent inhibitors of enzymes325 and accelerate the formation
of reactive oxygen species159,160 similar to iron. They can
cause inflammation360 and direct damage to cell membranes
and mitochondria.16,325 In addition, copper ions can induce
retinal neuron death by interaction with glutamatergic
NMDA311 and AMPA222 receptors and activation of nitric oxide
synthetase.216
4.3.3. Retinal disease associated with disregulation of copper
homeostasis
4.3.3.1. Menkes disease. This X-linked disorder with a loss-of-
function mutation in the gene encoding ATP7A369 leads to
impaired activity of specific cuproenzymes, disruption of
intracellular copper excretion, and systemic copper depletion.
Retinal signs97,107,384 present in early infancy, revealing a crit-
ical role of ATP7A in retinal development. The peripheral
retinal appears hypopigmented. The scotopic ERG shows low
amplitude a- and b-waves.97 Neuropathological studies in
humans have demonstrated ganglion cell loss, thinning of the
nerve fiber layer, optic atrophy, swelling of the mitochondria
in the photoreceptors and ganglion cells together with RPE
accumulation of electron dense inclusion bodies, small
irregular melanin granules, and abnormal elastin in Bruch
membrane.383 Similar changes have been identified in the
retina of macular mouse, a model of Menkes disease with
defective ATP7A,251 including reduced melanin granules in
the RPE,230 swollen mitochondria in the RIS230 with reduced
CCO activity,230 and optic nerve demyelination.229
4.3.3.2. Wilson disease. This autosomal recessive disorder
with loss-of-function mutation in the ATP7B gene results in
high plasma copper levels and copper overload in body
tissues.72,96 Eight newly diagnosed adults with Wilson disease
revealed retinal dysfunction associated with prolonged oscil-
latory potentials and reduced a- and b-wave amplitudes of
scotopic ERGs.308 These changes were reversed with recovery
of plasma copper levels following treatment with the copper
chelator d-penicillamine, consistent with the concept that
copper can modulate retinal synaptic function.
Alterations in the systemic homeostasis of copper and zinc
have also been suggested to occur in retinitis pigmentosa168
and in high myopes with and without retinal detachment,332
598 s u r v e y o f o p h t h a l m o l o g y 5 8 ( 2 0 1 3 ) 5 8 5 e6 0 9
although this needs further investigation. Silverstone
measured high levels of zinc and low levels of copper in serum
from myopic white patients without retinal detachment. In
the high myope group with retinal detachment, both serum
zinc and copper levels were significantly elevated. The
authors consider the systemic changes in zinc and copper
metabolism could compromise the RPE function.
Based on the evidence presented here, endogenous retinal
iron and copper seem to be largely unresponsive to reductions
in circulating levels. In contrast, the functional pool of retinal
zinc exchanging with plasma seems to be larger. A decline in
body zinc levels is associated with retinal dysfunction. These
differences may in part be a consequence of different turnover
rate and the retinal uptake mechanisms. Zinc is thought to be
transported into the retina from the circulation via concen-
tration gradients through Zip transporters, whereas iron and
copper uptake occurs via “active transporters” against
concentration gradients.
5. Age-induced changes in retinal
homeostasis of iron, zinc, and copper
During aging, the systemic metabolism of iron, zinc, and copper
changes. The average serum ferritin concentration, a reflection
of body iron stores, increases,45,67,228,405 plasma and serum zinc
decreases,120 and copper blood levels increase.24 Iron stores in
liver and spleen are significantly elevated in older rats and mice
in some studies,67,219,334,345 although others have reported no
age-related increase.3 There is evidence that iron levels also
increase with aging in the mammalian retina (Table 1), with
higher increases in women than men.128 In rats the rises are 3-
fold in the RPE,50 1.3-fold in the neuroretina49 compared with
young animals, and do not reflect changes in blood levels,50
suggesting tissue-specific mechanisms. In mice, the iron
increase varies among strains.129
Age-induced retinal iron accumulation in rodents is asso-
ciated with alterations in homeostatic molecules, with
different changes in the RPE/choroid and the neuro-
retina.49,50,52 In the RPE ferritin and ceruloplasmin increase,
whereas transferrin and transferrin receptor decrease.49 In
the neuroretina, transferrin was decreased, but transferrin
receptor, ferritin, ceruloplasmin, and ferroportin were all
increased.49 These alterations may arise from failure of the
homeostatic mechanisms with increased uptake and/or poor
excretion of excess iron. The increase in transferrin receptor
protein might contribute to iron accumulation. The changes in
transferrin, ferritin, and ceruloplasmin suggest the retinal
cells sense an increase in intracellular iron.
Aging has been associated with zinc depletion. Wills
et al378,379 detected a reduction in total zinc in the neuroretina
of men, although they did not notice any change in women.
Tate et al349 found a 9% reduction in total RPE zinc and a 45%
reduction in the solubilizable zinc (separate from pigment
granule fractions) in eyes from donors more than 70 years of
age compared with younger donors. They also found
a decrease in the zinc storage molecule, MT, in RPE cells from
the macular area.349 In vitro studies have also shown that RPE
cells contain less endogenous zinc ions and zinc influx
transporters Zip2 and Zip4 with increased age.197
6. AMD and iron, zinc, and copper retinal
homeostasis
The etiology of the progressive RPE and neuroretina degen-
eration in AMD, the most common retinal disorder affecting
macular function in the elderly population in the developed
world,260 is incompletely understood. Age, environmental
(e.g., smoking), and genetic factors have been shown to
influence susceptibility. Genetic studies have implicated
polymorphisms in genes encoding the alternative comple-
ment pathway,61 alterations of lipid metabolism,61 matrix
homeostasis,61 angiogenesis,61 and iron metabolism (e.g.,
DMT1,389 transferrin388) in its pathogenesis. Dysregulation of
retinal iron,89,104,137,383,385 zinc,92,379 and copper92,379 homeo-
stases may contribute to the pathology. Molecular studies
have shown deposition of loosely bound, histochemically
reactive iron in human RPE, Bruch membrane, and photore-
ceptors in macula tissue from donors who had both dry
(geographic atrophy) and wet (exudative) AMD compared with
age-matched healthy maculas.80,125 The content of zinc and
copper in human RPE/choroid in AMD is decreased by 24% and
23%, respectively.379 High levels of zinc colocalize with dru-
sen,194 which might affect oligomerization of complement
factor H.246 In AMD maculas, the expression of transferrin,58
ferritin80 and ferroportin80 is upregulated, and Zip2,197
Zip4,197 MT,252,349 semenogelin I and II,35 and bone morpho-
metric protein 6124 are downregulated.
It is still unclear whether the metal-related abnormalities
are a cause or an effect of the retinal degeneration in AMD.
Processes such as inflammation may initiate the AMD
abnormality and result in secondary alterations in trace
element homeostasis; experimental evidence suggests that
retinal deposition of chelatable iron participates in the path-
ogenesis, however. Aceruloplasminemia and retinal iron
overload in humans88 result in early onset drusen. Retinas
from iron-overloaded mice deficient in ceruloplasmin and
hephaestin have some features of AMD.127 Elevated retinal
iron levels are associated with retinal degeneration in the
Royal College of Surgeons rats,396 rd1079 mice, and several
rodent models with alterations in iron-regulating proteins
(e.g., hepcidin,123 ferritin,278 hemojuvelin,115 bone morpho-
metric protein 6124).
Although there is no conclusive evidence as to why iron is
increased in the retina, one explanation is low zinc levels in
the RPE. Zinc-deficient animals accumulate iron in several
organs.170,298 Numerous genes respond to alterations in
cellular zinc levels with changes in mRNA levels.253 In vitro
studies zinc deficiency results in increased levels of metal
regulatory proteins and enhances transferrin receptor
expression. An increase in transferrin receptor could raise
cellular iron uptake and hence intracellular levels.253
7. Metal chelators and supplements as
potential treatments for retinal disease
The changes detected in retinal iron and zinc homeostasis in
AMD have led to the idea that iron chelators and zinc
supplements may be beneficial in the treatment of this
debilitating disease.22,54,156,248,250,363
 s u r v e y o f o p h t h a l m o l o g y 5 8 ( 2 0 1 3 ) 5 8 5 e6 0 9
7.1. Iron chelators
Several authors123,261,383 suggest that therapy with iron
chelators such as deferoxamine, deferasirox, and deferiprone
may help in the treatment of retinal diseases associated with
iron overload. These chelators have a high affinity for Fe(III)
and remove it from hemosiderin, ferritin, and, to a lesser
extent, transferrin.240,336 Detailed investigation of the effects
at the cellular and molecular level, and the potential toxicity
of systemic iron chelators in the absence of systemic iron
overload are needed.
Desferrioxamine treatment has been associated with
retinal toxicity.15,17,25,74,108,116,130,189,287 Patients presented
with poor dark adaptation, centrocecal scotomas, peripheral
visual field constriction, pigmentary retinal degeneration,
macular vitelliform lesions, and optic neuropathy. ERG and
electrooculography130 demonstrated photoreceptor and RPE
dysfunction. Rahi et al287 examined with light and
electron microscopy the retina of a 24-year-old man with
beta-thalassemia major who had received regular blood
transfusion from the age of 6 months and 500-mg daily
intramuscular deferoxamine from the age of 8 years. His RPE
showed loss of apical microvilli, depigmentation, vacuoliza-
tion of the cytoplasm, swelling and calcification of mito-
chondria, and disorganization of the plasma membrane.
Bruch membrane overlying degenerate RPE was thickened.
Whether the retinal toxicity is a direct effect of the deferox-
amine, the iron overload prior to starting deferoxamine
treatment, other trace metals, the functional retinal defi-
ciency, or a combination of these factors is uncertain. In a rat
model of deferoxamine retinopathy,108,116 the ERG changes
were worsened by exposure to white light and oxygen, sug-
gesting that oxidative stress and decompartmentalization of
metals might have been involved.
7.2. Zinc supplements
A 2-year randomized, double-masked, controlled trial with
151 patients showed that 200 mg/day of zinc sulfate (81 mg/
day of elemental zinc) reduced visual loss in patients with dry
AMD,248 although no effect was demonstrated in wet AMD.340
A more recent trial with 40 patients treated with 25 g oral zinc-
monocysteine complex twice daily for 6 months demon-
strated that the visual acuity, contrast sensitivity, and
photorecovery time improved in zinc-treated patients with
dry AMD compared with placebo.250
A large, randomized, controlled trial (AREDS2) of daily
supplementation with high-dose zinc alone (80 mg of zinc as
zinc oxide) or in combination with antioxidants (500 mg of
vitamin C, 400 IU of vitamin E, and 15 mg of beta carotene) and
copper (2 mg of copper as cupric oxide) found that both
significantly reduced the risk of progression to advanced AMD
compared with placebo in individuals with signs of moderate
to AMD in at least one eye. The effect of AREDS supplements
including zinc might depend on genotype (e.g., complement
factor H).175,192
Treatment of experimental animals with zinc supplements
increases zinc levels in the RPE263 and alters expression of
genes related to cell growth, proliferation, cell cycle, and cell
death, and may protect the retina from oxidative stress in
599
ischemia,171 a “diabetes-like” model by intraperitoneal injec-
tion of alloxan,237 and light-induced retinal injury.263 Some of
the zinc-induced effects on RPE cells might be mediated by the
extracellular Zn(II) sensing G-protein coupled receptor
GPR39.47
8. Summary
Iron, zinc, and copper have key functions in retinal cell
metabolism and specific retinal processes. The requirements
for these metals vary according to cell type, leading to a non-
uniform distribution within the retina. Iron and copper seem
to have a relatively slow turnover rate, and levels are largely
unresponsive to alterations in plasma levels. By contrast, the
functional pool of retinal zinc exchanges with plasma rapidly.
The variation in metabolic requirements for iron-, zinc-, and
copper-dependent functions in different retinal regions is
likely to be influenced by light exposure with changes in metal
ion bioavailability, reactivity, distribution, and specific
delivery for incorporation in metalloproteins. The retinal
uptake, delivery, storage, and extrusion of these three trace
metals must be tightly regulated by their interrelated
homeostatic mechanisms to ensure normal retinal function.
Retinal iron, zinc, and copper availability may be altered in
inherited diseases by mutations in genes encoding proteins
concerned with their metabolism. In aging and AMD, changes
in the molecules involved in retinal metal homeostasis have
been described. These changes might affect the handling of
metal ion reactivity and availability and result in retinal
cytotoxicity.
9. Future directions
Many aspects of the homeostasis of iron, zinc, and copper in
the retina are incompletely understood and, given their
importance, further research is needed to clarify these issues.
More detailed information is necessary on how iron, zinc, and
copper are taken up by the retina from blood; the turnover,
exchange between RPE cells, photoreceptors, inner neurones,
and glial cells; together with their direct and/or indirect
interactions. Furthermore, the contribution of these metals to
the pathogenesis of diseases including AMD, diabetic reti-
nopathy, and retinal dystrophies requires further study as
modulating levels may provide a viable therapeutic strategy.
10. Method of literature search
A literature search was conducted using OVID, Medline, and
EMBASE by meshing keywords iron; zinc; copper; eye; retina;
homeostasis; electroretinogram; retinal pathology; retinal ultra-
structure; trace metal cellular metabolism; trace metal transporters;
trace metal chaperones; trace metal storage molecules; mitochon-
drial function; mitochondrial metal metabolism; metal-dependent
functions; trace metal homeostasis regulation; iron, zinc, and
copper deficiency; iron, zinc, and copper overload; age-related
macular degeneration; iron, zinc, and copper chelators; iron, zinc,
and copper supplements in different combinations. Articles
600 s u r v e y o f o p h t h a l m o l o g y 5 8 ( 2 0 1 3 ) 5 8 5 e6 0 9
providing information about the content and function of iron,
zinc, and copper in the retina were included, as well as those
with evidence on retinal localization of molecules involved in
iron, zinc, and copper homeostasis. Articles were excluded if
an abstract in English was not available.
Acknowledgments
M.U. is a National Institute of Health Research (NIHR) Clinical
Lecturer. We acknowledge support from the NIHR Manchester
Biomedical Research Centre. We are most grateful to Dr.
Kalotina Geraki from Ion beam I18 at Diamond Light Source
(Harwell Science and Innovation Campus, Didcot, Oxfordshire
OX11 0DE, UK) for her help with the synchrotron XRF analysis
of rat retina (Fig. 1).
references
1. Afridi HI, Kazi TG, Kazi N, et al. Evaluation of status of zinc,
copper, and iron levels in biological samples of normal
children and children with night blindness with age groups
of 3e7 and 8e12 years. Biol Trace Elem Res. 2011;142:323e34
2. Age-Related Eye Disease Study Research Group.
A randomized, placebo-controlled, clinical trial of high-dose
supplementation with vitamins Cand E, beta carotene, and
zinc for age-related macular degeneration and vision loss:
AREDS report no. 8. Arch Ophthalmol. 2001;119:1417e36
3. Ahluwalia N, Gordon MA, Handte G, et al. Iron status and
stores decline with age in Lewis rats. J Nutr.
2000;130:2378e83
4. Aisen P, Enns C, Wessling-Resnick M. Chemistry and biology
of eukaryotic iron metabolism. Int J Biochem Cell Biol.
2001;33:940e59
5. Aizenman E, Stout AK, Hartnett KA, et al. Induction of
neuronal apoptosis by thiol oxidation: putative role of
intracellular zinc release. J Neurochem. 2000;75:1878e88
6. Ajioka RS, Phillips JD, Kushner JP. Biosynthesis of heme in
mammals. Biochim Biophys Acta. 2006;1763:723e36
7. Akagi T, Kaneda M, Ishii K, et al. Differential subcellular
localization of zinc in the rat retina. J Histochem Cytochem.
2001;49:87e96
8. Akeo K, Hiramitsu T, Yorifuji H, et al. Membranes of retinal
pigment epithelial cells in vitro are damaged in the
phagocytotic process of the photoreceptor outer segment
discs peroxidized by ferrous ions. Pigment Cell Res.
2002;15:341e7
9. Algarı́n C, Peirano P, Garrido M, et al. Iron deficiency anemia
in infancy: long-lasting effects on auditory and visual
system functioning. Pediatr Res. 2003;53:217e23
10. Alldredge CD, Schlieve CR, Miller NR, et al. Pathophysiology
of the optic neuropathy associated with Friedreich ataxia.
Arch Ophthalmol. 2003;121:1582e5
11. Alvarado G, Murillo M. Multielemental fractionation in
human peripheral blood mononuclear cells by size exclusion
liquid chromatography coupled to UV andICP-MS detection.
J Chromatogr Sci. 2010;48:697e703
12. Andreini C, Banci L, Bertini I, et al. Zinc through the three
domains of life. J Proteome Res. 2006;5:3173e8
13. Andrews NC. Ferrit(in)ing out new mechanisms in iron
homeostasis. Cell Metab. 2010;12:203e4
14. Andrzejczyk J, Buszman E. Interaction of Fe3þ, Cu2þ and
Zn2þ with melanin and melanoproteins from bovine eyes.
Acta Biochim Pol. 1992;39:85e8
15. Arden GB, Wonke B, Kennedy C, et al. Ocular changes in
patients undergoing long-term desferrioxamine treatment.
Br J Ophthalmol. 1984;68:873e7
16. Armstrong C, Leong W, Lees GJ. Comparative effects of metal
chelating agents on the neuronal cytotoxicity induced by
copper (Cuþ2), iron (Feþ3) and zinc in the hippocampus.
Brain Res. 2001;892:51e62
17. Arora A, Wren S, Gregory Evans K. Desferrioxamine related
maculopathy: a case report. Am J Hematol. 2004;76:386e8
18. Arranz V, Dreuillet C, Crisanti P, et al. The zinc finger
transcription factor, MOK2, negatively modulates expression
of the interphotoreceptor retinoid-binding protein gene.
IRBP J Biol Chem. 2001;276:11963e9
19. Badaracco ME, Siri MV, Pasquini JM. Oligodendrogenesis: the
role of iron. Biofactors. 2010;36:98e102
20. Bal W, Christodoulou J, Sadler PJ, et al. Multi-metal binding
site of serum albumin. J Inorg Biochem. 1998;70:33e9
21. Banci L, Bertini I, Ciofi-Baffoni S, et al. Mitochondrial
copper(I) transfer from Cox17 to Sco1 is coupled to electron
transfer. Proc Natl Acad Sci USA. 2008;105:6803e8
22. Bartlett H, Eperjesi F. Age-related macular degeneration and
nutritional supplementation: a review of randomised
controlled trials. Ophthalmic Physiol Opt. 2003;23:383e99
23. Beard JL, Murray-Kolb LE, Rosales FJ, et al. Interpretation
of serum ferritin concentrations as indicators of total-
body iron stores in survey populations: the role of
biomarkers for the acute phase response. Am J Clin Nutr.
2006;84:1498e505
24. Belbraouet S, Biaudet H, Tébi A, et al. Serum zinc and copper
status in hospitalized vs. healthy elderly subjects. J Am Coll
Nutr. 2007;26:650e4
25. Bene C, Manzler A, Bene D, et al. Irreversible ocular toxicity
from single “challenge” dose of deferoxamine. Clin Nephrol.
1989;31:45e8
26. Bergstedt M, Johansson S, Muller R. Hereditary spastic ataxia
with central retinal degeneration and vestibular
impairment. A clinical report on a family. Neurology.
1962;12:124e32
27. Bermejo F, Garcı́a-López S. A guide to diagnosis of iron
deficiency and iron deficiency anemia in digestive diseases.
World J Gastroenterol. 2009;15:4638e43
28. Bernard M, Voisin P. Photoreceptor-specific expression,
light-dependent localization, and transcriptional targets of
the zinc-finger protein Yin Yang 1 in the chicken retina.
J Neurochem. 2008;105:595e604
29. Bettger WJ. Zinc and selenium, site-specific versus general
antioxidation. Can J Physiol Pharmacol. 1993;71:721e4
30. Biesemeier A, Schraermeyer U, Eibl O. Chemical composition
of melanosomes, lipofuscin and melanolipofuscin granules
of human RPE tissues. Exp Eye Res. 2011;93:29e39
31. Biesemeier A, Julien S, Kokkinou D, et al. A low zinc diet
leads to loss of Zn in melanosomes of the RPE but not in
melanosomes of the choroidal melanocytes. Metallomics.
2012;4:323e32
32. Bito LZ, Baroody RA. Ocular trace metal kinetics and
toxicology. I. The distribution of intravitreally injected
67Cuþþ within intraocular compartments and its loss from
the globe. Invest Ophthalmol Vis Sci. 1987;28:101e5
33. Bjork A, Lindblom U, Wadensten L. Retinal degeneration in
hereditary ataxia. J Neurol Neurosurg Psychiatry.
1956;19:186e93
34. Bonilha VL, Rayborn ME, Shadrach K, et al. Characterization
of semenogelin proteins in the human retina. Exp Eye Res.
2006;83:120e7
 s u r v e y o f o p h t h a l m o l o g y 5 8 ( 2 0 1 3 ) 5 8 5 e6 0 9
35. Bonilha VL, Rayborn ME, Shadrach KG, et al. Semenogelins
in the human retina: differences in distribution and content
between AMD and normal donor tissues. Exp Eye Res.
2008;86:150e6
36. Bowness JM, Morton RA, Shakir MH, et al. Distribution of
copper and zinc in mammalian eyes. Occurrence of metals
in melanin fractions from eye tissues. Biochem J.
1952;51:521e30
37. Bozym RA, Chimienti F, Giblin LJ, et al. Free zinc ions
outside a narrow concentration range are toxic to a variety
of cells in vitro. Exp Biol Med (Maywood). 2010;235:741e50
38. Bray TM, Bettger WJ. The physiological role of zinc as an
antioxidant. Free Radic Biol Med. 1990;8:281e91
39. Brewer GJ, Hill GM, Dick RD, et al. Interactions of trace
elements: clinical significance. J Am Coll Nutr. 1985;4:33e8
40. Brittenham GM, Danish EH, Harris JW. Assessment of bone
marrow and body iron stores: old techniques and new
technologies. Semin Hematol. 1981;18:194e221
41. Brown AM, Kristal BS, Effron MS, et al. Zn2þ inhibits alpha-
ketoglutarate-stimulated mitochondrial respiration and the
isolated alpha-ketoglutarate dehydrogenase complex. J Biol
Chem. 2000;275:13441e7
42. Buettner GR. Superoxide dismutase in redox biology: the
roles of superoxide and hydrogen peroxide. Anticancer
Agents Med Chem. 2011;11:341e6
43. Burger PC, Klintworth GK. Experimental retinal degeneration
in the rabbit produced by intraocular iron. Lab Invest.
1974;30:9e19
44. Burri L, Vascotto K, Fredersdorf S, et al. Zim17, a novel zinc
finger protein essential for protein import into
mitochondria. J Biol Chem. 2004;279:50243e9
45. Cals MJ, Bories PN, Devanlay M, et al. Extensive laboratory
assessment of nutritional status in fit, health-conscious,
elderly people living in the Paris area. Research Group on
Aging. J Am Coll Nutr. 1994;13:646e57
46. Cameron JD, McClain CJ. Ocular histopathology of
acrodermatitis enteropathica. Br J Ophthalmol.
1986;70:662e7
47. Camina JP, Campos JF, Caminos JE, et al. Obestatin-mediated
proliferation of human retinal pigment epithelial cells:
regulatory mechanisms. J Cell Physiol. 2007;211:1e9
48. Chappell RL, Redenti S. Endogenous zinc as
a neuromodulator in vertebrate retina: evidence from the
retinal slice. Biol Bull. 2001;201:265e7
49. Chen H, Liu B, Lukas TJ, et al. Changes in iron-regulatory
proteins in the aged rodent neural retina. Neurobiol Aging.
2009;30:1865e76
50. Chen H, Lukas TJ, Du N, et al. Dysfunction of the retinal
pigment epithelium with age: increased iron decreases
phagocytosis and lysosomal activity. Invest Ophthalmol Vis
Sci. 2009;50:1895e902
51. Chen L, Wu W, Dentchev T, et al. Increased metallothionein
in light damaged mouse retinas. Exp Eye Res. 2004;79:287e93
52. Chen L, Wu W, Dentchev T, et al. Light damage induced
changes in mouse retinal gene expression. Exp Eye Res.
2004;79:239e47
53. Chen W, Wang Z, Zhang Y. The effect of zinc on the
apoptosis of cultured human retinal pigment epithelial cells.
J Huazhong Univ Sci Technolog Med Sci. 2003;23:414e7
54. Cho E, Stampfer MJ, Seddon JM, et al. Prospective study of
zinc intake and the risk of age-related macular
degeneration. Ann Epidemiol. 2001;11:328e36
55. Choi BS, Zheng W. Copper transport to the brain by the
bloodebrain barrier and bloodeCSF barrier. Brain Res.
2009;1248:14e21
56. Choi JS, Kim KA, Yoon YJ, et al. Inhibition of cyclooxygenase-
2 expression by zinc-chelator in retinal ischemia. Vision Res.
2006;46:2721e7
601
57. Chothe PP, Gnana-Prakasam JP, Ananth S, et al. Transport of
hepcidin, an iron-regulatory peptide hormone, into retinal
pigment epithelial cells via oligopeptide transporters and its
relevance to iron homeostasis. Biochem Biophys Res
Commun. 2011;405:244e9
58. Chowers I, Wong R, Dentchev T, et al. The iron carrier
transferrin is upregulated in retinas from patients with age-
related macular degeneration. Invest Ophthalmol Vis Sci.
2006;47:2135e40
59. Chua AC, Graham RM, Trinder D, et al. The regulation of
cellular iron metabolism. Crit Rev Clin Lab Sci.
2007;44:413e59
60. Cibis PA, Yamashita T, Rodriguez F. Clinical aspects of ocular
siderosis and hemosiderosis. AMA Arch Ophthalmol.
1959;62:180e7
61. Cipriani V, Leung HT, Plagnol V, et al. Genome-wide
association study of age-related macular degeneration
identifies associated variants in the TNXB-FKBPL-NOTCH4
region of chromosome 6p21.3. Hum Mol Genet.
2012;21:4138e50
62. Clegg MS, Hanna LA, Niles BJ, et al. Zinc deficiency-induced
cell death. IUBMB Life. 2005;57:661e9
63. Cobine PA, Ojeda LD, Rigby KM, et al. Yeast contain a non-
proteinaceous pool of copper in the mitochondrial matrix.
J Biol Chem. 2004;279:14447e55
64. Cobine PA, Pierrel F, Winge DR. Copper trafficking to the
mitochondrion and assembly of copper metalloenzymes.
Biochim Biophys Acta. 2006;1763:759e72
65. Coleman JE. Zinc proteins: enzymes, storage proteins,
transcription factors, and replication proteins. Annu Rev
Biochem. 1992;61:897e946
66. Connor JR, Menzies SL, Burdo JR, et al. Iron and iron
management proteins in neurobiology. Pediatr Neurol.
2001;25:118e29
67. Cook CI, Yu BP. Iron accumulation in aging: modulation by
dietary restriction. Mech Ageing Dev. 1998;102:1e13
68. Cousins RJ, Liuzzi JP, Lichten LA. Mammalian zinc transport,
trafficking, and signals. J Biol Chem. 2006;281:24085e9
69. Coyne HJ 3rd,, Ciofi-Baffoni S, Banci L, et al. The
characterization and role of zinc binding in yeast Cox4. J Biol
Chem. 2007;282:8926e34
70. Dake Y, Amemiya T. Electron microscopic study of the
optic nerve in copper deficient rats. Exp Eye Res.
1991;52:277e81
71. Dancis A, Yuan DS, Haile D, et al. Molecular
characterization of a copper transport protein in S.
cerevisiae: an unexpected role for copper in iron transport.
Cell. 1994;76:393e402
72. Das SK, Ray K. Wilson’s disease: an update. Nat Clin Pract
Neurol. 2006;2:482e93
73. Davies KM, Strauss M, Daum B, et al. Macromolecular
organization of ATP synthase and complex I in whole
mitochondria. Proc Natl Acad Sci USA. 2011;108:14121e6
74. Davies SC, Marcus RE, Hungerford JL, et al. Ocular toxicity of
high-dose intravenous desferrioxamine. Lancet.
1983;2:181e4
75. Davis AA, Hunt RC. Transferrin is made and bound by
photoreceptor cells. J Cell Physiol. 1993;156:280e5
76. D’Cruz PM, Yasumura D, Weir J, et al. Mutation of the
receptor tyrosine kinase gene Mertk in the retinal dystrophic
RCS rat. Hum Mol Genet. 2000;9:645e51
77. Declercq SS, Meredith PC, Rosenthal AR. Experimental
siderosis in the rabbit: correlation between
electroretinography and histopathology. Arch Ophthalmol.
1977;95:1051e8
78. del Valle LJ, Ramon E, Canavate X, et al. Zinc-induced
decrease of the thermal stability and regeneration of
rhodopsin. J Biol Chem. 2003;278:4719e24
602 s u r v e y o f o p h t h a l m o l o g y 5 8 ( 2 0 1 3 ) 5 8 5 e6 0 9
79. Deleon E, Lederman M, Berenstein E, et al. Alteration in iron
metabolism during retinal degeneration in rd10 mouse.
Invest Ophthalmol Vis Sci. 2009;50:1360e5
80. Dentchev T, Hahn P, Dunaief JL. Strong labeling for iron and
the iron-handling proteins ferritin and ferroportin in the
photoreceptor layer in age-related macular degeneration.
Arch Ophthalmol. 2005;123:1745e6
81. Deugnier Y. The iron driven pathway of hepcidin synthesis.
Gastroenterol Clin Biol. 2010;34:351e4
82. Dineley KE. On the use of fluorescent probes to distinguish
Ca2þ from Zn2þ in models of excitotoxicity. Cell Calcium.
2007;42:341e2
83. Dineley KE, Richards LL, Votyakova TV, et al. Zinc causes
loss of membrane potential and elevates reactive oxygen
species in rat brain mitochondria. Mitochondrion.
2005;5:55e65
84. Dineley KE, Votyakova TV, Reynolds IJ. Zinc inhibition of
cellular energy production: implications for mitochondria
and neurodegeneration. J Neurochem. 2003;85:563e70
85. Doherty K, Connor M, Cruickshank R. Zinc-containing
denture adhesive: a potential source of excess zinc resulting
in copper deficiency myelopathy. BrDent J. 2011;210:523e5
86. Donovan A, Brownlie A, Zhou Y, et al. Positional cloning of
zebrafish ferroportin1 identifies a conserved vertebrate iron
exporter. Nature. 2000;403:776e81
87. Dorea JG, Olson JA. The rate of rhodopsin regeneration in the
bleached eyes of zinc-deficient rats in the dark. J Nutr.
1986;116:121e7
88. Dunaief JL, Richa C, Franks EP, et al. Macular degeneration in
a patient with aceruloplasminemia, a disease associated
with retinal iron overload. Ophthalmology. 2005;112:1062e5
89. Dunaief JL. Iron induced oxidative damage as a potential
factor in age-related macular degeneration: the Cogan
Lecture. Invest Ophthalmol Vis Sci. 2006;47:4660e4
90. Ebadi M, Iversen PL, Hao R, et al. Expression and regulation
of brain metallothionein. Neurochem Int. 1995;27:1e22
91. Eckhert CD. Elemental concentrations in ocular tissues of
various species. Exp Eye Res. 1983;37:639e47
92. Erie JC, Good JA, Butz JA, et al. Reduced zinc and copper in
the retinal pigment epithelium and choroid in age-related
macular degeneration. Am J Ophthalmol. 2009;147:276e82
93. Evans GW. Zinc and its deficiency diseases. Clin Physiol
Biochem. 1986;4:94e8
94. Fabe JS, Grahn BH, Paterson PG. Zinc concentration of
selected ocular tissues in zinc-deficient rats. Biol Trace Elem
Res. 2000;75:43e52
95. Fabiano A, Panfoli I, Calzia D, et al. Catalytic properties of the
retinal rod outer segment disk ADP-ribosyl cyclase. Vis
Neurosci. 2011;28:121e8
96. Ferenci P. Pathophysiology and clinical features of Wilson
disease. Metab Brain Dis. 2004;19:229e39
97. Ferreira RC, Heckenlively JR, Menkes JH, et al. Menkes
disease. New ocular and electroretinographic findings.
Ophthalmology. 1998;105:1076e8
98. Finney LA, O’Halloran TV. Transition metal speciation in the
cell: insights from the chemistry of metal ion receptors.
Science. 2003;300:931e6
99. Forster HS. Optic disc edema due to iron deficiency.
Occurrence with normal cerebrospinal fluid pressure. Conn
Med. 1985;49:290e2
100. Fortuna F, Barboni P, Liguori R, et al. Visual system
involvement in patients with Friedreich’s ataxia. Brain.
2009;132:116e23
101. Furuyama K, Kaneko K, Vargas PD. Heme as a magnificent
molecule with multiple emissions: heme determines its own
fate and governs cellular homeostasis. Tohoku J Exp Med.
2007;213:1e16
102. Ganz T. Hepcidin and iron regulation, 10 years later. Blood.
2011;117:4425e33
103. Gao HL, Feng WY, Li XL, et al. Golgi apparatus localization of
ZNT7 in the mouse cerebellum. Histol Histopathol.
2009;24:567e72
104. Garcı́a-Castineiras S. Iron, the retina and the lens: a focused
review. Exp Eye Res. 2010;90:664e78
105. Garry PJ, Goodwin JS, Hunt WC. Iron status and anemia in
the elderly: new findings and a review of previous studies.
J Am Geriatr Soc. 1983;31:389e99
106. Gartaganis S, Ismiridis K, Papageorgiou O, et al. Ocular
abnormalities in patients with beta thalassemia. Am J
Ophthalmol. 1989;108:699e703
107. Gasch AT, Caruso RC, Kaler SG, et al. Menkes’
syndrome: ophthalmic findings. Ophthalmology.
2002;109:1477e83
108. Gehlbach PL, Purple RL, Hallaway PE, et al. Polymer
conjugation reduces deferoxamine induced retinopathy in
an albino rat model. Invest Ophthalmol Vis Sci.
1993;34:2871e7
109. Giroux E, Schoun J. Copper and zinc ion binding by bovine,
dog, and rat serum albumins. J Inorg Biochem.
1981;14:359e62
110. Gleim S, Stojanovic A, Arehart E, et al. Conserved rhodopsin
intradiscal structural motifs mediate stabilization: effects of
zinc. Biochemistry. 2009;48:1793e800
111. Gnana-Prakasam JP, Martin PM, Mysona BA, et al. Hepcidin
expression in mouse retina and its regulation via
lipopolysaccharide/Toll-like receptor-4 pathway
independent of Hfe. Biochem J. 2008;411:79e88
112. Gnana-Prakasam JP, Thangaraju M, Liu K, et al. Absence of
iron-regulatory protein Hfe results in hyperproliferation of
retinal pigment epithelium: role of cystine/glutamate
exchanger. Biochem J. 2009;424:243e52
113. Gnana-Prakasam JP, Martin PM, Smith SB, et al. Expression
and function of iron-regulatory proteins in retina. IUBMB
Life. 2010;62:363e70
114. Gnana-Prakasam JP, Reddy SK, Veeranan-Karmegam R, et al.
Polarized distribution of heme transporters in retinal
pigment epithelium and their regulation in the iron-
overload disease hemochromatosis. Invest Ophthalmol Vis
Sci. 2011;52:9279e86
115. Gnana-Prakasam JP, Tawfik A, Romej M, et al. Iron-mediated
retinal degeneration in haemojuvelin-knockout mice.
Biochem J. 2012;441:599e608
116. Good PA, Claxson A, Morris CJ, et al. A model for
desferrioxamine-induced retinopathy using the albino rat.
Ophthalmologica. 1990;201:32e6
117. Grahn BH, Paterson PG, Gottschall-Pass KT, et al. Zinc and
the eye. J Am Coll Nutr. 2001;20(2 Suppl):106e18
118. Greenberg SA, Briemberg HR. A neurological and
hematological syndrome associated with zinc excess and
copper deficiency. J Neurol. 2004;251:111e4
119. Guo B, Brown FM, Phillips JD, et al. Characterization and
expression of iron regulatory protein 2 (IRP2). Presence of
multiple IRP2 transcripts regulated by intracellular iron
levels. J Biol Chem. 1995;270:16529e35
120. Haase H, Rink L. The immune system and the impact of zinc
during aging. Immun Ageing. 2009;6:9
121. Hadziahmetovic M, Dentchev T, Song Y, et al.
Ceruloplasmin/hephaestin knockout mice model
morphologic and molecular features of AMD. Invest
Ophthalmol Vis Sci. 2008;49:2728e36
122. Hadziahmetovic M, Song Y, Wolkow N, et al. The oral iron
chelator deferiprone protects against iron overload-induced
retinal degeneration. Invest Ophthalmol Vis Sci.
2011;52:959e68
 s u r v e y o f o p h t h a l m o l o g y 5 8 ( 2 0 1 3 ) 5 8 5 e6 0 9
123. Hadziahmetovic M, Song Y, Ponnuru P, et al. Age-dependent
retinal iron accumulation and degeneration in hepcidin
knockout mice. Invest Ophthalmol Vis Sci. 2011;52:109e18
124. Hadziahmetovic M, Song Y, Wolkow N, et al. Bmp6
regulates retinal iron homeostasis and has altered
expression in age-related macular degeneration. Am J
Pathol. 2011;179:335e48
125. Hahn P, Milam AH, Dunaief JL. Maculas affected by age-
related macular degeneration contain increased chelatable
iron in the retinal pigment epithelium and Bruch’s
membrane. Arch Ophthalmol. 2003;121:1099e105
126. Hahn P, Dentchev T, Qian Y, et al. Immunolocalization and
regulation of iron handling proteins ferritin and ferroportin
in the retina. Mol Vis. 2004;10:598e607
127. Hahn P, Qian Y, Dentchev T, et al. Disruption of
ceruloplasmin and hephaestin in mice causes retinal iron
overload and retinal degeneration with features of age-
related macular degeneration. Proc Natl Acad Sci USA.
2004;101:13850e5
128. Hahn P, Ying GS, Beard J, et al. Iron levels in human retina:
sex difference and increase with age. Neuroreport.
2006;17:1803e6
129. Hahn P, Song Y, Ying GS, et al. Age-dependent and gender-
specific changes in mouse tissue iron by strain. Exp
Gerontol. 2009;44:594e600
130. Haimovici R, D’Amico DJ, Gragoudas ES, et al. Deferoxamine
Retinopathy Study Group. The expanded clinical spectrum
of deferoxamine retinopathy. Ophthalmology.
2002;109:164e71
131. Hall AC, Young BW, Bremner I. Intestinal metallothionein
and the mutual antagonism between copper and zinc in the
rat. J Inorg Biochem. 1979;11:57e66
132. Hamza I, Gitlin JD. Copper chaperones for cytochrome c
oxidase and human disease. J Bioenerg Biomembr.
2002;34:381e8
133. Han Y, Wu SM. Modulation of glycine receptors in retinal
ganglion cells by zinc. Proc Natl Acad Sci USA.
1999;96:3234e8
134. Han MH, Yang XL. Zn2þ differentially modulates kinetics of
GABA(C) vs GABA(A) receptors in carp retinal bipolar cells.
Neuroreport. 1999;10:2593e7
135. Harvey LJ, Ashton K, Hooper L, et al. Methods of assessment
of copper status in humans: a systematic review. Am J Clin
Nutr. 2009;89:2009Se24S
136. He F, Seryshev AB, Cowan CW, et al. Multiple zinc binding
sites in retinal rod cGMP phosphodiesterase, PDE6alpha
beta. J Biol Chem. 2000;275:20572e7
137. He X, Hahn P, Iacovelli J, et al. Iron homeostasis and toxicity
in retinal degeneration. Prog Retin Eye Res. 2007;26:649e73
138. Hedera P, Fink JK, Bockenstedt PL, et al.
Myelopolyneuropathy and pancytopenia due to copper
deficiency and high zinc levels of unknown origin:further
support for existence of a new zinc overload syndrome. Arch
Neurol. 2003;60:1303e6
139. Henkin RI. Metal-albumin-amino acid interactions: chemical
and physiological interrelationships. Adv Exp Med Biol.
1974;48:299e328
140. Hentze MW, Kuhn LC. Molecular control of vertebrate iron
metabolism: mRNA-based regulatory circuits operated by
iron, nitric oxide, and oxidative stress. Proc Natl Acad Sci
USA. 1996;93:8175e82
141. Hirayama Y. Histochemical localization of zinc and copper
in rat ocular tissues. Acta Histochem. 1990;89:107e11
142. Hooper NM. Families of zinc metalloproteases. FEBS Lett.
1994;354:1e6
143. Huang ML, Lane DJ, Richardson DR. Mitochondrial mayhem:
the mitochondrion as a modulator of iron metabolism and
its role in disease. Antioxid Redox Signal. 2011;15:3003e19
603
144. Huber AM, Gershoff SN. Effects of zinc deficiency on the
oxidation of retinol and ethanol in rats. J Nutr.
1975;105:1486e90
145. Huibi X, Kaixun H, Qiuhua G, et al. Prevention of axial
elongation in myopia by the trace element zinc. Biol Trace
Elem Res. 2001;79:39e47
146. Hunt RC, Dewey A, Davis AA. Transferrin receptors on the
surfaces of retinal pigment epithelial cells are associated
with the cytoskeleton. J Cell Sci. 1989;92:655e66
147. Hunt RC, Davis AA. Release of iron by human retinal
pigment epithelial cells. J Cell Physiol. 1992;152:102e10
148. Hutchens TW, Allen MH. Differences in the conformational
state of a zinc-finger DNA-binding protein domain occupied
by zinc and copper revealed by electrospray ionization mass
spectrometry. Rapid Commun Mass Spectrom.
1992;6:469e73
149. Hyndman AG, Hockberger PE, Zeevalk GD, Connor JA.
Transferrin can alter physiological properties of retinal
neurons. Brain Res. 1991;561:318e23
150. Hyun HJ, Sohn J, Ahn YH, et al. Depletion of intracellular zinc
induces macromolecule synthesis- and caspase-dependent
apoptosis of cultured retinal cells. Brain Res. 2000;869:39e48
151. Hyun HJ, Sohn JH, Ha DW, et al. Depletion of intracellular
zinc and copper with TPEN results in apoptosis of cultured
human retinal pigment epithelial cells. Invest Ophthalmol
Vis Sci. 2001;42:460e5
152. Iacopetta BJ, Morgan EH. The kinetics of transferrin
endocytosis and iron uptake from transferrin in rabbit
reticulocytes. J Biol Chem. 1983;258:9108e15
153. Ikkala E, Laitinen L. Papilloedema due to iron deficiency
anaemia. Acta Haematol. 1963;29:368e70
154. Irato P, Albergoni V. Interaction between copper and zinc in
metal accumulation in rats with particular reference to the
synthesis of induced-metallothionein. Chem Biol Interact.
2005;155:155e64
155. Jacobson SG, Meadows NJ, Keeling PW, et al. Rod mediated
retinal dysfunction in cats with zinc depletion: comparison
with taurine depletion. Clin Sci (Lond). 1986;71:559e64
156. Jampol LM. Antioxidants and zinc to prevent progression of
age-related macular degeneration. JAMA. 2001;286:2466e8
157. Jethani J, Marwah K, Nikul, et al. Ocular abnormalities in
patients with beta thalassemia on transfusion and
chelation therapy: our experience. Indian J Ophthalmol.
2010;58:451e2
158. Jiang D, Sullivan PG, Sensi SL, et al. Zn(2þ) induces
permeability transition pore opening and release of pro-
apoptotic peptides from neuronal mitochondria. J Biol
Chem. 2001;276:47524e9
159. Jomova K, Vondrakova D, Lawson M, et al. Metals, oxidative
stress and neurodegenerative disorders. Mol Cell Biochem.
2010;345:91e104
160. Jomova K, Valko M. Advances in metal-induced oxidative
stress and human disease. Toxicology. 2011;283:65e87
161. Jonas EA. Molecular participants in mitochondrial cell death
channel formation during neuronal ischemia. Exp Neurol.
2009;218:203e12
162. Jonsson M, Linse S, Frohm B, et al. Semenogelins I and II bind
zinc and regulate the activity of prostate-specific antigen.
Biochem J. 2005;387:447e53
163. Julien S, Biesemeier A, Kokkinou D, et al. Zinc deficiency
leads to lipofuscin accumulation in the retinal pigment
epithelium of pigmented rats. PLoS One. 2011;6:e29245
164. Kacer B, Hattenbach LO, Horle S, et al. Central retinal vein
occlusion and nonarteritic ischemic optic neuropathy in 2
patients with mild iron deficiency anemia.
Ophthalmologica. 2001;215:128e31
165. Kadenbach B, Arnold S, Lee I, et al. The possible role of
cytochrome c oxidase in stress-induced apoptosis and
604 s u r v e y o f o p h t h a l m o l o g y 5 8 ( 2 0 1 3 ) 5 8 5 e6 0 9
degenerative diseases. Biochim BiophysActa.
2004;1655:400e8
166. Kagan HM, Li W. Lysyl oxidase: properties, specificity, and
biological roles inside and outside of the cell. J Cell Biochem.
2003;88:660e72
167. Kaneda M, Ishii K, Akagi T, et al. Endogenous zinc can be
a modulator of glycinergic signaling pathway in the rat
retina. J Mol Histol. 2005;36:179e85
168. Karcioglu ZA, Stout R, Hahn HJ. Serum zinc levels in retinitis
pigmentosa. Curr Eye Res. 1984;3:1043e8
169. Keeling PW, O’Day J, Ruse W, et al. Zinc deficiency and
photoreceptor dysfunction in chronic liver disease. Clin Sci
(Lond). 1982;62:109e11
170. Keen CL, Golub MS, Gershwin ME, et al. Studies of marginal
zinc deprivation in rhesus monkeys. III. Use of liver biopsy in
the assessment of zinc status. Am J Clin Nutr.
1988;47:1041e5
171. Kim SY, Kwak JS, Shin JP, et al. The protection of the retina
from ischemic injury by the free radical scavenger EGb 761
and zinc in the cat retina. Ophthalmologica. 1998;212:268e74
172. King JC. Effect of reproduction on the bioavailability of
calcium, zinc and selenium. J Nutr. 2001;131:1355Se8S
173. King JC. Zinc: an essential but elusive nutrient. Am J Clin
Nutr. 2011;94:679Se84S
174. Kirkham TH, Wrigley PF, Holt JM. Central retinal vein
occlusion complicating iron deficiency anaemia. Br J
Ophthalmol. 1971;55:777e80
175. Klein ML, Francis PJ, Rosner B, et al. CFH and LOC387715/
ARMS2 genotypes and treatment with antioxidants and zinc
for age-related macular degeneration. Ophthalmology.
2008;115:1019e25
176. Klomp AE, van de Sluis B, Klomp LW, et al. The ubiquitously
expressed MURR1 protein is absent in canine copper
toxicosis. J Hepatol. 2003;39:703e9
177. Klomp LW, Gitlin JD. Expression of the ceruloplasmin gene
in the human retina and brain: implications for a pathogenic
model in aceruloplasminemia. Hum Mol Genet.
1996;5:1989e96
178. Knizley H Jr, Noyes WD. Iron deficiency anemia,
papilledema, thrombocytosis, and transient hemiparesis.
Arch Intern Med. 1972;129:483e6
179. Koeppen AH. Friedreich’s ataxia: pathology, pathogenesis,
and molecular genetics. J Neurol Sci. 2011;303:1e12
180. Kokkinou D, Kasper HU, Schwarz T, et al. Zinc uptake and
storage: the role of fundus pigmentation. Graefes Arch Clin
Exp Ophthalmol. 2005;243:1050e5
181. Kozlowski H, Janicka-Klos A, Brasun J, et al. Copper, iron and
zinc ions homeostasis and their role in neurodegenerative
disorders. Coordination Chem Rev. 2009;253:2665
182. Kraft SP, Parker JA, Matuk Y, et al. The rat electroretinogram
in combined zinc and vitamin A deficiency. Invest
Ophthalmol Vis Sci. 1987;28:975e84
183. Krajacic P, Qian Y, Hahn P, et al. Retinal localization and
copper-dependent relocalization of the Wilson and Menkes
disease proteins. Invest Ophthalmol Vis Sci. 2006;47:3129e34
184. Kumar A, Singh BK, Ahmad I, et al. Involvement of NADPH
oxidase and glutathione in zinc-induced dopaminergic
neurodegeneration in rats: Similarity with paraquat
neurotoxicity. Brain Res. 2012;1438:48e64
185. Kumar N, Ahlskog JE, Gross JB Jr. Acquired hypocupremia
after gastric surgery. Clin Gastroenterol Hepatol.
2004;2:1074e9
186. Kuo YM, Gybina AA, Pyatskowit JW, et al. Copper transport
protein (Ctr1) levels in mice are tissue specific and
dependent on copper status. J Nutr. 2006;136:21e6
187. La Fontaine S, Ackland ML, Mercer JF. Mammalian copper-
transporting P-type ATPases, ATP7A and ATP7B: emerging
roles. Int J Biochem Cell Biol. 2010;42:206e9
188. Labbe, Dewanji A. Iron assessment tests: transferrin
receptor vs zinc protoporphyrin. Clin Biochem.
2004;37:165e74
189. Lakhanpal V, Schocket SS, Jiji R. Deferoxamine (Desferal)-
induced toxic retinal pigmentary degeneration and
presumed optic neuropathy. Ophthalmology.
1984;91:443e51
190. Le TH, Blair D, McManus DP. A leucine zipper protein of
mitochondrial origin. Biochim Biophys Acta. 2001;1546.
435e3.
191. Lederman M, Obolensky A, Grunin M, et al. Retinal function
and structure in the hypotransferrinemic mouse. Invest
Ophthalmol Vis Sci. 2012;53:605e12
192. Lee AY, Brantley MA Jr,. CFH and LOC387715/ARMS2
genotypes and antioxidants and zinc therapy for age-
related macular degeneration. Pharmacogenomics.
2008;9:1547e50
193. Lengyel D, Török B. [Acquired temporary night blindness in
vitamin A and zinc deficiency in anorexia nervosa nine years
after kidney transplantation]. Klin Monbl Augenheilkd.
2006;223:453e5
194. Lengyel I, Flinn JM, Peto T, et al. High concentration of zinc
in sub-retinal pigment epithelial deposits. Exp Eye Res.
2007;84:772e80
195. Lesuisse E, Santos R, Matzanke BF, et al. Iron use for haeme
synthesis is under control of the yeast frataxin homologue
(Yfh1). Hum Mol Genet. 2003;12:879e89
196. Leung KW, Liu M, Xu X, et al. Expression of ZnT and ZIP zinc
transporters in the human RPE and their regulation by
neurotrophic factors. Invest Ophthalmol Vis Sci.
2008;49:1221e31
197. Leung KW, Gvritishvili A, Liu Y, et al. ZIP2 and ZIP4 mediate
age-related zinc fluxes across the retinal pigment
epithelium. J Mol Neurosci. 2012;46:122e37
198. Leure-du Pree AE, McClain CJ. The effect of severe zinc
deficiency on the morphology of the rat retinal pigment
epithelium. Invest Ophthalmol Vis Sci. 1982;23:425e34
199. Levin LA, Geszvain KM. Expression of ceruloplasmin in the
retina: induction after optic nerve crush. Invest Ophthalmol
Vis Sci. 1998;39:157e63
200. Li H, Wang H, Wang F, et al. Snail involves in the
transforming growth factor b1-mediated epithelial-
mesenchymal transition of retinal pigment epithelial cells.
PLoS One. 2011;6:e23322
201. Linder MC, Lomeli NA, Donley S, et al. Copper transport in
mammals. Adv Exp Med Biol. 1999;448:1e16
202. Link TA, von Jagow G. Zinc ions inhibit the QP center of
bovine heart mitochondrial bc1 complex by blocking
a protonatable group. J Biol Chem. 1995;270:25001e6
203. Lowe NM, Fekete K, Decsi T. Methods of assessment of zinc
status in humans: a systematic review. Am J Clin Nutr.
2009;89:2040Se51S
204. Lu J, Stewart AJ, Sadler PJ, et al. Albumin as a zinc carrier:
properties of its high-affinity zinc-binding site. Biochem Soc
Trans. 2008;36:1317e21
205. Lubeck MJ. Papilledema caused by iron-deficiency anemia.
Trans Am Acad Ophthalmol Otolaryngol. 1959;63:306e10
206. Luo DG, Yang XL. Zn2þ differentially modulates signals from
red- and short wavelength-sensitive cones to horizontal
cells in carp retina. Brain Res. 2001;900:95e102
207. Lutsenko S, Tsivkovskii R, Walker JM. Functional properties
of the human copper-transporting ATPase ATP7B (the
Wilson’s disease protein) and regulation by
metallochaperone Atox1. Ann NY Acad Sci. 2003;986:204e11
208. Lutsenko S, Bhattacharjee A, Hubbard AL. Copper handling
machinery of the brain. Metallomics. 2010;2:596e608
209. Lynch S. Case studies: iron. Am J Clin Nutr.
2011;94::637Se78S
 s u r v e y o f o p h t h a l m o l o g y 5 8 ( 2 0 1 3 ) 5 8 5 e6 0 9
210. Lovstad RA. A kinetic study on the distribution of Cu(II)-ions
between albumin and transferrin. Biometals. 2004;17:111e3
211. Mackenzie B, Takanaga H, Hubert N, et al. Functional
properties of multiple isoforms of human divalent metal-ion
transporter 1 (DMT1). Biochem J. 2007;403:59e69
212. MacPherson IS, Murphy ME. Type-2 copper-containing
enzymes. Cell Mol Life Sci. 2007;64:2887e99
213. Mainous AG 3rd, Diaz VA, Everett CJ, et al. IRon Overload
screeNing tool (IRON): development of a tool to guide
screening in primary care. Am J Hematol. 2011;86:733e7
214. Maret W. Metals on the move: zinc ions in cellular regulation
and in the coordination dynamics of zinc proteins.
Biometals. 2011;24:411e8
215. Maret W. Molecular aspects of human cellular zinc
homeostasis: redox control of zinc potentials and zinc
signals. Biometals. 2009;22:149e57
216. Marmolino D, Manto M. Pregabalin antagonizes copper-
induced toxicity in the brain: in vitro and in vivo studies.
Neurosignals. 2010;18:210e22
217. Martin PM, Gnana-Prakasam JP, Roon P, et al. Expression and
polarized localization of the hemochromatosis gene product
HFE in retinal pigment epithelium. Invest Ophthalmol Vis
Sci. 2006;47:4238e44
218. Masciulli L, Anderson DR, Charles S. Experimental ocular
siderosis in the squirrel monkey. Am J Ophthalmol.
1972;74:638e61
219. Massie HR, Aiello VR, Banziger V. Iron accumulation and
lipid peroxidation in aging C57BL/6J mice. Exp Gerontol.
1983;18:277e85
220. Masuoka J, Saltman P. Zinc(II) and copper(II) binding to
serum albumin. A comparative study of dog, bovine, and
human albumin. J Biol Chem. 1994;269:25557e61
221. Materia S, Cater MA, Klomp LW, et al. Clusterin and
COMMD1 independently regulate degradation of the
mammalian copper-ATPases ATP7Aand ATP7B. J Biol Chem.
2011;287:2485e99
222. Mathie A, Sutton GL, Clarke CE, et al. Zinc and copper:
pharmacological probes and endogenous modulators of
neuronal excitability. Pharmacol Ther. 2006;111:567e83
223. Matoba Y, Bando N, Oda K, et al. molecular mechanism for
copper transportation to tyrosinase that is assisted by
a metallochaperone, caddie protein. J Biol Chem.
2011;286:30219e31
224. Matsuoka Y, Hayasaka S, Yamada K. Incomplete occlusion
of central retinal artery in a girl with iron deficiency anemia.
Ophthalmologica. 1996;210:358e60
225. McCormick LD. Bound trace element content of bovine
retinal disk membranes as determined by particle-induced
x-ray emission. Biophys J. 1985;47:381e5
226. Medvedeva YV, Lin B, Shuttleworth CW, et al. Intracellular
Zn2þaccumulation contributes to synaptic failure,
mitochondrial depolarization, and cell death in an acute
slice oxygen-glucose deprivation model of ischemia.
J Neurosci. 2009;29:1105e14
227. Miceli MV, Tate DJ Jr,, Alcock NW, et al. Zinc deficiency and
oxidative stress in the retina of pigmented rats. Invest
Ophthalmol Vis Sci. 1999;40:1238e44
228. Milman N, Schultz-Larsen K. Iron stores in 70-year-old
Danish men and women. Evaluation in 469 individuals by
serum ferritin and hemoglobin. Aging (Milano).
1994;6:97e103
229. Mishima K, Dake Y, Amemiya T, et al. Electron microscopic
study of optic nerves of macular mice. Exp Eye Res.
1996;63:85e90
230. Mishima K, Amemiya T, Takano K. X-ray microanalysis of
melanin granules of retinal pigment epithelium and choroid
in hereditary copper deficient mice (macular mice). Exp Eye
Res. 1999;68:59e65
605
231. Mochizuki K, Murase H, Imose M, et al. Improvement of
scotopic electroretinograms and night blindness with
recovery of serum zinc levels. Jpn J Ophthalmol.
2006;50:532e6
232. Moiseyev G, Chen Y, Takahashi Y, et al. RPE65 is the
isomerohydrolase in the retinoid visual cycle. Proc Natl Acad
Sci USA. 2005;102:12413e8
233. Monga M, Walia V, Gandhi A, et al. Effect of iron deficiency
anemia on visual evoked potential of growing children.
Brain Dev. 2010;32:213e6
234. Moos T, Bernth N, Courtois Y, et al. Developmental iron
uptake and axonal transport in the retina of the rat. Mol Cell
Neurosci. 2011;46:607e13
235. Moriya M, Ho YH, Grana A, et al. Copper is taken up
efficiently from albumin and alpha2-macroglobulin by
cultured human cells by more than one mechanism. Am J
Physiol Cell Physiol. 2008;295:C708e21
236. Morrison SA, Russell RM, Carney EA, et al. Zinc deficiency:
a cause of abnormal dark adaptation in cirrhotics. Am J Clin
Nutr. 1978;31:276e81
237. Moustafa SA. Zinc might protect oxidative changes in the
retina and pancreas at the early stage of diabetic rats.
Toxicol Appl Pharmacol. 2004;201:149e55
238. Muller PA, Klomp LW. ATOX1: a novel copper-responsive
transcription factor in mammals? Int J Biochem Cell Biol.
2009;41:1233e6
239. Murdanoto AP, Sakai Y, Konishi T, et al. Purification and
properties of methyl formate synthase, a mitochondrial
alcohol dehydrogenase, participating in formaldehyde
oxidation in methylotrophic yeasts. Appl Environ Microbiol.
1997;63:1715e20
240. Musallam KM, Taher AT. Iron chelation therapy for
transfusional iron overload: a swift evolution. Hemoglobin.
2011;35:565e73
241. Munoz M, Garcı́a-Erce JA, Remacha AF. Disorders of iron
metabolism. Part II: iron deficiency and iron overload. J Clin
Pathol. 2011;64:287e96
242. Nagy B, Lehrer SS. Circular dichroism of iron, copper, and
zinc complexes of transferrin. Arch Biochem Biophys.
1972;148:27e36
243. Naismith RT, Shepherd JB, Weihl CC, et al. Acute and
bilateral blindness due to optic neuropathy associated with
copper deficiency. Arch Neurol. 2009;66:1025e7
244. Nakamichi N, Chidlow G, Osborne NN. Effects of intraocular
injection of a low concentration of zinc on the rat retina.
Neuropharmacology. 2003;45:637e48
245. Nam H, Knutson MD. Effect of dietary iron deficiency and
overload on the expression of ZIP metal-ion transporters in
rat liver. Biometals. 2012;25:115e24
246. Nan R, Gor J, Lengyel I, et al. Uncontrolled zinc- and copper-
induced oligomerisation of the human complement
regulator factor H and its possible implications for function
and disease. J Mol Biol. 2008;384:1341e52
247. Nandal A, Ruiz JC, Subramanian P, et al. Activation of the HIF
prolyl hydroxylase by the iron chaperones PCBP1 and PCBP2.
Cell Metab. 2011;14:647e57
248. Newsome DA, Swartz M, Leone NC, et al. Oral zinc in
macular degeneration. Arch Ophthalmol. 1988;106:192e8
249. Newsome DA, Oliver PD, Deupree DM, et al. Zinc uptake by
primate retinal pigment epithelium and choroid. Curr Eye
Res. 1992;11:213e7
250. Newsome DA. A randomized, prospective, placebo-
controlled clinical trial of a novel zinc-monocysteine
compound in age-related macular degeneration. Curr Eye
Res. 2008;33:591e8
251. Niciu MJ, Ma XM, El Meskini R, et al. Altered ATP7A
expression and other compensatory responses in a murine
model of Menkes disease. Neurobiol Dis. 2007;27:278e91
606 s u r v e y o f o p h t h a l m o l o g y 5 8 ( 2 0 1 3 ) 5 8 5 e6 0 9
252. Nicolas MG, Fujiki K, Murayama K, et al. Studies on the
mechanism of early onset macular degeneration in
cynomolgus monkeys. II. Suppression of metallothionein
synthesis in the retina in oxidative stress. Exp Eye Res.
1996;62:399e408
253. Niles BJ, Clegg MS, Hanna LA, et al. Zinc deficiency-induced
iron accumulation, a consequence of alterations in iron
regulatory protein-binding activity, iron transporters, and
iron storage proteins. J Biol Chem. 2008;283:5168e77
254. Noh KM, Koh JY. Induction and activation by zinc of NADPH
oxidase in cultured cortical neurons and astrocytes.
J Neurosci. 2000;20:RC111
255. Noh KM, Kim YH, Koh JY. Mediation by membrane protein
kinase C of zinc-induced oxidative neuronal injury in mouse
cortical cultures. J Neurochem. 1999;72:1609e16
256. Nose Y, Wood LK, Kim BE, et al. Ctr1 is an apical copper
transporter in mammalian intestinal epithelial cells in vivo
that is controlled at the level of protein stability. J Biol Chem.
2010;285:32385e92
257. O’Dell BL. Mineral interactions relevant to nutrient
requirements. J Nutr. 1989;119(12 Suppl):1832e8
258. O’Halloran TV, Culotta VC. Metallochaperones, an
intracellular shuttle service for metal ions. J Biol Chem.
2000;275:25057e60
259. O’Neil-Cutting MA, Bomford A, Munro HN. Effect of excess
dietary zinc on tissue storage of iron in rats. J Nutr.
1981;111:1969e79
260. O’Shea JG. Age-related macular degeneration: a leading
cause of blindness. Med J Aust. 1996;165:561e4
261. Obolensky A, Berenshtein E, Lederman M, et al. Zinc-
desferrioxamine attenuates retinal degeneration in the rd10
mouse model of retinitis pigmentosa. Free Radic BiolMed.
2011;51:1482e91
262. Okawa H, Sampath AP, Laughlin SB, et al. ATP consumption
by mammalian rod photoreceptors in darkness and in light.
Curr Biol. 2008;18:1917e21
263. Organisciak D, Wong P, Rapp C, et al. Light-induced retinal
degeneration is prevented by zinc, a component in the age-
related eye disease study formulation. Photochem Photobiol.
2012;88:1396e407
264. Osaki S. Kinetic studies of ferrous ion oxidation with
crystalline human ferroxidase (ceruloplasmin). J Biol Chem.
1966;241:5053e9
265. Osborne NN, Wood JP. The beta-adrenergic receptor
antagonist metipranolol blunts zinc-induced photoreceptor
and RPE apoptosis. Invest Ophthalmol Vis Sci.
2006;47:3178e86
266. Otteson DC, Liu Y, Lai H, et al. Kruppel-like factor 15, a zinc-
finger transcriptional regulator, represses the rhodopsin and
interphotoreceptor retinoid-binding protein promoters.
Invest Ophthalmol Vis Sci. 2004;45:2522e30
267. Palacios O, Atrian S, Capdevila M. Zn- and Cu-thioneins:
a functional classification for metallothioneins? J Biol Inorg
Chem. 2011;16:991e1009
268. Pandolfo M. Friedreich ataxia. Handb Clin Neurol.
2012;103:275e94
269. Paradkar PN, Zumbrennen KB, Paw BH, et al. Regulation of
mitochondrial iron import through differential turnover of
mitoferrin 1 and mitoferrin 2. Mol Cell Biol. 2009;29:1007e16
270. Park PS, Sapra KT, Kolinski M, et al. Stabilizing effect of Zn2þ
in native bovine rhodopsin. J Biol Chem. 2007;282:11377e85
271. Patel BN, David S. A novel glycosylphosphatidylinositol-
anchored form of ceruloplasmin is expressed by
mammalian astrocytes. J Biol Chem. 1997;272:20185e90
272. Patterson AJ, Brown WJ, Powers JR, et al. Iron deficiency,
general health and fatigue: results from the Australian
Longitudinal Study on Women’s Health. Qual Life Res.
2000;9:491e7
273. Pedraza-Chaverrı́ J, Torres-Rodrı́guez GA, Cruz C, et al.
Copper and zinc metabolism in aminonucleoside-induced
nephrotic syndrome. Nephron. 1994;66:87e92
274. Permyakov SE, Cherskaya AM, Wasserman LA, et al.
Recoverin is a zinc-binding protein. J Proteome Res.
2003;2:51e7
275. Petrak J, Vyoral D. Hephaestinda ferroxidase of cellular iron
export. Int J Biochem Cell Biol. 2005;37:1173e8
276. Picard E, Fontaine I, Jonet L, et al. The protective role of
transferrin in Muller glial cells after iron-induced toxicity.
Mol Vis. 2008;14:928e41
277. Picard E, Jonet L, Sergeant C, et al. Overexpressed or
intraperitoneally injected human transferrin prevents
photoreceptor degeneration in rd10 mice. Mol Vis.
2010;16:2612e25
278. Picard E, Ranchon-Cole I, Jonet L, et al. Light-induced retinal
degeneration correlates with changes in iron metabolism
gene expression, ferritin level, and aging. Invest Ophthalmol
Vis Sci. 2011;52:1261e74
279. Pineles SL, Wilson CA, Balcer LJ, et al. Combined optic
neuropathy and myelopathy secondary to copper deficiency.
Surv Ophthalmol. 2010;55:386e92
280. Prasad AS. Impact of the discovery of human zinc deficiency
on health. J Am Coll Nutr. 2009;28:257e65
281. Predki PF, Sarkar B. Effect of replacement of “zinc finger”
zinc on estrogen receptor DNA interactions. J Biol Chem.
1992;267:5842e6
282. Prodan CI, Holland NR, Wisdom PJ, et al. CNS demyelination
associated with copper deficiency and hyperzincemia.
Neurology. 2002;59:1453e6
283. Prohaska JR, Bailey WR. Regional specificity in alterations of
rat brain copper and catecholamines following perinatal
copper deficiency. J Neurochem. 1994;63:1551e7
284. Prohaska JR, Gybina AA. Intracellular copper transport in
mammals. J Nutr. 2004;134:1003e6
285. Punnonen K, Irjala K, Rajamaki A. Serum transferrin
receptor and its ratio to serum ferritin in the diagnosis of
iron deficiency. Blood. 1997;89:1052e7
286. Qian H, Li L, Chappell RL, et al. GABA receptors of bipolar
cells from the skate retina: actions of zinc on GABA-
mediated membrane currents. J Neurophysiol.
1997;78:2402e12
287. Rahi AH, Hungerford JL, Ahmed AI. Ocular toxicity of
desferrioxamine: light microscopic histochemical and
ultrastructural findings. Br J Ophthalmol. 1986;70:373e81
288. Ramey G, Deschemin JC, Vaulont S. Cross-talk between the
mitogen activated protein kinase and bone morphogenetic
protein/hemojuvelin pathways is required for the induction
of hepcidin by holotransferrin in primary mouse
hepatocytes. Haematologica. 2009;94:765e72
289. Redenti S, Chappell RL. Localization of zinc transporter-3
(ZnT-3) in mouse retina. Vision Res. 2004;44:3317e21
290. Redenti S, Chappell RL. Neuroimaging of zinc released by
depolarization of rat retinal cells. Vision Res. 2005;45:3520e5
291. Redenti S, Chappell RL. Muller cell zinc transporter-3
labeling suggests a role in outer retina zinc homeostasis. Mol
Med. 2007;13:376e9
292. Redenti S, Ripps H, Chappell RL. Zinc release at the synaptic
terminals of rod photoreceptors. Exp Eye Res. 2007;85:580e4
293. Richardson DR, Lane DJ, Becker EM, et al. Mitochondrial iron
trafficking and the integration of iron metabolism between
the mitochondrion and cytosol. Proc Natl Acad Sci USA.
2010;107:10775e82
294. Rinaldi M, Della Corte M, Ruocco V, et al. Ocular involvement
correlated with age in patients affected by major and
intermedia beta-thalassemia treated or not with
desferrioxamine. Metab Pediatr Syst Ophthalmol.
1993;16:23e5
 s u r v e y o f o p h t h a l m o l o g y 5 8 ( 2 0 1 3 ) 5 8 5 e6 0 9
295. Rink L, Gabriel P. Zinc and the immune system. Proc Nutr
Soc. 2000;59:541e52
296. Robinson NJ, Winge DR. Copper metallochaperones. Annu
Rev Biochem. 2010;79:537e62
297. Rogers BS, Symons RC, Komeima K, et al. Differential
sensitivity of cones to iron-mediated oxidative damage.
Invest Ophthalmol Vis Sci. 2007;48:438e45
298. Rogers JM, Keen CL, Hurley LS. Zinc deficiency in pregnant
Long-Evans hooded rats: teratogenicity and tissue trace
elements. Teratology. 1985;31:89e100
299. Roth AM, Foos RY. Ocular pathologic changes in primary
hemochromatosis. Arch Ophthalmol. 1972;87:507e14
300. Rouault TA, Tong WH. Iron-sulphur cluster biogenesis and
mitochondrial iron homeostasis. Nat Rev Mol Cell Biol.
2005;6:345e51
301. Rowin J, Lewis SL. Copper deficiency myeloneuropathy and
pancytopenia secondary to overuse of zinc
supplementation. J Neurol Neurosurg Psychiatry.
2005;76:750e1
302. Saghizadeh M, Akhmedov NB, Yamashita CK, et al. ZBED4,
a BED-type zinc-finger protein in the cones of the human
retina. Invest Ophthalmol Vis Sci. 2009;50:3580e8
303. Saleh T, Green W. Bilateral reversible optic disc oedema
associated with iron deficiency anaemia. Eye (Lond).
2000;14:672e3
304. Salmi M, Jalkanen S. VAP-1: an adhesin and an enzyme.
Trends Immunol. 2001;22:211e6
305. Samuelson DA, Smith P, Ulshafer RJ, et al. X-ray
microanalysis of ocular melanin in pigs maintained on
normal and low zinc diets. Exp Eye Res. 1993;56:63e70
306. Sarici SU, Okutan V, Dundaroz MR, et al. The effect of
iron supplementation on visual-evoked potentials in
infants with iron-deficiency anemia. J Trop Pediatr.
2001;47:132e5
307. Sarkar B, Roberts EA. The puzzle posed by COMMD1, a newly
discovered protein binding Cu(II). Metallomics. 2011;3:20e7
308. Satishchandra P, Ravishankar Naik K. Visual pathway
abnormalities Wilson’s disease: an electrophysiological
study using electroretinography and visual evoked
potentials. J Neurol Sci. 2000;176:13e20
309. Schippert R, Burkhardt E, Feldkaemper M, et al. Relative
axial myopia in Egr-1 (ZENK) knockout mice. Invest
Ophthalmol Vis Sci. 2007;48:11e7
310. Schlief ML, Craig AM, Gitlin JD. NMDA receptor activation
mediates copper homeostasis in hippocampal neurons.
J Neurosci. 2005;25:239e46
311. Schlief ML, Gitlin JD. Copper homeostasis in the CNS: a novel
link between the NMDA receptor and copper homeostasis in
the hippocampus. Mol Neurobiol. 2006;33:81e90
312. Schmitt S, Kury S, Giraud M, et al. An update on mutations of
the SLC39A4 gene in acrodermatitis enteropathica. Hum
Mutat. 2009;30:926e33
313. Sebastiani G, Pantopoulos K. Disorders associated with
systemic or local iron overload: from pathophysiology to
clinical practice. Metallomics. 2011;3:971e86
314. Sensi SL, Yin HZ, Carriedo SG, et al. Preferential Zn2þ influx
through Ca2þ-permeable AMPA/kainate channels triggers
prolonged mitochondrial superoxide production. Proc Natl
Acad Sci USA. 1999;96:2414e9
315. Sensi SL, Jeng JM. Rethinking the excitotoxic ionic milieu:
the emerging role of Zn(2þ) in ischemic neuronal injury.
Curr Mol Med. 2004;4:87e111
316. Sensi SL, Paoletti P, Koh JY, et al. The neurophysiology and
pathology of brain zinc. J Neurosci. 2011;31:16076e85
317. Sergeant C, Gouget B, Llabador Y, et al. Iron in hereditary
retinal degeneration: PIXE microanalysis. Nuclear
Instruments and Methods in Physics. Research.
1999;158:344e8
607
318. Sergeant C, Vesvres MS, Pravikoff MS, et al. Trace metals in
human retina during aging period, in Cser MA, Laszlo IS,
Etienne JC, et al (eds) Metals Ions in Biology and Medicine.
vol. 8. Paris, John Libbey Eurotext; 2004, pp 491e5
319. Setty SR, Tenza D, Sviderskaya EV, et al. Cell-specific ATP7A
transport sustains copper-dependent tyrosinase activity in
melanosomes. Nature. 2008;454:1142e6
320. Shakespeare PG. Studies on the serum levels of iron, copper
and zinc and the urinary excretion of zinc after burn injury.
Burns Incl Therm Inj. 1982;8:358e64
321. Shang HF, Jiang XF, Burgunder JM, et al. Novel mutation in
the ceruloplasmin gene causing a cognitive and movement
disorder with diabetes mellitus. Mov Disord.
2006;21:2217e20
322. Sharma S, Dimasi D, Higginson K, et al. RZF, a zinc-finger
protein in the photoreceptors of human retina. Gene.
2004;342:219e29
323. Shaw GC, Cope JJ, Li L, Corson K, et al. Mitoferrin is essential
for erythroid iron assimilation. Nature. 2006;440:96e100
324. Sheikh SP, Zvyaga TA, Lichtarge O, et al. Rhodopsin
activation blocked by metal-ion-binding sites linking
transmembrane helices C andF. Nature. 1996;383:347e50
325. Sheline CT, Choi DW. Cu2þ toxicity inhibition of
mitochondrial dehydrogenases in vitro and in vivo. Ann
Neurol. 2004;55:645e53
326. Sheline CT, Zhou Y, Bai S. Light-induced photoreceptor and
RPE degeneration involve zinc toxicity and are attenuated by
pyruvate, nicotinamide, or cyclic light. Mol Vis.
2010;16:2639e52
327. Shi H, Bencze KZ, Stemmler TL, et al. A cytosolic iron
chaperone that delivers iron to ferritin. Science.
2008;320:1207e10
328. Shichi H. Microsomal electron transfer system of bovine
retinal pigment epithelium. Exp Eye Res. 1969;8:60e8
329. Shuster TA, Nagy AK, Conly DC, et al. Direct zinc binding to
purified rhodopsin and disc membranes. Biochem J.
1992;282:123e8
330. Shuster TA, Martin F, Nagy AK. Zinc causes an apparent
increase in rhodopsin phosphorylation. Curr Eye Res.
1996;15:1019e24
331. Siapich SA, Wrubel H, Albanna W, et al. Effect of ZnCl2 and
chelation of zinc ions by N, N-diethyldithiocarbamate
(DEDTC) on the ERG b-wave amplitude from the isolated
superfused vertebrate retina. Curr Eye Res. 2010;35:322e34
332. Silverstone BZ. Effects of zinc and copper metabolism in
highly myopic patients. Ciba Found Symp. 1990;155:210e21
333. Smidt K, Rungby J. ZnT3: a zinc transporter active in several
organs. Biometals. 2012;25:1e8
334. Sohal RS, Wennberg-Kirch E, Jaiswal K, et al. Effect of age
and caloric restriction on bleomycin-chelatable and
nonheme iron in different tissues of C57BL/6 mice. Free
Radic Biol Med. 1999;27:287e93
335. Solomons NW. Biochemical, metabolic, and clinical role of
copper in human nutrition. J Am Coll Nutr. 1985;4:83e105
336. Sooriyaarachchi M, Gailer J. Removal of Fe3þ and Zn2þ from
plasma metalloproteins by iron chelating therapeutics
depicted with SEC-ICP-AES. Dalton Trans. 2010;39:7466e73
337. Sorcinelli R, Sitzia A, Figus A, et al. Ocular findings in beta-
thalassemia. Metab Pediatr Syst Ophthalmol. 1990;13:23e5
338. Stoebner R, Kiser R, Alperin JB. Iron deficiency anemia and
papilledema. Rapid resolution with oral iron therapy. Am J
Dig Dis. 1970;15:919e22
339. Stojanovic A, Stitham J, Hwa J. Critical role of
transmembrane segment zinc binding in the structure and
function of rhodopsin. J Biol Chem. 2004;279:35932e41
340. Stur M, Tittl M, Reitner A, et al. Oral zinc and the second eye
in age-related macular degeneration. Invest Ophthalmol Vis
Sci. 1996;37:1225e35
608 s u r v e y o f o p h t h a l m o l o g y 5 8 ( 2 0 1 3 ) 5 8 5 e6 0 9
341. Subramanian P, Rodrigues AV, Ghimire-Rijal S, et al. Iron
chaperones for mitochondrial Fe-S cluster biosynthesis and
ferritin iron storage. Curr Opin Chem Biol. 2011;15:312e8
342. Sun Y, Zhang YT, Gong HQ, et al. The mechanisms of Zn2þ
effects onCa2þ-permeable AMPA receptors on carp retinal
horizontal cells. Brain Res. 2010;1345:103e9
343. Sun Z, Zhang DQ, McMahon DG. Zinc modulation of hemi-
gap-junction channel currents in retinal horizontal cells.
J Neurophysiol. 2009;101:1774e80
344. Suzuki KT, Someya A, Komada Y, et al. Roles of
metallothionein in copper homeostasis: responses to Cu-
deficient diets in mice. J Inorg Biochem. 2002;88:173e82
345. Takeda T, Kimura M, Yokoi K, et al. Effect of age and dietary
protein level on tissue mineral levels in female rats. Biol
Trace Elem Res. 1996;54:55e74
346. Tam SW, Wilber KE, Wagner FW. Light sensitive zinc content
of protein fractions from bovine rod outer segments.
Biochem Biophys Res Commun. 1976;72:302e9
347. Tamada Y, Walkup RD, Shearer TR, et al. Contribution of
calpain to cellular damage in human retinal pigment
epithelial cells cultured with zinc chelator. Curr Eye Res.
2007;32:565e73
348. Taneja R, Malik P, Sharma M, et al. Multiple transfused
thalassemia major: ocular manifestations in a hospital-
based population. Indian J Ophthalmol. 2010;58:125e30
349. Tate DJ Jr, Newsome DA, Oliver PD. Metallothionein
shows an age-related decrease in human macular retinal
pigment epithelium. Invest Ophthalmol Vis Sci.
1993;34:2348e51
350. Tate DJ Jr, Miceli MV, Newsome DA. Zinc protects against
oxidative damage in cultured human retinal pigment
epithelial cells. Free Radic Biol Med. 1999;26:704e13
351. Tate DJ, Miceli MV, Newsome DA, et al. Influence of zinc on
selected cellular functions of cultured human retinal
pigment epithelium. Curr Eye Res. 1995;14:897e903
352. Tate DJ, Miceli MV, Newsome DA. Expression of
metallothionein isoforms in human chorioretinal complex.
Curr Eye Res. 2002;24:12e25
353. Theil EC. Iron homeostasis and nutritional iron deficiency.
J Nutr. 2011;141:724Se8S
354. Toledo D, Cordomi, Proietti MG, et al. Structural
characterization of a zinc high-affinity binding site in
rhodopsin. Photochem Photobiol. 2009;85:479e84
355. Trujillo MH, Desenne JJ, Pinto HB. Reversible papilledema in
iron deficiency anemia. Two cases with normal spinal fluid
pressure. Ann Ophthalmol. 1972;4:378e80
356. Uehara F, Matthes MT, Yasumura D, et al. Light-evoked
changes in the interphotoreceptor matrix. Science.
1990;248:1633e6
357. Ugarte M, Osborne NN. The localization of endogenous zinc
and the in vitro effect of exogenous zinc on the GABA
immunoreactivity and formation of reactive oxygen species
in the retina. Gen Pharmacol. 1998;30:297e303
358. Ugarte M, Osborne NN. The localization of free zinc varies in
rat photoreceptors during light and dark adaptation. Exp Eye
Res. 1999;69:459e61
359. Ugarte M, Osborne NN. Zinc in the retina. Prog Neurobiol.
2001;64:219e49
360. Ugarte M, Nicol DA, Jones NP, et al. Chronic intraocular
copper foreign body and candida: a unique combination.
Ocul Immunol Inflamm. 2009;17:356e60
361. Ugarte M, Grime GW, Lord G, et al. Concentration of various
trace elements in the rat retina and their distribution in
different structures. Metallomics. 2012;4:1245e54
362. Vallee BL, Falchuk KH. The biochemical basis of zinc
physiology. Physiol Rev. 1993;73:79e118
363. VandenLangenberg GM, Mares-Perlman JA, Klein R, et al.
Associations between antioxidant and zinc intake and the 5-
year incidence of early age-related maculopathy in the
Beaver Dam Eye Study. Am J Epidemiol. 1998;148:204e14
364. Veldhuis NA, Valova VA, Gaeth AP, et al. Phosphorylation
regulates copper-responsive trafficking of the Menkes
copper transporting P-type ATPase. Int J Biochem Cell Biol.
2009;41:2403e12
365. Vergara O, Ogden T, Ryan S. Posterior penetrating injury in
the rabbit eye: effect of blood and ferrous ions. Exp Eye Res.
1989;49:1115e26
366. Vilardaga JP, Frank M, Krasel C, et al. Differential
conformational requirements for activation of G proteins
and the regulatory proteins arrestin and G protein-coupled
receptor kinase in the G protein-coupled receptor for
parathyroid hormone (PTH)/PTH-related protein. J Biol
Chem. 2001;276:33435e43
367. Vollrath D, Feng W, Duncan JL, et al. Correction of the retinal
dystrophy phenotype of the RCS rat by viral gene transfer of
Mertk. Proc Natl Acad Sci USA. 2001;98:12584e9
368. Vulpe CD, Kuo YM, Murphy TL, et al. Hephaestin,
a ceruloplasmin homologue implicated in intestinal iron
transport, is defective in the sla mouse. Nat Genet.
1999;21:195e9
369. Vulpe C, Levinson B, Whitney S, et al. Isolation of
a candidate gene for Menkes disease and evidence that it
encodes a copper-transporting ATPase. Nat Genet.
1993;3:7e13, Erratum in: Nat Genet 1993;3:273.
370. Walters GO, Miller FM, Worwood M. Serum ferritin
concentration and iron stores in normal subjects. J Clin
Pathol. 1973;26:770e2
371. Wang W, Knovich MA, Coffman LG, et al. Serum ferritin:
past, present and future. Biochim Biophys Acta.
2010;1800:760e9
372. Wang X, Wang ZY, Gao HL, et al. Localization of ZnT7 and
zinc ions in mouse retinaeimmunohistochemistry and
selenium autometallography. Brain Res Bull. 2006;71:91e6
373. Wang ZJ, Lam KW, Lam TT, et al. Iron-induced apoptosis in
the photoreceptor cells of rats. Invest Ophthalmol Vis Sci.
1998;39:631e3
374. Wastney ME, Aamodt RL, Rumble WF, et al. Kinetic analysis
of zinc metabolism and its regulation in normal humans.
Am J Physiol. 1986;251:R398e408
375. Watabe Y, Baba Y, Nakauchi H, et al. The role of Zic family
zinc finger transcription factors in the proliferation and
differentiation of retinal progenitor cells. Biochem Biophys
Res Commun. 2011;415:42e7
376. Webb M, Cain K. Functions of metallothionein. Biochem
Pharmacol. 1982;31:137e42
377. Wills MS, Monaghan SA, Miller ML, et al. Zinc-induced
copper deficiency: a report of three cases initially recognized
on bone marrow examination. Am J Clin Pathol.
2005;123:125e31
378. Wills NK, Ramanujam VM, Kalariya N, et al. Copper and zinc
distribution in the human retina: relationship to cadmium
accumulation, age, and gender. Exp Eye Res. 2008;87:80e8
379. Wills NK, Kalariya N, Sadagopa Ramanujam VM, et al.
Human retinal cadmium accumulation as a factor in the
etiology of age-related macular degeneration. Exp Eye Res.
2009;89:79e87
380. Wish JB. Assessing iron status: beyond serum ferritin and
transferrin saturation. Clin J Am Soc Nephrol. 2006;1(Suppl
1)):S4e8
381. Wolkow N, Song Y, Wu TD, et al. Aceruloplasminemia:
retinal histopathologic manifestations and iron-mediated
melanosome degradation. Arch Ophthalmol.
2011;129:1466e74
382. Wolkow N, Song D, Song Y, et al. Ferroxidase hephaestin’s
cell-autonomous role in the retinal pigment epithelium. Am
J Pathol. 2012;180:1614e24
 s u r v e y o f o p h t h a l m o l o g y 5 8 ( 2 0 1 3 ) 5 8 5 e6 0 9
383. Wong RW, Richa DC, Hahn P, et al. Iron toxicity as
a potential factor in AMD. Retina. 2007;27:997e1003
384. Wray SH, Kuwabara T, Sanderson P. Menkes’ kinky hair
disease: a light and electron microscopic study of the eye.
Invest Ophthalmol. 1976;15:128e38
385. Wu L, Cao XY, Chen Y, et al. Metabolic disturbance in age-
related macular degeneration. Metab Pediatr Syst
Ophthalmol. 1994;17:38e40
386. Wu YH, Frey AG, Eide DJ. Transcriptional regulation of the
Zrg17 zinc transporter of the yeast secretory pathway.
Biochem J. 2011;435:259e66
387. Wunderlich KA, Leveillard T, Penkowa M, et al. Altered
expression of metallothionein-I and -II and their receptor
megalin in inherited photoreceptor degeneration. Invest
Ophthalmol Vis Sci. 2010;51:4809e20
388. Wysokinski D, Danisz K, Blasiak J, et al. An association of
transferrin gene polymorphism and serum transferrin levels
with age-related macular degeneration. Exp Eye Res.
2013;106:14e23
389. Wysokinski D, Zaras M, Dorecka M, et al. An association
between environmental factors and the IVS4þ44C>A
polymorphism of the DMT1 gene in age-related macular
degeneration. Graefes Arch Clin Exp Ophthalmol.
2012;250:1057e65
390. Xu X, Pin S, Gathinji M, et al. Aceruloplasminemia: an
inherited neurodegenerative disease with impairment of
iron homeostasis. Ann NY Acad Sci. 2004;1012:299e305
391. Yamaguchi K, Takahashi S, Kawanami T, et al. Retinal
degeneration in hereditary ceruloplasmin deficiency.
Ophthalmologica. 1998;212:11e4
392. Yamasaki S, Sakata-Sogawa K, Hasegawa A, et al. Zinc is
a novel intracellular second messenger. J Cell Biol.
2007;177:637e45
393. Yau KW, Baylor DA. Cyclic GMP-activated conductance of
retinal photoreceptor cells. Annu Rev Neurosci.
1989;12:289e327
394. Ye H, Rouault TA. Human iron-sulfur cluster assembly,
cellular iron homeostasis, and disease. Biochemistry.
2010;49:4945e56
395. Yefimova MG, Jeanny JC, Guillonneau X, et al. Iron, ferritin,
transferrin, and transferrin receptor in the adult rat retina.
Invest Ophthalmol Vis Sci. 2000;41:2343e51
396. Yefimova MG, Jeanny JC, Keller N, et al. Impaired retinal iron
homeostasis associated with defective phagocytosis in Royal
609
College of Surgeons rats. Invest Ophthalmol Vis Sci.
2002;43:537e45
397. Yim MB, Chock PB, Stadtman ER. Enzyme function of copper,
zinc superoxide dismutase as a free radical generator. J Biol
Chem. 1993;268:4099e105
398. Yin SJ, Chou CF, Lai CL, et al. Human class IV alcohol
dehydrogenase: kinetic mechanism, functional roles and
medical relevance. Chem Biol Interact.
2003;143e144:219e27
399. Yoo MH, Lee JY, Lee SE, et al. Protection by pyruvate of rat
retinal cells against zinc toxicity in vitro, and pressure-
induced ischemia in vivo. Invest Ophthalmol Vis Sci.
2004;45:1523e30
400. Yoshikawa S, Muramoto K, Shinzawa-Itoh K. Proton-
pumping mechanism of cytochrome C oxidase. Annu Rev
Biophys. 2011;40:205e23
401. Yoshikumi Y, Mashima H, Ueda N, et al. Roles of CTPL/Sfxn3
and Sfxn family members in pancreatic islet. J Cell Biochem.
2005;95:1157e68
402. Yu DY, Cringle SJ. Retinal degeneration and local oxygen
metabolism. Exp Eye Res. 2005;80:745e51
403. Yu TY, Acosta ML, Ready S, et al. Light exposure causes
functional changes in the retina: increased photoreceptor
cation channel permeability, photoreceptor apoptosis, and
altered retinal metabolic function. J Neurochem.
2007;103:714e24
404. Zatta P, Frank A. Copper deficiency and neurological
disorders in man and animals. Brain Res Rev. 2007;54:19e33
405. Zauber NP, Zauber AG. Hematologic data of healthy very old
people. JAMA. 1987;257:2181e4
406. Zhang DQ, Sun Z, McMahon DG. Modulation of A-type
potassium currents in retinal horizontal cells by
extracellular calcium and zinc. Vis Neurosci.
2006;23:825e32
407. Zhang J, Jin Z, Bao ZZ. Disruption of gradient expression of
Zic3 resulted in abnormal intra-retinal axon projection.
Development. 2004;131:1553e62
408. Zhang Q, Mashima Y, Noda S, et al. Characterization of
AOC2 gene encoding a copper-binding amine oxidase
expressed specifically in retina. Gene. 2003;318:45e53
409. Zimmermann MB, Hurrell RF. Nutritional iron deficiency.
Lancet. 2007;370:511e20
410. Zimmermann MB. Methods to assess iron and iodine status.
Br J Nutr. 2008;99(Suppl 3):S2e9