The atrophic form of age-related macular degeneration (dry AMD) affects nearly 200 million people worldwide. There is no Food and Drug Administration (FDA)-approved therapy for this disease, which is the leading cause of irreversible blindness among people over 50 y of age. Vision loss in dry AMD results from degeneration of the retinal pigmented epithelium (RPE). RPE cell death is driven in part by accumulation of Alu RNAs, which are noncoding transcripts of a human retrotransposon. Alu RNA induces RPE degeneration by activating the NLRP3-ASC inflammasome. We report that fluoxetine, an FDA-approved drug for treating clinical depression, binds NLRP3 in silico, in vitro, and in vivo and inhibits activation of the NLRP3-ASC inflammasome and inflammatory cytokine release in RPE cells and macrophages, two critical cell types in dry AMD. We also demonstrate that fluoxetine, unlike several other antidepressant drugs, reduces Alu RNA–induced RPE degeneration in mice. Finally, by analyzing two health insurance databases comprising more than 100 million Americans, we report a reduced hazard of developing dry AMD among patients with depression who were treated with fluoxetine. Collectively, these studies identify fluoxetine as a potential drug-repurposing candidate for dry AMD. Significance Dry age-related macular degeneration (AMD) affects the vision of millions of people worldwide. There is currently no Food and Drug Administration–approved treatment for dry AMD. The inflammasome components NLRP3 and ASC have been implicated in the pathogenesis of dry AMD. We report that fluoxetine, which is approved for the treatment of clinical depression, directly binds the NLRP3 protein and prevents NLRP3-ASC inflammasome assembly and activation. Fluoxetine prevents the degeneration of retinal pigmented epithelium cells in an animal model of dry AMD. We also present evidence from a big data analysis of health insurance databases that fluoxetine use is associated with reduced risk of developing dry AMD. These studies identify a potential repurposing candidate for a prevalent cause of blindness.

Significance: Alu elements, comprising more than 10% of the human genome, propagate via retrotransposition. This genomic expansion requires enzymatic activity of L1 that reverse transcribes Alu RNA into Alu cDNA in the nucleus. We report Alu also undergoes L1-mediated reverse transcription via self-priming in the cytoplasm independent of retrotransposition, providing evidence of human DNA synthesis in this cellular compartment. This newly discovered shunt molecule in the Alu replication cycle also induces death of the retinal pigmented epithelium, a hallmark of atrophic age-related macular degeneration. A Big Data Archeology analysis of multiple health insurance databases reveals that use of FDA-approved nucleoside reverse transcriptase inhibitors is associated with protection against macular degeneration, identifying a repurposing candidate for this blinding disease.

DDX17 senses retrotransposon RNA and activates a noncanonical NLRC4 inflammasome.

Endogenous Alu cDNA triggers inflammasome-mediated cell death in age-related macular degeneration.

Significance: DICER1 processes micro-RNAs into their bioactive forms and metabolizes RNAs from short interspersed nuclear element genetic repeats, principally Alu RNAs in humans. DICER1 deficiency is implicated in retinal pigmented epithelium (RPE) degeneration in atrophic age-related macular degeneration (AMD). Here, we report that three independent mouse models of DICER1 deficiency develop RPE degeneration and aberrant choroidal and retinal neovascularization (CRNV), both hallmarks of advanced AMD. These pathologies were dependent on inflammatory caspases 1 and 11 and the signaling adaptor MyD88. We observed reduced DICER1 abundance in a separate model of spontaneous CRNV and developed an adenoassociated vector-mediated DICER1 delivery construct, which reduced the severity of established spontaneous CRNV. Thus, persistent deficiency in DICER1 results in RPE degeneration and CRNV.

Muller glia (MG) play a central role in reactive gliosis, a stress response associated with rare and common retinal degenerative diseases, including age-related macular degeneration (AMD). The posttranslational modification citrullination​ targeting glial fibrillary acidic protein (GFAP) in MG was initially discovered in a panocular chemical injury model. Here, we report in the paradigms of retinal laser injury, a genetic model of spontaneous retinal degeneration (JR5558 mice) and human wet-AMD tissues that MG citrullination is broadly conserved. After laser injury, GFAP polymers that accumulate in reactive MG are citrullinated in MG endfeet and glial cell processes. The enzyme responsible for citrullination, peptidyl arginine deiminase-4 (PAD4), localizes to endfeet and associates with GFAP polymers. Glial cell–specific PAD4 deficiency attenuates retinal hypercitrullination in injured retinas, indicating PAD4 requirement for MG citrullination. In retinas of 1-mo-old JR5558 mice, hypercitrullinated GFAP and PAD4 accumulate in MG endfeet/cell processes in a lesion-specific manner. Finally, we show that human donor maculae from patients with wet-AMD also feature the canonical endfeet localization of hypercitrullinated GFAP. Thus, we propose that endfeet are a “citrullination bunker” that initiates and sustains citrullination in retinal degeneration.