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Biber J, Jabri Y, Glänzer S, Dort A, Hoffelner P, Schmidt CQ, Bludau O, Pauly D, Grosche A. Gliosis-dependent expression of complement factor H truncated variants attenuates retinal neurodegeneration following ischemic injury. J Neuroinflammation 2024; 21:56. [PMID: 38388518 PMCID: PMC10885619 DOI: 10.1186/s12974-024-03045-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 02/14/2024] [Indexed: 02/24/2024] Open
Abstract
Inherited, age-related, and acute retinal diseases are often exacerbated by an aberrant or excessive activity of the complement system. Consequently, cells not directly affected by an acute event or genetic variants may degenerate, resulting in enhanced visual impairment. The therapeutic potential of supplementation of complement factor H (FH), a key regulator of the complement cascade, is therefore particularly promising in the context of retinal diseases caused by complement activation. In this study, we engineered adeno-associated viruses (AAVs) containing sequences of two truncated human FH variants. The expression of these variants was regulated by the glial fibrillary acidic protein (GFAP) promoter, which is selectively active in gliotic Müller cells. Both FH variants consisted of FH domains 19-20, which were connected to domains 1-4 and 1-7, respectively, by a polyglycine linker. These AAVs were intravitreally injected following ischemic injury of C57BL/6J mouse retinas. We observed transgene expression in gliotic Müller cells and to some extent in astrocytes. The expression correlated directly with damage severity. Interventions resulted in decreased complement activation, accelerated normalization of microglia activity and morphological improvements. Reduced levels of C3 transcripts and C3d protein in conjunction with higher transcript levels of inhibitory regulators like Cfi and Cfh, hinted at attenuated complement activity. This study demonstrates the great potential of complement regulatory gene addition therapy. With further in vivo testing it could be applied to treat a wide range of retinal diseases where no causative therapies are available.
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Affiliation(s)
- Josef Biber
- Department of Physiological Genomics, Ludwig-Maximilians-Universität München, Planegg-Martinsried, Germany
| | - Yassin Jabri
- Department of Ophthalmology, University Hospital Regensburg, Regensburg, Germany
| | - Sarah Glänzer
- Department of Physiological Genomics, Ludwig-Maximilians-Universität München, Planegg-Martinsried, Germany
| | - Aaron Dort
- Experimental Ophthalmology, University of Marburg, Marburg, Germany
| | - Patricia Hoffelner
- Department of Physiological Genomics, Ludwig-Maximilians-Universität München, Planegg-Martinsried, Germany
| | - Christoph Q Schmidt
- Institute of Experimental and Clinical Pharmacology, Toxicology and Pharmacology of Natural Products, University of Ulm Medical Center, Ulm, Germany
- Institute of Pharmacy, Biochemical Pharmacy Group, Martin Luther University Halle-Wittenberg, Halle, Germany
| | - Oliver Bludau
- Department of Physiological Genomics, Ludwig-Maximilians-Universität München, Planegg-Martinsried, Germany
| | - Diana Pauly
- Experimental Ophthalmology, University of Marburg, Marburg, Germany.
| | - Antje Grosche
- Department of Physiological Genomics, Ludwig-Maximilians-Universität München, Planegg-Martinsried, Germany
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2
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Yang Z, Yan L, Zhang W, Qi J, An W, Yao K. Dyschromatopsia: a comprehensive analysis of mechanisms and cutting-edge treatments for color vision deficiency. Front Neurosci 2024; 18:1265630. [PMID: 38298913 PMCID: PMC10828017 DOI: 10.3389/fnins.2024.1265630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Accepted: 01/02/2024] [Indexed: 02/02/2024] Open
Abstract
Color blindness is a retinal disease that mainly manifests as a color vision disorder, characterized by achromatopsia, red-green color blindness, and blue-yellow color blindness. With the development of technology and progress in theory, extensive research has been conducted on the genetic basis of color blindness, and various approaches have been explored for its treatment. This article aims to provide a comprehensive review of recent advances in understanding the pathological mechanism, clinical symptoms, and treatment options for color blindness. Additionally, we discuss the various treatment approaches that have been developed to address color blindness, including gene therapy, pharmacological interventions, and visual aids. Furthermore, we highlight the promising results from clinical trials of these treatments, as well as the ongoing challenges that must be addressed to achieve effective and long-lasting therapeutic outcomes. Overall, this review provides valuable insights into the current state of research on color blindness, with the intention of informing further investigation and development of effective treatments for this disease.
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Affiliation(s)
- Zihao Yang
- Institute of Visual Neuroscience and Stem Cell Engineering, Wuhan University of Science and Technology, Wuhan, China
- College of Life Sciences and Health, Wuhan University of Science and Technology, Wuhan, China
| | - Lin Yan
- Institute of Visual Neuroscience and Stem Cell Engineering, Wuhan University of Science and Technology, Wuhan, China
- College of Life Sciences and Health, Wuhan University of Science and Technology, Wuhan, China
| | - Wenliang Zhang
- Institute of Visual Neuroscience and Stem Cell Engineering, Wuhan University of Science and Technology, Wuhan, China
- College of Life Sciences and Health, Wuhan University of Science and Technology, Wuhan, China
| | - Jia Qi
- Institute of Visual Neuroscience and Stem Cell Engineering, Wuhan University of Science and Technology, Wuhan, China
- College of Life Sciences and Health, Wuhan University of Science and Technology, Wuhan, China
| | - Wenjing An
- Institute of Visual Neuroscience and Stem Cell Engineering, Wuhan University of Science and Technology, Wuhan, China
- College of Life Sciences and Health, Wuhan University of Science and Technology, Wuhan, China
| | - Kai Yao
- Institute of Visual Neuroscience and Stem Cell Engineering, Wuhan University of Science and Technology, Wuhan, China
- College of Life Sciences and Health, Wuhan University of Science and Technology, Wuhan, China
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3
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Biology, Pathobiology and Gene Therapy of CNG Channel-Related Retinopathies. Biomedicines 2023; 11:biomedicines11020269. [PMID: 36830806 PMCID: PMC9953513 DOI: 10.3390/biomedicines11020269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Revised: 01/16/2023] [Accepted: 01/17/2023] [Indexed: 01/21/2023] Open
Abstract
The visual process begins with the absorption of photons by photopigments of cone and rod photoreceptors in the retina. In this process, the signal is first amplified by a cyclic guanosine monophosphate (cGMP)-based signaling cascade and then converted into an electrical signal by cyclic nucleotide-gated (CNG) channels. CNG channels are purely ligand-gated channels whose activity can be controlled by cGMP, which induces a depolarizing Na+/Ca2+ current upon binding to the channel. Structurally, CNG channels belong to the superfamily of pore-loop cation channels and share structural similarities with hyperpolarization-activated cyclic nucleotide (HCN) and voltage-gated potassium (KCN) channels. Cone and rod photoreceptors express distinct CNG channels encoded by homologous genes. Mutations in the genes encoding the rod CNG channel (CNGA1 and CNGB1) result in retinitis-pigmentosa-type blindness. Mutations in the genes encoding the cone CNG channel (CNGA3 and CNGB3) lead to achromatopsia. Here, we review the molecular properties of CNG channels and describe their physiological and pathophysiological roles in the retina. Moreover, we summarize recent activities in the field of gene therapy aimed at developing the first gene therapies for CNG channelopathies.
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Xu K, Yu L, Wang Z, Lin P, Zhang N, Xing Y, Yang N. Use of gene therapy for optic nerve protection: Current concepts. Front Neurosci 2023; 17:1158030. [PMID: 37090805 PMCID: PMC10117674 DOI: 10.3389/fnins.2023.1158030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 03/20/2023] [Indexed: 04/25/2023] Open
Abstract
Gene therapy has become an essential treatment for optic nerve injury (ONI) in recent years, and great strides have been made using animal models. ONI, which is characterized by the loss of retinal ganglion cells (RGCs) and axons, can induce abnormalities in the pupil light reflex, visual field defects, and even vision loss. The eye is a natural organ to target with gene therapy because of its high accessibility and certain immune privilege. As such, numerous gene therapy trials are underway for treating eye diseases such as glaucoma. The aim of this review was to cover research progress made in gene therapy for ONI. Specifically, we focus on the potential of gene therapy to prevent the progression of neurodegenerative diseases and protect both RGCs and axons. We cover the basic information of gene therapy, including the classification of gene therapy, especially focusing on genome editing therapy, and then we introduce common editing tools and vector tools such as Clustered Regularly Interspaced Short Palindromic Repeats (CRISPR) -Cas9 and adeno-associated virus (AAV). We also summarize the progress made on understanding the roles of brain derived neurotrophic factor (BDNF), ciliary neurotrophic factor (CNTF), phosphatase-tensin homolog (PTEN), suppressor of cytokine signal transduction 3 (SOCS3), histone acetyltransferases (HATs), and other important molecules in optic nerve protection. However, gene therapy still has many challenges, such as misalignment and mutations, immunogenicity of AAV, time it takes and economic cost involved, which means that these issues need to be addressed before clinical trials can be considered.
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Affiliation(s)
- Kexin Xu
- Department of Ophthalmology, Renmin Hospital of Wuhan University, Wuhan, Hubei, China
| | - Lu Yu
- Department of Ophthalmology, Renmin Hospital of Wuhan University, Wuhan, Hubei, China
- Department of Ophthalmology, Aier Eye Hospital of Wuhan University, Wuhan, Hubei, China
| | - Zhiyi Wang
- Department of Ophthalmology, Renmin Hospital of Wuhan University, Wuhan, Hubei, China
| | - Pei Lin
- Department of Ophthalmology, Renmin Hospital of Wuhan University, Wuhan, Hubei, China
| | - Ningzhi Zhang
- Department of Ophthalmology, Renmin Hospital of Wuhan University, Wuhan, Hubei, China
| | - Yiqiao Xing
- Department of Ophthalmology, Renmin Hospital of Wuhan University, Wuhan, Hubei, China
- Department of Ophthalmology, Aier Eye Hospital of Wuhan University, Wuhan, Hubei, China
- *Correspondence: Yiqiao Xing,
| | - Ning Yang
- Department of Ophthalmology, Renmin Hospital of Wuhan University, Wuhan, Hubei, China
- Ning Yang,
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5
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Maloca PM, Valmaggia P, Hartmann T, Juedes M, Hasler PW, Scholl HPN, Denk N. Volumetric subfield analysis of cynomolgus monkey’s choroid derived from hybrid machine learning optical coherence tomography segmentation. PLoS One 2022; 17:e0275050. [PMID: 36149881 PMCID: PMC9506635 DOI: 10.1371/journal.pone.0275050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 09/10/2022] [Indexed: 12/01/2022] Open
Abstract
This study aimed to provide volumetric choroidal readings regarding sex, origin, and eye side from healthy cynomolgus monkey eyes as a reference database using optical coherence tomography (OCT) imaging. A machine learning (ML) algorithm was used to extract the choroid from the volumetric OCT data. Classical computer vision methods were then applied to automatically identify the deepest location in the foveolar depression. The choroidal thickness was determined from this reference point. A total of 374 eyes of 203 cynomolgus macaques from Asian and Mauritius origin were included in the analysis. The overall subfoveolar mean choroidal volume in zone 1, in the region of the central bouquet, was 0.156 mm3 (range, 0.131–0.193 mm3). For the central choroid volume, the coefficient of variation (CV) was found of 6.3%, indicating relatively little variation. Our results show, based on analyses of variance, that monkey origin (Asian or Mauritius) does not influence choroid volumes. Sex had a significant influence on choroidal volumes in the superior-inferior axis (p ≤ 0.01), but not in the fovea centralis. A homogeneous foveolar choroidal architecture was also observed.
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Affiliation(s)
- Peter M. Maloca
- Institute of Molecular and Clinical Ophthalmology Basel (IOB), Basel, Switzerland
- Department of Ophthalmology, University Hospital Basel, Basel, Switzerland
- Moorfields Eye Hospital NHS Foundation Trust, London, United Kingdom
- * E-mail:
| | - Philippe Valmaggia
- Institute of Molecular and Clinical Ophthalmology Basel (IOB), Basel, Switzerland
- Department of Ophthalmology, University Hospital Basel, Basel, Switzerland
| | - Theresa Hartmann
- Pharma Research and Early Development (pRED), Pharmaceutical Sciences (PS), Roche, Innovation Center Basel, Basel, Switzerland
| | - Marlene Juedes
- Pharma Research and Early Development (pRED), Pharmaceutical Sciences (PS), Roche, Innovation Center Basel, Basel, Switzerland
| | - Pascal W. Hasler
- Department of Ophthalmology, University Hospital Basel, Basel, Switzerland
| | - Hendrik P. N. Scholl
- Institute of Molecular and Clinical Ophthalmology Basel (IOB), Basel, Switzerland
- Department of Ophthalmology, University Hospital Basel, Basel, Switzerland
| | - Nora Denk
- Institute of Molecular and Clinical Ophthalmology Basel (IOB), Basel, Switzerland
- Pharma Research and Early Development (pRED), Pharmaceutical Sciences (PS), Roche, Innovation Center Basel, Basel, Switzerland
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Maloca PM, Freichel C, Hänsli C, Valmaggia P, Müller PL, Zweifel S, Seeger C, Inglin N, Scholl HPN, Denk N. Cynomolgus monkey's choroid reference database derived from hybrid deep learning optical coherence tomography segmentation. Sci Rep 2022; 12:13276. [PMID: 35918392 PMCID: PMC9346135 DOI: 10.1038/s41598-022-17699-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 07/29/2022] [Indexed: 11/18/2022] Open
Abstract
Cynomolgus monkeys exhibit human-like features, such as a fovea, so they are often used in non-clinical research. Nevertheless, little is known about the natural variation of the choroidal thickness in relation to origin and sex. A combination of deep learning and a deterministic computer vision algorithm was applied for automatic segmentation of foveolar optical coherence tomography images in cynomolgus monkeys. The main evaluation parameters were choroidal thickness and surface area directed from the deepest point on OCT images within the fovea, marked as the nulla with regard to sex and origin. Reference choroid landmarks were set underneath the nulla and at 500 µm intervals laterally up to a distance of 2000 µm nasally and temporally, complemented by a sub-analysis of the central bouquet of cones. 203 animals contributed 374 eyes for a reference choroid database. The overall average central choroidal thickness was 193 µm with a coefficient of variation of 7.8%, and the overall mean surface area of the central bouquet temporally was 19,335 µm2 and nasally was 19,283 µm2. The choroidal thickness of the fovea appears relatively homogeneous between the sexes and the studied origins. However, considerable natural variation has been observed, which needs to be appreciated.
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Affiliation(s)
- Peter M Maloca
- Institute of Molecular and Clinical Ophthalmology Basel (IOB), 4031, Basel, Switzerland. .,Department of Ophthalmology, University Hospital Basel, 4031, Basel, Switzerland. .,Moorfields Eye Hospital NHS Foundation Trust, London, EC1V 2PD, UK.
| | - Christian Freichel
- Pharma Research and Early Development (pRED), Pharmaceutical Sciences (PS), Roche, Innovation Center Basel, 4070, Basel, Switzerland
| | - Christof Hänsli
- Berner Augenklinik Am Lindenhofspital and University of Bern, Bern, Switzerland
| | - Philippe Valmaggia
- Institute of Molecular and Clinical Ophthalmology Basel (IOB), 4031, Basel, Switzerland
| | - Philipp L Müller
- Moorfields Eye Hospital NHS Foundation Trust, London, EC1V 2PD, UK.,Department of Ophthalmology, University of Bonn, Bonn, Germany.,Makulazentrum Augsburg, Fachärzte Augenheilkunde, Augsburg, Germany
| | - Sandrine Zweifel
- University Hospital Zurich, Frauenklinikstrasse 24, 8091, Zurich, Switzerland.,University of Zurich, Rämistrasse 71, 8006, Zürich, Switzerland
| | - Christine Seeger
- Pharma Research and Early Development (pRED), Pharmaceutical Sciences (PS), Roche, Innovation Center Basel, 4070, Basel, Switzerland
| | - Nadja Inglin
- Institute of Molecular and Clinical Ophthalmology Basel (IOB), 4031, Basel, Switzerland
| | - Hendrik P N Scholl
- Institute of Molecular and Clinical Ophthalmology Basel (IOB), 4031, Basel, Switzerland.,Department of Ophthalmology, University Hospital Basel, 4031, Basel, Switzerland
| | - Nora Denk
- Institute of Molecular and Clinical Ophthalmology Basel (IOB), 4031, Basel, Switzerland.,Pharma Research and Early Development (pRED), Pharmaceutical Sciences (PS), Roche, Innovation Center Basel, 4070, Basel, Switzerland
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7
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Morgan JIW, Jiang YY, Vergilio GK, Serrano LW, Pearson DJ, Bennett J, Maguire AM, Aleman TS. Short-term Assessment of Subfoveal Injection of Adeno-Associated Virus-Mediated hCHM Gene Augmentation in Choroideremia Using Adaptive Optics Ophthalmoscopy. JAMA Ophthalmol 2022; 140:411-420. [PMID: 35266957 PMCID: PMC8914909 DOI: 10.1001/jamaophthalmol.2022.0158] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Subretinal injection for gene augmentation in retinal degenerations forcefully detaches the neural retina from the retinal pigment epithelium, potentially damaging photoreceptors and/or retinal pigment epithelium cells. Objective To use adaptive optics scanning light ophthalmoscopy (AOSLO) to assess the short-term integrity of the cone mosaic following subretinal injections of adeno-associated virus vector designed to deliver a functional version of the CHM gene (AAV2-hCHM) in patients with choroideremia. Design, Setting, and Participants This longitudinal case series study enrolled adult patients with choroideremia from February 2015 to January 2016 in the US. To be included in the study, study participants must have received uniocular subfoveal injections of low-dose (5 × 1010 vector genome per eye) or high-dose (1 × 1011 vector genome per eye) AAV2-hCHM. Analysis began February 2015. Main Outcomes and Measures The macular regions of both eyes were imaged before and 1 month after injection using a custom-built multimodal AOSLO. Postinjection cone inner segment mosaics were compared with preinjection mosaics at multiple regions of interest. Colocalized spectral-domain optical coherence tomography and dark-adapted cone sensitivity was also acquired at each time point. Results Nine study participants ranged in age from 26 to 50 years at the time of enrollment, and all were White men. Postinjection AOSLO images showed preservation of the cone mosaic in all 9 AAV2-hCHM-injected eyes. Mosaics appeared intact and contiguous 1 month postinjection, with the exception of foveal disruption in 1 patient. Optical coherence tomography showed foveal cone outer segment shortening postinjection. Cone-mediated sensitivities were unchanged in 8 of 9 injected and 9 of 9 uninjected eyes. One participant showed acute loss of foveal optical coherence tomography cone outer segment-related signals along with cone sensitivity loss that colocalized with disruption of the mosaic on AOSLO. Conclusions and Relevance Integrity of the cone mosaic is maintained following subretinal delivery of AAV2-hCHM, providing strong evidence in support of the safety of the injections. Minor foveal thinning observed following surgery corresponds with short-term cone outer segment shortening rather than cone cell loss. Foveal cone loss in 1 participant raises the possibility of individual vulnerability to the subretinal injection.
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Affiliation(s)
- Jessica I W Morgan
- Scheie Eye Institute, University of Pennsylvania, Philadelphia.,Center for Advanced Retinal & Ocular Therapeutics, University of Pennsylvania, Philadelphia
| | - Yu You Jiang
- Scheie Eye Institute, University of Pennsylvania, Philadelphia.,Center for Advanced Retinal & Ocular Therapeutics, University of Pennsylvania, Philadelphia
| | - Grace K Vergilio
- Scheie Eye Institute, University of Pennsylvania, Philadelphia.,Center for Advanced Retinal & Ocular Therapeutics, University of Pennsylvania, Philadelphia
| | - Leona W Serrano
- Scheie Eye Institute, University of Pennsylvania, Philadelphia.,Center for Advanced Retinal & Ocular Therapeutics, University of Pennsylvania, Philadelphia
| | - Denise J Pearson
- Scheie Eye Institute, University of Pennsylvania, Philadelphia.,Center for Advanced Retinal & Ocular Therapeutics, University of Pennsylvania, Philadelphia
| | - Jean Bennett
- Scheie Eye Institute, University of Pennsylvania, Philadelphia.,Center for Advanced Retinal & Ocular Therapeutics, University of Pennsylvania, Philadelphia
| | - Albert M Maguire
- Scheie Eye Institute, University of Pennsylvania, Philadelphia.,Center for Advanced Retinal & Ocular Therapeutics, University of Pennsylvania, Philadelphia
| | - Tomas S Aleman
- Scheie Eye Institute, University of Pennsylvania, Philadelphia.,Center for Advanced Retinal & Ocular Therapeutics, University of Pennsylvania, Philadelphia
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Michalakis S, Gerhardt M, Rudolph G, Priglinger S, Priglinger C. Achromatopsia: Genetics and Gene Therapy. Mol Diagn Ther 2022; 26:51-59. [PMID: 34860352 PMCID: PMC8766373 DOI: 10.1007/s40291-021-00565-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/02/2021] [Indexed: 01/02/2023]
Abstract
Achromatopsia (ACHM), also known as rod monochromatism or total color blindness, is an autosomal recessively inherited retinal disorder that affects the cones of the retina, the type of photoreceptors responsible for high-acuity daylight vision. ACHM is caused by pathogenic variants in one of six cone photoreceptor-expressed genes. These mutations result in a functional loss and a slow progressive degeneration of cone photoreceptors. The loss of cone photoreceptor function manifests at birth or early in childhood and results in decreased visual acuity, lack of color discrimination, abnormal intolerance to light (photophobia), and rapid involuntary eye movement (nystagmus). Up to 90% of patients with ACHM carry mutations in CNGA3 or CNGB3, which are the genes encoding the alpha and beta subunits of the cone cyclic nucleotide-gated (CNG) channel, respectively. No authorized therapy for ACHM exists, but research activities have intensified over the past decade and have led to several preclinical gene therapy studies that have shown functional and morphological improvements in animal models of ACHM. These encouraging preclinical data helped advance multiple gene therapy programs for CNGA3- and CNGB3-linked ACHM into the clinical phase. Here, we provide an overview of the genetic and molecular basis of ACHM, summarize the gene therapy-related research activities, and provide an outlook for their clinical application.
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Affiliation(s)
- Stylianos Michalakis
- Department of Ophthalmology, University Hospital, LMU Munich, Mathildenstr. 8, 80336, Munich, Germany.
| | - Maximilian Gerhardt
- Department of Ophthalmology, University Hospital, LMU Munich, Mathildenstr. 8, 80336, Munich, Germany
| | - Günther Rudolph
- Department of Ophthalmology, University Hospital, LMU Munich, Mathildenstr. 8, 80336, Munich, Germany
| | - Siegfried Priglinger
- Department of Ophthalmology, University Hospital, LMU Munich, Mathildenstr. 8, 80336, Munich, Germany
| | - Claudia Priglinger
- Department of Ophthalmology, University Hospital, LMU Munich, Mathildenstr. 8, 80336, Munich, Germany
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9
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Varin J, Morival C, Maillard N, Adjali O, Cronin T. Risk Mitigation of Immunogenicity: A Key to Personalized Retinal Gene Therapy. Int J Mol Sci 2021; 22:12818. [PMID: 34884622 PMCID: PMC8658027 DOI: 10.3390/ijms222312818] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Revised: 11/17/2021] [Accepted: 11/23/2021] [Indexed: 12/27/2022] Open
Abstract
Gene therapy (GT) for ocular disorders has advanced the most among adeno-associated virus (AAV)-mediated therapies, with one product already approved in the market. The bank of retinal gene mutations carefully compiled over 30 years, the small retinal surface that does not require high clinical vector stocks, and the relatively immune-privileged environment of the eye explain such success. However, adverse effects due to AAV-delivery, though rare in the retina have led to the interruption of clinical trials. Risk mitigation, as the key to safe and efficient GT, has become the focus of 'bedside-back-to-bench' studies. Herein, we overview the inflammatory adverse events described in retinal GT trials and analyze which components of the retinal immunological environment might be the most involved in these immune responses, with a focus on the innate immune system composed of microglial surveillance. We consider the factors that can influence inflammation in the retina after GT such as viral sensors in the retinal tissue and CpG content in promoters or transgene sequences. Finally, we consider options to reduce the immunological risk, including dose, modified capsids or exclusion criteria for clinical trials. A better understanding and mitigation of immune risk factors inducing host immunity in AAV-mediated retinal GT is the key to achieving safe and efficient GT.
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Affiliation(s)
| | | | | | - Oumeya Adjali
- CHU de Nantes, INSERM UMR1089, Translational Gene Therapy for Genetic Diseases, Université de Nantes, F-44200 Nantes, France; (J.V.); (C.M.); (N.M.)
| | - Therese Cronin
- CHU de Nantes, INSERM UMR1089, Translational Gene Therapy for Genetic Diseases, Université de Nantes, F-44200 Nantes, France; (J.V.); (C.M.); (N.M.)
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10
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Liu D, Deng Q, Lei X, Lu W, Zhao Q, Shen Y. Overexpression of BMP4 protects retinal ganglion cells in a mouse model of experimental glaucoma. Exp Eye Res 2021; 210:108728. [PMID: 34390734 DOI: 10.1016/j.exer.2021.108728] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 08/02/2021] [Accepted: 08/10/2021] [Indexed: 01/10/2023]
Abstract
PURPOSE Activation of bone morphogenetic protein (BMP) 4 signaling promotes the survival of retinal ganglion cell (RGC) after acute injury. Chordin-like 1 (CHRDL1) is an endogenous BMP antagonist. In this study, we researched whether CHRDL1 was involved in BMP4 signaling and regulation of RGC degeneration in a mouse model of glaucoma. METHODS Magnetic microbeads were intracameral injected to induce experimental glaucoma in a mouse model. A recombinant adeno-associated virus (rAAV) system was designed for overexpression of BMP4 or CHRDL1 in mouse retina. Immunohistochemistry and hematoxylin-eosin (HE) stains were performed to identify changes in retinal morphology. Electroretinogram (ERG) recordings were used to assess changes in visual function. RESULTS The mRNA expression levels of Bmp4 and its downstream BMPRIa, small mothers against decapentaplegic 1 (Smad1), were significantly upregulated in retinas with glaucoma. RGC survival was significantly enhanced in the beads + AAV-BMP4 group and significantly reduced in the beads + AAV-CHRDL1 group, compared with the beads + AAV-EGFP group. Similar results were observed in retinal explant culture in vitro. Consistent with these findings, the photopic negative response (PhNR)responses in ERG, which indicate RGC function, were restored in mice overexpressing BMP4, whereas a-wave and b-wave responses were not. Activation of CHRLD1 inhibited Smad1/5/8 phosphorylation and exacerbated RGC damage. The expression of Glial fibrillary acidic protein (GFAP) was decreased significantly in beads + AAV-BMP4 group. CONCLUSIONS BMP4 promoted RGC survival and visual function in an experimental glaucoma model. Activation of CHRDL1 exaggerated RGC degeneration by inhibiting the BMP4/Smad1/5/8 pathway. The mechanism of BMP4/Smad1/5/8 pathway may be related to the inhibition of glial cell activation. Our studies suggested that BMP4 and CHRLD1 might serve as therapeutic targets in glaucoma.
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Affiliation(s)
- Dongmei Liu
- Eye Institute, Renmin Hospital of Wuhan University, Wuhan University, Wuhan, 430060, Hubei, China
| | - Qinqin Deng
- Eye Institute, Renmin Hospital of Wuhan University, Wuhan University, Wuhan, 430060, Hubei, China
| | - Xinlan Lei
- Eye Institute, Renmin Hospital of Wuhan University, Wuhan University, Wuhan, 430060, Hubei, China
| | - Wei Lu
- Eye Institute, Renmin Hospital of Wuhan University, Wuhan University, Wuhan, 430060, Hubei, China
| | - Qingqing Zhao
- Eye Institute, Renmin Hospital of Wuhan University, Wuhan University, Wuhan, 430060, Hubei, China
| | - Yin Shen
- Eye Institute, Renmin Hospital of Wuhan University, Wuhan University, Wuhan, 430060, Hubei, China; Frontier Science Center for Immunology and Metabolism, Medical Research Institute, Wuhan University, Wuhan, 430071, Hubei, China.
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11
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Bucher K, Rodríguez-Bocanegra E, Dauletbekov D, Fischer MD. Immune responses to retinal gene therapy using adeno-associated viral vectors - Implications for treatment success and safety. Prog Retin Eye Res 2020; 83:100915. [PMID: 33069860 DOI: 10.1016/j.preteyeres.2020.100915] [Citation(s) in RCA: 96] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 10/08/2020] [Accepted: 10/10/2020] [Indexed: 02/06/2023]
Abstract
Recombinant adeno-associated virus (AAV) is the leading vector for gene therapy in the retina. As non-pathogenic, non-integrating, replication deficient vector, the recombinant virus efficiently transduces all key retinal cell populations. Successful testing of AAV vectors in clinical trials of inherited retinal diseases led to the recent approval of voretigene neparvovec (Luxturna) for the treatment of RPE65 mutation-associated retinal dystrophies. However, studies applying AAV-mediated retinal gene therapy independently reported intraocular inflammation and/or loss of efficacy after initial functional improvements. Both observations might be explained by targeted removal of transduced cells via anti-viral defence mechanisms. AAV has been shown to activate innate pattern recognition receptors (PRRs) such as toll-like receptor (TLR)-2 and TLR-9 resulting in the release of inflammatory cytokines and type I interferons. The vector can also induce capsid-specific and transgene-specific T cell responses and neutralizing anti-AAV antibodies which both limit the therapeutic effect. However, the target organ of retinal gene therapy, the eye, is known as an immune-privileged site. It is characterized by suppression of inflammation and promotion of immune tolerance which might prevent AAV-induced immune responses. This review evaluates AAV-related immune responses, toxicity and inflammation in studies of retinal gene therapy, identifies influencing variables of these responses and discusses potential strategies to modulate immune reactions to AAV vectors to increase the safety and efficacy of ocular gene therapy.
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Affiliation(s)
- Kirsten Bucher
- University Eye Hospital, Centre for Ophthalmology, University Hospital Tübingen, Tübingen, Germany; Institute for Ophthalmic Research, Centre for Ophthalmology, University Hospital Tübingen, Tübingen, Germany
| | - Eduardo Rodríguez-Bocanegra
- University Eye Hospital, Centre for Ophthalmology, University Hospital Tübingen, Tübingen, Germany; Institute for Ophthalmic Research, Centre for Ophthalmology, University Hospital Tübingen, Tübingen, Germany
| | - Daniyar Dauletbekov
- University Eye Hospital, Centre for Ophthalmology, University Hospital Tübingen, Tübingen, Germany; Institute for Ophthalmic Research, Centre for Ophthalmology, University Hospital Tübingen, Tübingen, Germany
| | - M Dominik Fischer
- University Eye Hospital, Centre for Ophthalmology, University Hospital Tübingen, Tübingen, Germany; Institute for Ophthalmic Research, Centre for Ophthalmology, University Hospital Tübingen, Tübingen, Germany; Oxford Eye Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK; Nuffield Laboratory of Ophthalmology, Department of Clinical Neurosciences, University of Oxford, Oxford, UK.
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12
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Lin Q, Lv JN, Wu KC, Zhang CJ, Liu Q, Jin ZB. Generation of Nonhuman Primate Model of Cone Dysfunction through In Situ AAV-Mediated CNGB3 Ablation. Mol Ther Methods Clin Dev 2020; 18:869-879. [PMID: 32953936 PMCID: PMC7479327 DOI: 10.1016/j.omtm.2020.08.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 08/05/2020] [Indexed: 11/24/2022]
Abstract
A major challenge to the development of therapies for human retinal degenerative diseases is the lack of an ideal preclinical model because of the physiological differences between humans and most model animals. Despite the successful generation of a primate model through germline knockout of a disease-causing gene, the major issues restricting modeling in nonhuman primates (NHPs) are their relatively long lifespan, lengthy gestation, and dominant pattern of singleton births. Herein, we generated three cynomolgus macaques with macular in situ knockout by subretinal delivery of an adeno-associated virus (AAV)-mediated CRISPR-Cas9 system targeting CNGB3, the gene responsible for achromatopsia. The in vivo targeting efficiency of CRISPR-Cas9 was 12%-14%, as shown by both immunohistochemistry and single-cell transcriptomic analysis. Through clinical ophthalmic examinations, we observed a reduced response of electroretinogram in the central retina, which corresponds to a somatic disruption of CNGB3. In addition, we did not detect CRISPR-Cas9 residue in the heart, liver, spleen, kidney, brain, testis, or blood a year after administration. In conclusion, we successfully generated a NHP model of cone photoreceptor dysfunction in the central retina using an in situ CNGB3-knockout strategy.
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Affiliation(s)
- Qiang Lin
- Laboratory of Stem Cell & Retinal Regeneration, Division of Ophthalmic Genetics, The Eye Hospital, Wenzhou Medical University, Wenzhou 325027, China
| | - Ji-Neng Lv
- Laboratory of Stem Cell & Retinal Regeneration, Division of Ophthalmic Genetics, The Eye Hospital, Wenzhou Medical University, Wenzhou 325027, China
| | - Kun-Chao Wu
- Laboratory of Stem Cell & Retinal Regeneration, Division of Ophthalmic Genetics, The Eye Hospital, Wenzhou Medical University, Wenzhou 325027, China
| | - Chang-Jun Zhang
- Laboratory of Stem Cell & Retinal Regeneration, Division of Ophthalmic Genetics, The Eye Hospital, Wenzhou Medical University, Wenzhou 325027, China
| | - Qin Liu
- Ocular Genomics Institute, Massachusetts Eye and Ear Infirmary, Boston, MA, USA
- Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
| | - Zi-Bing Jin
- Laboratory of Stem Cell & Retinal Regeneration, Division of Ophthalmic Genetics, The Eye Hospital, Wenzhou Medical University, Wenzhou 325027, China
- Beijing Institute of Ophthalmology, Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing Ophthalmology & Visual Science Key Laboratory, Beijing 100730, China
- Beijing Advanced Innovation Center for Big Data-Based Precision Medicine, Beihang University & Capital Medical University, Beijing Tongren Hospital, Beijing 100730, China
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13
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Short B. Selected Aspects of Ocular Toxicity Studies With a Focus on High-Quality Pathology Reports: A Pathology/Toxicology Consultant's Perspective. Toxicol Pathol 2020; 49:673-699. [PMID: 32815474 DOI: 10.1177/0192623320946712] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Ocular toxicity studies are the bedrock of nonclinical ocular drug and drug-device development, and there has been an evolution in experience, technologies, and challenges to address that ensures safe clinical trials and marketing authorization. The expectations of a well-designed ocular toxicity study and the generation of a coherent, integrative ocular toxicology report and subreports are high, and this article provides a pathology/toxicology consultant's perspective on achieving that goal. The first objective is to cover selected aspects of study designs for ocular toxicity studies including considerations for contract research organization selection, minipig species selection, unilateral versus bilateral dosing, and in-life parameters based on fit-for-purpose study objectives. The main objective is a focus on a high-quality ocular pathology report that includes ocular histology procedures to meet regulatory expectations and a report narrative and tables that correlate microscopic findings with key ophthalmic findings and presents a clear interpretation of test article-, vehicle-, and procedure-related ocular and extraocular findings with identification of adversity and a pathology peer review. The last objective covers considerations for a high-quality ophthalmology report, which in concert with a high-quality pathology report, will pave the way for a best quality toxicology report for an ocular toxicity study.
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Affiliation(s)
- Brian Short
- Brian Short Consulting, LLC, Laguna Beach, CA, USA
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14
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Garafalo AV, Cideciyan AV, Héon E, Sheplock R, Pearson A, WeiYang Yu C, Sumaroka A, Aguirre GD, Jacobson SG. Progress in treating inherited retinal diseases: Early subretinal gene therapy clinical trials and candidates for future initiatives. Prog Retin Eye Res 2020; 77:100827. [PMID: 31899291 PMCID: PMC8714059 DOI: 10.1016/j.preteyeres.2019.100827] [Citation(s) in RCA: 108] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Revised: 12/21/2019] [Accepted: 12/26/2019] [Indexed: 12/15/2022]
Abstract
Due to improved phenotyping and genetic characterization, the field of 'incurable' and 'blinding' inherited retinal diseases (IRDs) has moved substantially forward. Decades of ascertainment of IRD patient data from Philadelphia and Toronto centers illustrate the progress from Mendelian genetic types to molecular diagnoses. Molecular genetics have been used not only to clarify diagnoses and to direct counseling but also to enable the first clinical trials of gene-based treatment in these diseases. An overview of the recent reports of gene augmentation clinical trials by subretinal injections is used to reflect on the reasons why there has been limited success in this early venture into therapy. These first-in human experiences have taught that there is a need for advancing the techniques of delivery of the gene products - not only for refining further subretinal trials, but also for evaluating intravitreal delivery. Candidate IRDs for intravitreal gene delivery are then suggested to illustrate some of the disorders that may be amenable to improvement of remaining central vision with the least photoreceptor trauma. A more detailed understanding of the human IRDs to be considered for therapy and the calculated potential for efficacy should be among the routine prerequisites for initiating a clinical trial.
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Affiliation(s)
- Alexandra V Garafalo
- Scheie Eye Institute, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Artur V Cideciyan
- Scheie Eye Institute, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Elise Héon
- Department of Ophthalmology and Vision Sciences, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Rebecca Sheplock
- Scheie Eye Institute, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Alexander Pearson
- Department of Ophthalmology and Vision Sciences, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Caberry WeiYang Yu
- Department of Ophthalmology and Vision Sciences, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Alexander Sumaroka
- Scheie Eye Institute, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Gustavo D Aguirre
- Division of Experimental Retinal Therapies, Department of Clinical Sciences & Advanced Medicine, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Samuel G Jacobson
- Scheie Eye Institute, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA.
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15
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Yiu G, Chung SH, Mollhoff IN, Nguyen UT, Thomasy SM, Yoo J, Taraborelli D, Noronha G. Suprachoroidal and Subretinal Injections of AAV Using Transscleral Microneedles for Retinal Gene Delivery in Nonhuman Primates. Mol Ther Methods Clin Dev 2020; 16:179-191. [PMID: 32055646 PMCID: PMC7005511 DOI: 10.1016/j.omtm.2020.01.002] [Citation(s) in RCA: 64] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Accepted: 01/06/2020] [Indexed: 02/01/2023]
Abstract
Retinal gene therapy using adeno-associated viruses (AAVs) is constrained by the mode of viral vector delivery. Intravitreal AAV injections are impeded by the internal limiting membrane barrier, while subretinal injections require invasive surgery and produce a limited region of therapeutic effect. In this study, we introduce a novel mode of ocular gene delivery in rhesus macaques using transscleral microneedles to inject AAV8 into the subretinal or suprachoroidal space, a potential space between the choroid and scleral wall of the eye. Using in vivo imaging, we found that suprachoroidal AAV8 produces diffuse, peripheral expression in retinal pigment epithelial (RPE) cells, but it elicited local infiltration of inflammatory cells. Transscleral subretinal injection of AAV8 using microneedles leads to focal gene expression with transduction of RPE and photoreceptors, and minimal intraocular inflammation. In comparison, intravitreal AAV8 shows minimal transduction of retinal cells, but elicits greater systemic humoral immune responses. Our study introduces a novel mode of transscleral viral delivery that can be performed without vitreoretinal surgery, with focal or diffuse transgene expression patterns suitable for different applications. The decoupling of local and systemic immune responses reveals important insights into the immunological consequences of AAV delivery to different ocular compartments surrounding the blood-retinal barrier.
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Affiliation(s)
- Glenn Yiu
- Department of Ophthalmology & Vision Science, University of California, Davis, 4860 Y Street, Suite 2400, Sacramento, CA 95817, USA
| | - Sook Hyun Chung
- Department of Ophthalmology & Vision Science, University of California, Davis, 4860 Y Street, Suite 2400, Sacramento, CA 95817, USA
| | - Iris N. Mollhoff
- Department of Ophthalmology & Vision Science, University of California, Davis, 4860 Y Street, Suite 2400, Sacramento, CA 95817, USA
| | - Uyen Tu Nguyen
- Department of Ophthalmology & Vision Science, University of California, Davis, 4860 Y Street, Suite 2400, Sacramento, CA 95817, USA
| | - Sara M. Thomasy
- Department of Ophthalmology & Vision Science, University of California, Davis, 4860 Y Street, Suite 2400, Sacramento, CA 95817, USA
- Department of Surgical and Radiological Sciences, School of Veterinary Medicine, University of California, Davis, 1 Garrod Drive, Davis, CA 95616, USA
| | - Jesse Yoo
- Clearside Biomedical, 900 North Point Parkway, Suite 200, Alpharetta, GA 30005, USA
| | - Donna Taraborelli
- Clearside Biomedical, 900 North Point Parkway, Suite 200, Alpharetta, GA 30005, USA
| | - Glenn Noronha
- Clearside Biomedical, 900 North Point Parkway, Suite 200, Alpharetta, GA 30005, USA
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16
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Weed L, Ammar MJ, Zhou S, Wei Z, Serrano LW, Sun J, Lee V, Maguire AM, Bennett J, Aleman TS. Safety of Same-Eye Subretinal Sequential Readministration of AAV2-hRPE65v2 in Non-human Primates. Mol Ther Methods Clin Dev 2019; 15:133-148. [PMID: 31660416 PMCID: PMC6807311 DOI: 10.1016/j.omtm.2019.08.011] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2019] [Accepted: 08/26/2019] [Indexed: 01/28/2023]
Abstract
We have demonstrated safe and effective subretinal readministration of recombinant adeno-associated virus serotype (rAAV) to the contralateral eye in large animals and humans even in the setting of preexisting neutralizing antibodies (NAbs). Readministration of AAV to the same retina may be desirable in order to treat additional areas of the retina not targeted initially or to boost transgene expression levels at a later time point. To better understand the immune and structural consequences of subretinal rAAV readministration to the same eye, we administered bilateral subretinal injections of rAAV2-hRPE65v2 to three unaffected non-human primates (NHPs) and repeated the injections in those same eyes 2 months later. Ophthalmic exams and retinal imaging were performed after the first and second injections. Peripheral blood monocytes, serum, and intraocular fluids were collected at baseline and post-injection time points to characterize the cellular and humoral immune responses. Histopathologic and immunohistochemical studies were carried out on the treated retinas. Ipsilateral readministration of AAV2-hRPE65v2 in NHPs did not threaten the ocular or systemic health through the time span of the study. The repeat injections were immunologically and structurally well tolerated, even in the setting of preexisting serum NAbs. Localized structural abnormalities confined to the outer retina and retinal pigmented epithelium (RPE) after readministration of the treatment do not differ from those observed after single or contralateral administration of an AAV carrying a non-therapeutic transgene in NHPs and were not observed in a patient treated with the nearly identical, FDA-approved, AAV2-hRPE65v2 vector (voretigene neparvovec-rzyl), suggesting NHP-specific abnormalities.
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Affiliation(s)
- Lindsey Weed
- Center for Advanced Retinal and Ocular Therapeutics (CAROT), Department of Ophthalmology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Michael J. Ammar
- Center for Advanced Retinal and Ocular Therapeutics (CAROT), Department of Ophthalmology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Shangzhen Zhou
- Center for Advanced Retinal and Ocular Therapeutics (CAROT), Department of Ophthalmology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Zhangyong Wei
- Center for Advanced Retinal and Ocular Therapeutics (CAROT), Department of Ophthalmology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Leona W. Serrano
- Center for Advanced Retinal and Ocular Therapeutics (CAROT), Department of Ophthalmology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Junwei Sun
- Center for Advanced Retinal and Ocular Therapeutics (CAROT), Department of Ophthalmology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Vivian Lee
- Center for Advanced Retinal and Ocular Therapeutics (CAROT), Department of Ophthalmology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Department of Dermatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Albert M. Maguire
- Center for Advanced Retinal and Ocular Therapeutics (CAROT), Department of Ophthalmology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Department of Dermatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Jean Bennett
- Center for Advanced Retinal and Ocular Therapeutics (CAROT), Department of Ophthalmology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- The Children’s Hospital of Philadelphia (CHOP), Philadelphia, PA, USA
| | - Tomas S. Aleman
- Center for Advanced Retinal and Ocular Therapeutics (CAROT), Department of Ophthalmology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- The Children’s Hospital of Philadelphia (CHOP), Philadelphia, PA, USA
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