1
|
Schmetterer L, Scholl H, Garhöfer G, Janeschitz-Kriegl L, Corvi F, Sadda SR, Medeiros FA. Endpoints for clinical trials in ophthalmology. Prog Retin Eye Res 2023; 97:101160. [PMID: 36599784 DOI: 10.1016/j.preteyeres.2022.101160] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 12/22/2022] [Accepted: 12/28/2022] [Indexed: 01/03/2023]
Abstract
With the identification of novel targets, the number of interventional clinical trials in ophthalmology has increased. Visual acuity has for a long time been considered the gold standard endpoint for clinical trials, but in the recent years it became evident that other endpoints are required for many indications including geographic atrophy and inherited retinal disease. In glaucoma the currently available drugs were approved based on their IOP lowering capacity. Some recent findings do, however, indicate that at the same level of IOP reduction, not all drugs have the same effect on visual field progression. For neuroprotection trials in glaucoma, novel surrogate endpoints are required, which may either include functional or structural parameters or a combination of both. A number of potential surrogate endpoints for ophthalmology clinical trials have been identified, but their validation is complicated and requires solid scientific evidence. In this article we summarize candidates for clinical endpoints in ophthalmology with a focus on retinal disease and glaucoma. Functional and structural biomarkers, as well as quality of life measures are discussed, and their potential to serve as endpoints in pivotal trials is critically evaluated.
Collapse
Affiliation(s)
- Leopold Schmetterer
- Singapore Eye Research Institute, Singapore; SERI-NTU Advanced Ocular Engineering (STANCE), Singapore; Academic Clinical Program, Duke-NUS Medical School, Singapore; School of Chemistry, Chemical Engineering and Biotechnology, Nanyang Technological University, Singapore; Department of Clinical Pharmacology, Medical University Vienna, Vienna, Austria; Center for Medical Physics and Biomedical Engineering, Medical University Vienna, Vienna, Austria; Institute of Molecular and Clinical Ophthalmology, Basel, Switzerland.
| | - Hendrik Scholl
- Institute of Molecular and Clinical Ophthalmology, Basel, Switzerland; Department of Ophthalmology, University of Basel, Basel, Switzerland
| | - Gerhard Garhöfer
- Department of Clinical Pharmacology, Medical University Vienna, Vienna, Austria
| | - Lucas Janeschitz-Kriegl
- Institute of Molecular and Clinical Ophthalmology, Basel, Switzerland; Department of Ophthalmology, University of Basel, Basel, Switzerland
| | - Federico Corvi
- Eye Clinic, Department of Biomedical and Clinical Sciences "Luigi Sacco", University of Milan, Italy
| | - SriniVas R Sadda
- Doheny Eye Institute, Los Angeles, CA, USA; Department of Ophthalmology, David Geffen School of Medicine at University of California, Los Angeles, CA, USA
| | - Felipe A Medeiros
- Vision, Imaging and Performance Laboratory, Department of Ophthalmology, Duke Eye Center, Duke University, Durham, NC, USA
| |
Collapse
|
2
|
Taylor LJ, Josan AS, Stratton I, Jolly JK, MacLaren RE. A cross-sectional study to assess the clinical utility of modern visual function assessments in patients with inherited retinal disease: a mixed methods observational study protocol. BMC Ophthalmol 2023; 23:234. [PMID: 37226218 DOI: 10.1186/s12886-023-02974-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 05/11/2023] [Indexed: 05/26/2023] Open
Abstract
BACKGROUND Treatment options for patients with inherited retinal disease are limited, although research into novel therapies is underway. To ensure the success of future clinical trials, appropriate visual function outcome measures that can assess changes resulting from therapeutic interventions are urgently required. Rod-cone degenerations are the most common type of inherited retinal disease. Visual acuity is a standard measure but is typically preserved until late disease stages, frequently making it an unsuitable visual function marker. Alternative measures are required. This study investigates the clinical utility of a range of carefully selected visual function tests and patient reported outcome measures. The aim is to identify suitable outcome measures for future clinical trials that could be considered for regulatory approval. METHODS This cross-sectional study involves two participant groups, patients with inherited retinal disease (n = 40) and healthy controls (n = 40). The study has been designed to be flexible and run alongside NHS clinics. The study is split into two parts. Part one includes examining standard visual acuity, low luminance visual acuity, the Moorfields acuity chart visual acuity, mesopic microperimetry and three separate patient reported outcome measures. Part two involves 20 min of dark adaptation followed by two-colour scotopic microperimetry. Repeat testing will be undertaken where possible to enable repeatability analyses. A subset of patients with inherited retinal disease will be invited to participate in a semi-structured interview to gain awareness of participants' thoughts and feelings around the study and different study tests. DISCUSSION The study highlights a need for reliable and sensitive validated visual function measures that can be used in future clinical trials. This work will build on work from other studies and be used to inform an outcome measure framework for rod-cone degenerations. The study is in keeping with the United Kingdom Department of Health and Social Care research initiatives and strategies for increasing research opportunities for NHS patients as part of their NHS care. TRIAL REGISTRATION ISRCTN registry, ISRCTN24016133, Visual Function in Retinal Degeneration, registered on 18th August 2022.
Collapse
Affiliation(s)
- Laura J Taylor
- Nuffield Laboratory of Ophthalmology, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK.
- Oxford Eye Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
| | - Amandeep S Josan
- Nuffield Laboratory of Ophthalmology, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
- Oxford Eye Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Irene Stratton
- Centre for Statistics in Medicine, University of Oxford, Oxford, UK
| | - Jasleen K Jolly
- Vision and Eye Research Institute, Anglia Ruskin University, Cambridge, UK
| | - Robert E MacLaren
- Nuffield Laboratory of Ophthalmology, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| |
Collapse
|
3
|
Jolly JK, Nanda A, Buckley TMW, Pfau M, Bridge H, MacLaren RE. Assessment of Scotopic Function in Rod-Cone Inherited Retinal Degeneration With the Scotopic Macular Integrity Assessment. Transl Vis Sci Technol 2023; 12:10. [PMID: 36749581 PMCID: PMC9919682 DOI: 10.1167/tvst.12.2.10] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Purpose The scotopic macular integrity assessment (S-MAIA) can perform scotopic assessment to detect localized changes to scotopic rod and cone function. This study is an exploratory investigation of the feasibility of using the S-MAIA in a rod-cone dystrophy population to identify the pattern of loss in scotopic photoreceptor function. Methods Twenty patients diagnosed with a rod-cone dystrophy underwent visual acuity testing, full-field stimulus threshold assessment, and multiple S-MAIA tests after dark adaptation periods of 20 minutes and 45 minutes performed separately. Only right eyes were tested. Three tests were performed following a learning test. A Bland-Altman analysis was used to assess repeatability and agreement between tests after the two time periods. Spatial interpolation maps were created from the group plots to display the pattern of rod and cone loss. Results Learning effects took place between testing sessions 1 and 2 but not 2 and 3. Limits of agreement were larger in the patient eyes than control eyes, but within previously reported values. Using longer adaptation time of 45 minutes did not offer a significant advantage over 20 minutes. Patterns for the cyan and red sensitivities were different, indicating different patterns of loss for rods and cones. Conclusions A dark adaptation time of 20 minutes before testing is sufficient for thresholding. The S-MAIA is suitable for use in patients with a logarithm of the minimum angle of resolution vision of at least 0.7 and provides a viable outcome measure for patients with rod-cone dystrophies and preserved central vision. The spatial information about scotopic function from the S-MAIA provides information about disease processes and progression. Translational Relevance There is a need for scotopic measures for use in clinical trials. Scotopic microperimetry works well in patients with early disease, allowing the extension of recruitment criteria for novel therapies of rod-cone dystrophies.
Collapse
Affiliation(s)
- Jasleen K. Jolly
- Nuffield Laboratory of Ophthalmology, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK,Oxford Eye Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK,Oxford Centre for Functional MRI of the Brain (FMRIB), Wellcome Centre for Integrative Neuroimaging, University of Oxford, Oxford, UK,Vision and Eye Research Institute, Anglia Ruskin University, Cambridge, UK
| | - Anika Nanda
- Nuffield Laboratory of Ophthalmology, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK,Oxford Eye Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Thomas M. W. Buckley
- Oxford Eye Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Maximilian Pfau
- Department of Ophthalmology, University of Bonn, Bonn, Germany,Ophthalmic Genetics and Visual Function Branch, National Eye Institute, National Institutes of Health, Bethesda, MD, USA
| | - Holly Bridge
- Oxford Centre for Functional MRI of the Brain (FMRIB), Wellcome Centre for Integrative Neuroimaging, University of Oxford, Oxford, UK
| | - Robert E. MacLaren
- Nuffield Laboratory of Ophthalmology, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK,Oxford Eye Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| |
Collapse
|
4
|
Taylor LJ, Josan AS, Pfau M, Simunovic MP, Jolly JK. Scotopic microperimetry: evolution, applications and future directions. Clin Exp Optom 2022; 105:793-800. [PMID: 35025727 DOI: 10.1080/08164622.2021.2023477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
For many inherited and acquired retinal diseases, reduced night vision is a primary symptom. Despite this, the clinical testing options for spatially resolved scotopic vision have until recently been limited. Scotopic microperimetry is a relatively new visual function test that combines two-colour perimetry with fundus-controlled perimetry performed in scotopic luminance conditions. The technique enables spatially resolved mapping of central retinal sensitivity alongside the ability to distinguish between rod and cone photoreceptor sensitivities. Two companies produce commercially available scotopic microperimeters - Nidek (Nidek Technologies Srl, Padova, Italy) and CenterVue (CenterVue S.p.A., Padova, Italy). Scotopic microperimetry is a promising technology capable of detecting changes in retinal sensitivity before changes in other measures of visual function. Scotopic microperimetry is a promising functional biomarker that has the potential as a useful clinical trial outcome measure. This review summarises the evolution and applications of scotopic microperimetry, and discusses testing options, including testing grid selection, dark-adaptation time and threshold sensitivity analyses.
Collapse
Affiliation(s)
- Laura J Taylor
- Nuffield Laboratory of Ophthalmology, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Amandeep S Josan
- Nuffield Laboratory of Ophthalmology, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Maximilian Pfau
- Ophthalmic Genetics and Visual Function Branch, National Eye Institute, National Institutes of Health, Bethesda, MD, USA
| | - Matthew P Simunovic
- Save Sight Institute, Discipline of Ophthalmology, University of Sydney, Sydney, Australia
| | - Jasleen K Jolly
- Nuffield Laboratory of Ophthalmology, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK.,Vision and Eye Research Institute, Anglia Ruskin University Medical School, Cambridge, UK
| |
Collapse
|
5
|
Montesano G, Ometto G, Higgins BE, Das R, Graham KW, Chakravarthy U, McGuiness B, Young IS, Kee F, Wright DM, Crabb DP, Hogg RE. Evidence for Structural and Functional Damage of the Inner Retina in Diabetes With No Diabetic Retinopathy. Invest Ophthalmol Vis Sci 2021; 62:35. [PMID: 33760040 PMCID: PMC7995918 DOI: 10.1167/iovs.62.3.35] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Purpose To provide structural and functional evidence of inner retinal loss in diabetes prior to vascular changes and interpret the structure-function relationship in the context of an established neural model. Methods Data from one eye of 505 participants (134 with diabetes and no clinically evident vascular alterations of the retina) were included in this analysis. The data were collected as part of a large population-based study. Functional tests included best-corrected visual acuity, Pelli-Robson contrast sensitivity, mesopic microperimetry, and frequency doubling technology perimetry (FDT). Macular optical coherence tomography volume scans were collected for all participants. To interpret the structure-function relationship in the context of a neural model, ganglion cell layer (GCL) thickness was converted to local ganglion cell (GC) counts. Results The GCL and inner plexiform layer were significantly thinner in participants with diabetes (P < 0.05), with no significant differences in the macular retinal nerve fiber layer or the outer retina. All functional tests except microperimetry showed a significant loss in diabetic patients (P < 0.05). Both FDT and microperimetry showed a significant relationship with the GC count (P < 0.05), consistent with predictions from a neural model for partial summation conditions. However, the FDT captured additional significant damage (P = 0.03) unexplained by the structural loss. Conclusions Functional and structural measurements support early neuronal loss in diabetes. The structure-function relationship follows the predictions from an established neural model. Functional tests could be improved to operate in total summation conditions in the macula, becoming more sensitive to early loss.
Collapse
Affiliation(s)
- Giovanni Montesano
- Optometry and Visual Sciences, City, University of London, London, United Kingdom.,NIHR Biomedical Research Centre, Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, United Kingdom
| | - Giovanni Ometto
- Optometry and Visual Sciences, City, University of London, London, United Kingdom.,NIHR Biomedical Research Centre, Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, United Kingdom
| | - Bethany E Higgins
- Optometry and Visual Sciences, City, University of London, London, United Kingdom
| | - Radha Das
- Centre for Public Health, Queen's University Belfast, Block B, Royal Hospital, Belfast, Northern Ireland
| | - Katie W Graham
- Centre for Public Health, Queen's University Belfast, Block B, Royal Hospital, Belfast, Northern Ireland
| | - Usha Chakravarthy
- Centre for Public Health, Queen's University Belfast, Block B, Royal Hospital, Belfast, Northern Ireland
| | - Bernadette McGuiness
- Centre for Public Health, Queen's University Belfast, Block B, Royal Hospital, Belfast, Northern Ireland
| | - Ian S Young
- Centre for Public Health, Queen's University Belfast, Block B, Royal Hospital, Belfast, Northern Ireland
| | - Frank Kee
- Centre for Public Health, Queen's University Belfast, Block B, Royal Hospital, Belfast, Northern Ireland
| | - David M Wright
- Centre for Public Health, Queen's University Belfast, Block B, Royal Hospital, Belfast, Northern Ireland
| | - David P Crabb
- Optometry and Visual Sciences, City, University of London, London, United Kingdom
| | - Ruth E Hogg
- Centre for Public Health, Queen's University Belfast, Block B, Royal Hospital, Belfast, Northern Ireland
| |
Collapse
|