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Treatment of retinitis pigmentosa due to MERTK mutations by ocular subretinal injection of adeno-associated virus gene vector: results of a phase I trial

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Abstract

MERTK is an essential component of the signaling network that controls phagocytosis in retinal pigment epithelium (RPE), the loss of which results in photoreceptor degeneration. Previous proof-of-concept studies have demonstrated the efficacy of gene therapy using human MERTK (hMERTK) packaged into adeno-associated virus (AAV2) in treating RCS rats and mice with MERTK deficiency. The purpose of this study was to assess the safety of gene transfer via subretinal administration of rAAV2-VMD2-hMERTK in subjects with MERTK-associated retinitis pigmentosa (RP). After a preclinical phase confirming the safety of the study vector in monkeys, six patients (aged 14 to 54, mean 33.3 years) with MERTK-related RP and baseline visual acuity (VA) ranging from 20/50 to <20/6400 were entered in a phase I open-label, dose-escalation trial. One eye of each patient (the worse-seeing eye in five subjects) received a submacular injection of the viral vector, first at a dose of 150 µl (5.96 × 1010vg; 2 patients) and then 450 µl (17.88 × 1010vg; 4 patients). Patients were followed daily for 10 days at 30, 60, 90, 180, 270, 365, 540, and 730 days post-injection. Collected data included (1) full ophthalmologic examination including best-corrected VA, intraocular pressure, color fundus photographs, macular spectral domain optical coherence tomography and full-field stimulus threshold test (FST) in both the study and fellow eyes; (2) systemic safety data including CBC, liver and kidney function tests, coagulation profiles, urine analysis, AAV antibody titers, peripheral blood PCR and ASR measurement; and (3) listing of ophthalmological or systemic adverse effects. All patients completed the 2-year follow-up. Subretinal injection of rAAV2-VMD2-hMERTK was associated with acceptable ocular and systemic safety profiles based on 2-year follow-up. None of the patients developed complications that could be attributed to the gene vector with certainty. Postoperatively, one patient developed filamentary keratitis, and two patients developed progressive cataract. Of these two patients, one also developed transient subfoveal fluid after the injection as well as monocular oscillopsia. Two patients developed a rise in AAV antibodies, but neither patient was positive for rAAV vector genomes via PCR. Three patients also displayed measurable improved visual acuity in the treated eye following surgery, although the improvement was lost by 2 years in two of these patients. Gene therapy for MERTK-related RP using careful subretinal injection of rAAV2-VMD2-hMERTK is not associated with major side effects and may result in clinical improvement in a subset of patients.

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Acknowledgments

This study was supported by King Salman Center for Disability Research grant (FSA).

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    Authors and Affiliations

    1. Vitreoretinal Division, King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia

      Nicola G. Ghazi, Emad B. Abboud, Sawsan R. Nowilaty, Abdulrahman Alhommadi & Hassan Al-Dhibi

    2. Department of Genetics, Stanford University School of Medicine, Stanford, CA, USA

      Douglas Vollrath

    3. Beckman Vision Center, University of California San Francisco, San Francisco, CA, USA

      Matthew M. LaVail

    4. Department of Ophthalmology, Institute for Genomic Medicine, University of California San Diego, San Diego, CA, USA

      Huimin Cai, Christopher Chung & Kang Zhang

    5. Department of Ophthalmology, University of Florida, Gainesville, USA

      Wen-Tao Deng, Sanford L. Boye & William Hauswirth

    6. Department of Pediatrics, Powell Gene Therapy Center, University of Florida, Gainesville, USA

      Kirsten Erger & Thomas Conlon

    7. Department of Genetics, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia

      Fowzan S. Alkuraya

    8. Department of Ophthalmology, University of Virginia, Charlottesville, VA, USA

      Nicola G. Ghazi

    9. Department of Anatomy and Cell Biology, College of Medicine, Alfaisal University, Riyadh, Saudi Arabia

      Fowzan S. Alkuraya

    10. Chengdu JiaChuan Biomedicine Co., Ltd, Chengdu, China

      Huimin Cai, Rui Hou & Wenqiu Wang

    11. Guangzhou KangRui Biological Pharmaceutical Technology Company Ltd., Guangzhou, China

      Huimin Cai, Rui Hou & Wenqiu Wang

    12. Veterans Administration Healthcare System, San Diego, CA, 92093, USA

      Kang Zhang

    13. Department of Ophthalmology, College of Medicine, Al-Imam Muhammad Ibn Saud Islamic University, Riyadh, Saudi Arabia

      Hisham Alkuraya

    14. Rose-Silverthorne Retinal Degenerations Laboratory, Retina Foundation of the Southwest, Dallas, USA

      David Birch

    15. Department of Biostatistics, Epidemiology and Scientific Computing, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia

      Dilek Colak

    16. Department of Medicine, King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia

      Abdulrahman Almaghamsi & Fahad Al Saikhan

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    1. Nicola G. Ghazi
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    Corresponding author

    Correspondence to Fowzan S. Alkuraya.

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    Conflict of interest

    W.W.H. and the University of Florida have a financial interest in the use of AAV therapies, and own equity in a company (AGTC Inc.) that might, in the future, commercialize some aspects of this work.

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    N. G. Ghazi, E. B. Abboud and S. R. Nowilaty have contributed equally to this work.

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    439_2016_1637_MOESM3_ESM.pdf

    Figure S1. Cartoon of the vector used in this study. Figure S2. Polyacrylamide electrophoretic gel of GMP AAV2-VMD2-hMERTK vector proteins to test for capsid purity. Lane 9 is the final product and shows that >95% of the protein is composed of the three AAV serotype 2 capsid proteins, thus passing this vector release criterion (PDF 1268 kb)

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    Ghazi, N.G., Abboud, E.B., Nowilaty, S.R. et al. Treatment of retinitis pigmentosa due to MERTK mutations by ocular subretinal injection of adeno-associated virus gene vector: results of a phase I trial. Hum Genet 135, 327–343 (2016). https://doi.org/10.1007/s00439-016-1637-y

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