The Role of Alpha Melanocyte Stimulating Hormone in Ocular Disease
Phase: NA
Conditions: Advanced Dry Macular Degeneration
Sponsor: Duke University

The Role of Alpha Melanocyte Stimulating Hormone (α-MSH) in Ocular Disease
NCT03451578
Dr. Sharon Fekrat 
8/13/18 Revision 
1
Research Summary 
Purpose of the Study: 
We aim to study the ocular levels of alpha melanocyte stimulating hormone in the 
aqueous humor of patients with severe geographic atrophy. As there currently are no 
therapeutic options for these patients, further research into potential therapeutic 
targets such as α-MSH, is of utmost importance.  
Background & Significance: 
Macular degeneration is a disease of the retina affecting the elderly. There are two 
forms of macular degeneration: dry and wet macular degeneration. Wet macular 
degeneration may be treated with anti-vascular endothelial growth factor (anti-VEGF) 
injections. Dry macular degeneration is slowly progressive and in its most advanced 
form causes severe atrophy and vision loss. There is currently no treatment for dry 
macular degeneration. 
The melanocortin system encompasses multiple peptides including α-, β-, γ-melanocyte 
stimulating hormone (MSH) and adrenocorticotropic hormone (ACTH). There are ﬁve 
MC receptors (MCR1-5) that are expressed in a multitude of cells and tissues. Alpha 
melanocyte stimulating hormone is widely expressed in the tissues such as the 
hypothalamus, skin and retina. 1 
There are several known effects of α-MSH including suppressing pro-inflammatory 
signals, promoting production of anti-inflammatory cytokines, inducing suppressor 
antigen presenting cells, inducing activation of regulatory T cells, and regulating the 
immunity in healthy eyes. 2–5 
Retina pigment epitheial (RPE) cells have been shown to be a source of α-MSH. RPE cells 
in culture produce 2 ng of α-MSH in 24 hours. There is possible loss of α-MSH in eyes 
with autoimmune disease or damaged retinas. Alpha MSH may increase RPE and 
photoreceptor cell survival. Both RPE and photoreceptors express melanocortin 
receptors through which alpha MSH promotes cell survival.6 In an experimental rat 
model for example when α-MSH analog was injected into the eyes of rats with retinal 
dystrophy photoreceptor rescue was seen through to the hormone’s neurotrophic 
activity.7 Additionally another study showed α-MSH protected RPE cells against 
oxidative stress.8  
Alpha-MSH is a molecule that is extremely probe to proteolysis, even when removed 
from animal or human eyes it is prone be being quickly denatured. This is why human 
eyes of living subjects are the best sample for the most accurate analysis of α-MSH 

The Role of Alpha Melanocyte Stimulating Hormone (α-MSH) in Ocular Disease 
Dr. Sharon Fekrat 
8/13/18 Revision 
 
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levels. Levels in normal eyes undergoing cataract surgery have been previously 
measured in one study of 8 eyes. The mean level in these eyes was 20pM with a range 
of 8-31 pM.9 As the concentration of α-MSH in the aqueous of normal eyes has 
previously been published, the next step is to describe levels in eyes with pathology, 
such as advanced macular degeneration.  
 
Alpha MSH  is a hormone that has been shown to be found in the eye. The goal of this 
study is to see if levels of this hormone are affected by advanced dry macular 
degeneration. As macular degeneration is a clinical diagnosis based on exam and 
imaging findings, levels of alpha mSH should not and will not be considered a diagnostic 
test for this disease.  
 
Currently there are no treatment options for patients with severe geographic atrophy. 
This is a blinding disease without a therapeutic option. Learning more about the levels 
of alpha MSH in patients with geographic atrophy may be beneficial in further 
understanding the disease and potential treatment options.  
 
We hypothesize that eyes with advanced geographic atrophy will have decreased levels 
of alpha MSH as compared to normal controls. As there are potential ways to 
supplement α-MSH in the eye and bloodstream, the finding of a low level of alpha MSH 
would be significant as it may provide a new potential therapeutic pathway to explore. 
The control used will include the prior published study of levels in 8 human eyes and the 
normative controls that will be gathered during routine cataract surgery during this 
study.  
 
Design & Procedures:  
 
If the subject decides to participate, the informed consent process will be completed. 
After completing the consent form, subjects will be asked to complete a short memory 
test, the Montreal Cognitive Assessment (MoCA), blind version (attached to IRB 
submission), to be administered by one of the key personnel. An aqueous paracentesis 
will be then be performed as follows:  
The anterior chamber paracentesis will be performed using povidone iodine preparation 
and post-procedural topical antibiotics. After informed consent is obtained the eye will 
be anesthetized using topical anesthesia. The lids will be cleaned with 10% povidone 
iodine and one drop of 5% povidone iodine will be applied to the ocular surface. A lid 
speculum will be placed to retract the eyelids. A 27-gauge needle will be placed through 
the clear cornea to aspirate approximately 100 µl of aqueous humor. Following the 
procedure, prophylactic topical antibiotics will be given for 3 days. 
 
The patient will be re-examined for possible immediate complication such as bleeding, 
hypotony or corneal scratch 20 minutes after the procedure at the slit lamp. 
 

The Role of Alpha Melanocyte Stimulating Hormone (α-MSH) in Ocular Disease 
Dr. Sharon Fekrat 
8/13/18 Revision 
 
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In 10 eyes of patients recruited prior to routine cataract surgery a careful anterior 
chamber paracentesis will be performed through the clear cornea immediately after the 
sideport incision is made. Care will be taken to avoid inadvertent introduction of blood 
into the syringe.  
 
Once collected the samples will be frozen at -80 degrees Celsius. The samples will then 
be sent by secure shipment to an outside lab to measure levels of α-MSH in aqueous 
samples using ELISA. Specifically, the samples will be sent to Dr. Andrew Taylor at 
Boston University who is a world expert in the measurement of alpha MSH in the eye 
using ELISA assays. Dr. Taylor has IRB approval for the measurement of alpha MSH in 
ELISA assays at Boston University under approval number H-32859 with original 
approval date 4/14/14. All of the samples sent to Dr. Taylor’s lab will be de-identified so 
he has no patient health information.  
 
A follow-up phone call will be made 5 days after the procedure for subjects with 
geographic atrophy to assure the eye feels back to baseline and the patient does not 
need closer follow-up. Control subjects will be asked to follow with their cataract 
surgeon for normal post operative checks as per the cataract surgeon (usually day 1, 
week 1 and month 1 after surgery).  
 
Selection of Subjects: 
 
The subject population will consist of up to 50 volunteers from the Duke Eye Center’s 
vitreoretinal clinic. All subjects will be 60 years of age or older. Subjects with severely 
limited vision or blindness from geographic atrophy and only those patients who are 
pseudophakic or aphakic will be included in the study. Subjects must have a best 
corrected visual acuity of 20/100 or worse in the eye undergoing the procedure.  If 
subjects with advanced macular degeneration are undergoing cataract surgery then the 
sample of aqueous will be obtained at the time of cataract surgery. Very few patients 
with geographic atrophy undergo cataract surgery. Enrollment solely from cataract 
surgery patients would be too low for results from the study to be meaningful. This is 
due primarily to the fact that in many patients with advanced geographic atrophy in the 
setting of macular degeneration, cataract surgery has most likely been previously 
performed due to their age. Second, if cataract surgery has not been performed it is 
often not recommend as it is unlikely to further improve their vision given the degree of 
vision loss from geographic atrophy. We propose to include eyes with only severe 
geographic atrophy with best corrected visual acuity of 20/100 or worse.  
 
Additionally, we will also attempt to get normative data on α-MSH levels to compare to 
previously reported levels and aim to gather 10 samples in healthy eyes at the time of 
cataract surgery.  Every reasonable attempt will be made to include subjects from all 
races. 

The Role of Alpha Melanocyte Stimulating Hormone (α-MSH) in Ocular Disease 
Dr. Sharon Fekrat 
8/13/18 Revision 
 
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Subject Recruitment & Compensation: 
 
Subjects with geographic atrophy and control subjects will be recruited by Dr. Sharon 
Fekrat or Dr. Dilraj Grewal from their vitreoretinal clinics during standard-of-care visits 
at the Duke Eye Center.  Controls will also be recruited form Dr. Terry Kim’s patients 
that are having cataract surgery. 
 
Subjects will not be compensated for their participation in this study. 
 
Consent Process – see Section 14 of the e-IRB submission form and complete the 
questions in that section.   
 
Dr. Sharon Fekrat (Principal Investigator) or other IRB listed staff for this project will 
conduct the consent process prior to enrolling subjects. Each portion of the consent will 
be reviewed with the subject with ample time provided to the subject for 
discussions/questions prior to enrolling onto the study. A copy of the consent will be 
given to the subject if they choose to participate.  
Patients with poor vision will have the consent form read to them in the presence of an 
impartial witness.   
 
Subject’s Capacity to Give Legally Effective Consent: 
 
Only subjects able to understand the informed consent process and with legal capacity 
to give consent will be included in the study.  
 
Study Interventions: 
 
There will be no study interventions apart from those described in #4 above.  
 
Risk/Benefit Assessment: 
 
While these patients will have significantly limited vision due to exceedingly advanced 
macular degeneration, the study poses certain risks to the patient. There is a low but 
serious risk of inoculation of the eye with an infectious organism. The risk of 
endophthalmitis from aqueous paracentesis has not been published or studied, 
however is much lower than that of a vitreous tap or intravitreal injection, which has a 
low rate of endophthalmitis of 0.05% or less. The previously published studies of 
patients undergoing AC paracentesis for uveitis have reported a 0% rate of serious 
infection such as endophthalmitis.10,11  
 
Other risks to consider include bleeding due to pressure change or inadvertent damage 
to the ocular structures by the needle and leaking from the needle track. A corneal 

The Role of Alpha Melanocyte Stimulating Hormone (α-MSH) in Ocular Disease 
Dr. Sharon Fekrat 
8/13/18 Revision 
 
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scratch may also occur during this procedure. Precautions, such as cleaning of the eye 
prior to the procedure and antibiotic use after the procedure, will be taken to minimize 
these risks.  
 
We will additionally examine the anterior chamber 20 minutes post-procedure as most 
complications such as hyphema (bleeding in the eye), leak from the needle track, or 
corneal scratch would be apparent during this time frame.   
 
As the eyes that will be chosen for the study will be pseudophakic there will be no risk of 
cataract or trauma to the lens which is the most worried about complication of an 
aqueous tap.  
 
While study subjects will not receive immediate direct benefit, the data acquired may 
provide valuable information that will support the potential understanding and possible 
development of therapeutics in disease without current therapeutic options.  
 
Potential loss of confidentiality is a risk of any study however we will take every 
precaution to keep patient health information confidential.  
 
Costs to the Subject: 
 
There will be no financial costs to the subjects for study participation. However, the 
subject would remain responsible for the costs of their clinical care, which are 
independent of this study. 
 
Data Analysis & Statistical Considerations: 
 
At this stage, only quantitative analysis of alpha MSH levels will be performed.  
 
Data & Safety Monitoring:  
 
We do not anticipate that the risk for adverse events will be any higher than for other 
commonly performed aqueous paracentesis in the clinic setting. Specifically, we do not 
anticipate any adverse event as a result of study participation in the study as every 
precaution will be taken to decrease the risk of potential infection. Additionally, by 
including only patients who have had prior cataract surgery (pseudophakic) or no lens 
(aphakic), there is no risk for trauma to the lens or induction of a cataract. The PI’s 
contact information will be available to each enrolled subject should a late event occur. 
The investigator will review and sign off on all adverse events and problems as they 
occur and they will be reported to the IRB per Duke IRB policies.  
 
Privacy, Data Storage & Confidentiality – see Section 12 of the e-IRB submission form 
and complete the questions in that section.   

The Role of Alpha Melanocyte Stimulating Hormone (α-MSH) in Ocular Disease 
Dr. Sharon Fekrat 
8/13/18 Revision 
 
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Collected clinical data, including a single master list to relink the study ID to the subject, 
will be stored on password-protected, hard drive encrypted departmental computers in 
the Department of Ophthalmology. Data will be stored in the P:drive in a secured folder 
under the PIs name. Only the study staff will have access to these files.  
 
References: 
 
1.  
Taylor AW, Lee D. Applications of the Role of α-MSH in Ocular Immune Privilege. 
In: Advances in Experimental Medicine and Biology. Vol 681. ; 2010:143-149. 
doi:10.1007/978-1-4419-6354-3_12. 
2.  
Edling AE, Gomes D, Weeden T, et al. Immunosuppressive activity of a novel 
peptide analog of alpha-melanocyte stimulating hormone (α-MSH) in 
experimental autoimmune uveitis. J Neuroimmunol. 2011;236(1-2):1-9. 
doi:10.1016/j.jneuroim.2011.04.015. 
3.  
Varga B, Gesztelyi R, Bombicz M, et al. Protective Effect of Alpha-Melanocyte-
Stimulating Hormone (α-MSH) on the Recovery of Ischemia/Reperfusion (I/R)-
Induced Retinal Damage in A Rat Model. J Mol Neurosci. 2013;50(3):558-570. 
doi:10.1007/s12031-013-9998-3. 
4.  
Lee DJ, Taylor AW. Recovery from experimental autoimmune uveitis promotes 
induction of antiuveitic inducible Tregs. J Leukoc Biol. 2015;97(6):1101-1109. 
doi:10.1189/jlb.3A1014-466RR. 
5.  
Ru Y, Huang Y, Liu H, et al. α-Melanocyte-stimulating hormone ameliorates ocular 
surface dysfunctions and lesions in a scopolamine-induced dry eye model via PKA-
CREB and MEK-Erk pathways. Sci Rep. 2016;5(1):18619. doi:10.1038/srep18619. 
6.  
Clemson CM, Yost J, Taylor AW. Ocular Immunology and Inflammation The Role 
of Alpha-MSH as a Modulator of Ocular Immunobiology Exemplifies Mechanistic 
Differences between Melanocortins and Steroids The Role of Alpha-MSH as a 
Modulator of Ocular Immunobiology Exemplifies Mechanistic Differences 
between Melanocortins and Steroids. Ocul Immunol Inflamm. 2017;25(2):179-
189. doi:10.3109/09273948.2015.1092560. 
7.  
Naveh N. Melanocortins applied intravitreally delay retinal dystrophy in Royal 
College of Surgeons rats. Graefe’s Arch Clin Exp Ophthalmol. 2003;241(12):1044-
1050. doi:10.1007/s00417-003-0781-y. 
8.  
Cheng L, Cheng L, Bi H, et al. Alpha-melanocyte stimulating hormone protects 
retinal pigment epithelium cells from oxidative stress through activation of 
melanocortin 1 receptor–Akt–mTOR signaling. Biochem Biophys Res Commun. 
2014;443(2):447-452. doi:10.1016/j.bbrc.2013.11.113. 
9.  
Taylor AW, Streilein JW, Cousins SW. Identification of alpha-melanocyte 
stimulating hormone as a potential immunosuppressive factor in aqueous humor. 
Curr Eye Res. 1992;11(12):1199-1206. doi:10.3109/02713689208999545. 
10.  
Cheung CMG, Durrani OM, Murray PI. The safety of anterior chamber 
paracentesis in patients with uveitis. Br J Ophthalmol. 2004;88(4):582-583. 

The Role of Alpha Melanocyte Stimulating Hormone (α-MSH) in Ocular Disease 
Dr. Sharon Fekrat 
8/13/18 Revision 
 
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doi:10.1136/BJO.2003.027219. 
11.  
Van der Lelij A, Rothova A. Diagnostic anterior chamber paracentesis in uveitis: a 
safe procedure? Br J Ophthalmol. 1997;81(11):976-979.