Clinical and Genetic Assessment of Treatment Response in Patients With Age-related Macular Degeneration Using Intravitreal Aflibercept Injection
Phase: PHASE4
Conditions: Macular Degeneration, Wet Macular Degeneration
Sponsor: University of California, San Diego

 
 
 
 
 
EAGLE: Evaluating Genotypes Using Intravitreal Aflibercept Injection 
NCT: 02689518 
Document Date: February 21, 2019 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
 
 
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UCSD Human Research Protections Program 
New Biomedical Application 
RESEARCH PLAN 
Version date: February 7, 2018 (Version 6.0)  
1. 
PROJECT TITLE 
EAGLE: Evaluating Genotypes Using Intravitreal Aflibercept Injection  
 
2. 
PRINCIPAL INVESTIGATOR  
Michael Goldbaum, M.D. 
 
3. 
FACILITIES 
University of California, San Diego 
Shiley Eye Institute 
9415 Campus Point Drive, La Jolla, CA 92093 
 
 
Biomedical Research Facility 2 
Osler Lane #4186, La Jolla, CA 92093 
 
Retina Consultants San Diego  
12630 Monte Vista Road, Suite#104 
Poway, CA 92064 
 
4. 
ESTIMATED DURATION OF THE STUDY 
12 months is the study duration. From start of recruitment to last subject’s final visit is estimated to be 
approximately 4 years (approximately 3 years to recruit, 1 year duration, last subject to end 1 year 
later estimated December 2017). 
 
5. 
LAY LANGUAGE SUMMARY OR SYNOPSIS (no more than one paragraph) 
The purpose of this study is to determine if known elements of an individual’s genetic makeup has 
any effect on his or her individual anatomical response to Eylea® (aflibercept). In addition to 
characterizing the subject’s response using measurements of central retinal thickness and presence 
of retinal fluid (as measured by optical coherence tomography), we will also be comparing individual 
visual acuity, presence of angiographic lesions, and number of injections accrued over the 12 months 
of participation.  
 
6. 
SPECIFIC AIMS 
This project will provide important information on inherent VEGF risk and the likelihood of intravitreal 
aflibercept injection treatment efficacy for AMD patients.  This project will also be signal seeking to 
see if different genetic polymorphisms correlate with treatment outcomes.   
 
Primary Endpoints 
Correlation of CFH, HTRA1, VEGFA, C3, TIMP3, APOE, CETP, LIPC, TGFBR1, CFI, and 
CFB allele frequencies and VEGFA expression in lymphoblastoid cell lines with response to 
intravitreal aflibercept injection treatment, based on anatomic outcomes: 
 
Early response (at Month 3; on SD-OCT) as compared to outcomes collected at the 
Screening Visit- 
o Reduction in central retinal thickness by > 50%, OR 

 
 
 
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o Central retinal thickness < 300um, OR 
o Absence of retinal fluid  
 
Later response (at Month 12; on SD-OCT) as compared to outcomes collected at the 
Screening Visit - 
o Reduction in central retinal thickness by > 50%, OR 
o Central retinal thickness < 300um, OR 
o Absence of retinal fluid  
 
Poor response, defined as no reduction of fluid, or central retinal thickness at Month 
12 as compared to outcomes collected at the Screening Visit 
 
Secondary Endpoints  
Correlation of CFH, VEGF and HTRA1, CFH, HTRA1, VEGFA, C3, TIMP3, APOE, CETP, 
LIPC, TGFBR1, CFI, and CFB allele frequencies: 
 
With visual outcomes as compared to outcomes collected at the Screening Visit – 
o Early response, defined as gain > 0 letters at Month 3 
o Later response, defined as gain > 0 letters at Month 12 
o Poor response, defined as loss of visual acuity (gain < 0 letters) at Month 12  
 
With change in angiographic characteristics on fluorescein angiography and/or OCT 
(lesion size, lesion type, etc) as compared to outcomes collected at the Screening Visit 
 
With number of injections through Month 12 
o Mean number of intravitreal aflibercept injection injections required through 
Month 12 will be calculated for the overall group, and separately by response 
group (early, later, and no response to treatment). 
 
Safety evaluation 
Incidence and severity of ocular and non-ocular adverse events will be evaluated. 
 
7. 
BACKGROUND AND SIGNIFICANCE 
Age-related macular degeneration (AMD) is a progressive disease that causes irreversible visual 
impairment and blindness in nearly 50 million people globally.  Current estimates of patients affected 
with AMD are higher than those affected by Alzheimer’s disease.  Although geographic atrophy and 
neovascularization represent the advanced forms of AMD, neovascular AMD is the more aggressive 
form and accounts for almost 90% of blindness from this disease.  It is characterized by choroidal 
neovascularization (CNV), which is the development of abnormal blood vessels underneath the 
retina. Recent randomized clinical trials (VIEW 1, VIEW 2) have conclusively demonstrated that 
continued intravitreal therapy with Intravitreal aflibercept injection in patients with subfoveal CNV from 
AMD leads to stabilization of vision in over 90% of patients and improvement in vision in at least a 
third of the patients and has led to the approval of Intravitreal aflibercept injection (2.0 mg) for the 
treatment of neovascular AMD.  Both Intravitreal aflibercept injection treatment arms (Intravitreal 
aflibercept injection 2 mg administered every 8 weeks following 3 initial monthly doses, or Q 4 weeks 
following 3 initial monthly doses) were shown to have efficacy that was clinically equivalent to existing 
therapy[1].  
 
Vascular endothelial growth factor (VEGF)’s mRNA and protein levels are elevated in individuals with 
the neovascular form of ocular diseases such as diabetic retinopathy and AMD. Despite empirical 
success in treating wet AMD patients with anti-VEGF drugs, the basic pathogenic mechanisms 
remain largely unknown. VEGFA gene serves as a good candidate for testing pharmacogenetic 
relationships between genotypes and therapy outcomes. VEGFA has been reported as a 

 
 
 
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predisposing gene to AMD [2-4], yet there have been few studies investigating the association 
between VEGFA genotypes and response to anti-VEGF therapy. A recent meta-analysis 
investigating the genetic susceptibility of AMD demonstrated that VEGFA-rs943080 is in strong 
linkage disequilibrium (LD) with rs4711751 (r2 = 1.0 in 1000 Genomes CEU data), which is 
significantly associated with advanced AMD ([OR=1.15 (95% CI: 1.10-1.21), P = 8.7x10-9])[3]. In 
preliminary work, we investigated whether there is an association between the response to anti-
VEGF treatment for neovascular AMD and the VEGFA gene, clinical characteristics, demographic 
factors, or comorbidities. We described a significant association between response to anti-VEGF 
therapy and the VEGFA-rs943080 variant. For the rs943080 polymorphism, the poor-responder 
group had a higher frequency of the T allele and TT genotype than the responder group. Lymphocyte 
cells with the VEGFA rs943080 TT genotype had a higher VEGFA expression than cells with the 
VEGFA rs943080 CC genotype, suggesting that VEGFA expression is associated with response to 
anti-VEGF therapy in neovascular AMD (6).  Additionally, we have recently demonstrated that 
nucleotide polymorphisms (SNP) and a haplotype in region of HTRA1 is a major risk factor for 
neovascular AMD. The HTRA1 gene encodes a secreted serine protease. Our study indicates a key 
role for HTRA1 in AMD susceptibility, and identifies a new pathway for neovascular AMD 
pathogenesis[5].  We will investigate the efficacy of Intravitreal aflibercept injection therapy relative to 
CFH, HTRA1, VEGFA, C3, TIMP3, APOE, CETP, LIPC, TGFBR1, CFI, and CFB and other AMD 
candidate gene status.  
 
Patient response to intravitreal aflibercept injection treatment is heterogeneous and currently not well 
understood. Recent data by several independent laboratories suggest that genetic polymorphisms 
affecting VEGF activity or expression may contribute to wet AMD pathogenesis. This will likely 
contribute to heterogeneity in anti-VEGF treatment responses.  HTRA1 has also been recently 
demonstrated to play an important role in neovascular AMD and is expressed in retinal vasculature 
as well. The goal of our study is to identify genetics determinants of anti-VEGF response. 
 
 
8. 
PROGRESS REPORT 
Not available at this time. 
 
9. 
RESEARCH DESIGN AND METHODS 
This is a phase IV, multicenter, open-label study of 100 treatment-naïve (study eye only) neovascular 
wet-AMD patients treated on-label with intravitreally administered aflibercept injection. Their blood 
will be genotyped and sequenced for various SNPs on VEGF and HTRA1 and other AMD candidate 
genes.  
 
 
V1 
V2 
V3 
V4 
V5 
V6 
V7 
V8 
V9 
V10 V11 V12 
V13 
 
D 0 
M 1 
M 2 
M 3 
M 4 
M 5 
M 6 
M 7 
M 8 
M 9 
M 
10 
M 
11 
M 12/ 
Early 
Term 
 
 
+7 
day
s 
+7 
day
s 
+7 
day
s 
+7 
day
s 
+7 
day
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+7 
day
s 
+7 
day
s 
+7 
day
s 
+7 
day
s 
+7 
day
s 
+7 
day
s 
+7 days 
Informed 
Consent 
X 
 
 
 
 
 
 
 
 
 
 
 
 
Initial Medical 
and Ocular 
History 
X 
 
 
 
 
 
 
 
 
 
 
 
 

 
 
 
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Demographic 
Data 
X 
 
 
 
 
 
 
 
 
 
 
 
 
ETDRS BCVA 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Slit Lamp Exam 
inc IOP 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Dilated Fundus 
Exam 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
OCT 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Fluorescein 
angiography 
X 
 
 
 
 
 
 
 
 
 
 
 
 
Blood draw 
X1 
 
 
 
 
 
 
 
 
 
 
 
 
Intravitreal 
Injection 
X 
X 
X 
X2 
X 
X2 
X 
X2 
X 
X2 
X 
X2 
 
Adverse Events 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
Procedures and assessments  
At baseline and all monthly visits:  
 Manifest refraction and best corrected visual acuity test using 4m ETDRS chart and standard 
trial lenses 3 
 Intraocular pressure test using Goldmann’s Applanation Tonometry or Tono-penTM    
 Optical coherence tomography 
 Dilated binocular indirect high magnification ophthalmoscopy  
 Slit lamp examination 
At baseline only: 
 Fluorescein angiography  
 
Treatment 
Intravitreal aflibercept injection 2 mg (0.05 mL) will be administered every 4 weeks for the first 3 
months, followed by 2 mg (0.05 mL) intravitreal injections once every 8 weeks (2 months) with the 
option to treat monthly based on retreatment criteria for a total duration of 12 months.  
 
10. 
HUMAN SUBJECTS 
Approximately 100 treatment- naïve wet-AMD patients will be recruited across the study sites.  
 
Inclusion Criteria  
A patient must meet the following criteria to be eligible for inclusion in the study: 
1. Age ≥ 50 years 
2. Naïve neovascular wet-AMD  
3. Willing and able to comply with clinic visits and study-related procedures 
4. Provide signed informed consent 
 
Exclusion Criteria 
A patient who meets any of the following criteria will be excluded from the study: 
                                                          
1 May be performed once, at any point during study participation. 
2 Per pre-defined criteria as outlined by study protocol. 
3 If manifest refraction and best corrected visual acuity test using 4m ETRS chart and standard trial lenses is not conducted during the Screening Visit, best 
corrected visual acuity measurement from the most recent clinical visit after diagnosis of neovascular-AMD may be used. 

 
 
 
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1. Previous therapy in study eye for AMD or other retinal disease which may be used in the treatment 
of AMD 
2. Previous subfoveal focal laser photocoagulation involving the foveal center in the study eye 
3. History of vitrectomy, submacular surgery, or other surgical intervention for AMD in the study eye 
4. Any concurrent intraocular condition in the study eye (e.g. diabetic retinopathy or glaucoma) that, in 
the opinion of the investigator, could either  
4.1 
Require medical or surgical intervention during the study period to prevent or treat visual 
loss that might result from that condition, or  
4.2 
If allowed to progress untreated, could likely contribute to loss of at least 2 Snellen 
equivalent lines of best corrected visual acuity over the study period 
5. Active intraocular inflammation (grade trace or above) in the study eye, or history of idiopathic or 
autoimmune-associated uveitis in either eye 
6. Current vitreous hemorrhage in the study eye 
7. History of rhegmatogenous retinal detachment or macular hole (Stage 3 or 4) in the study eye 
8. Active infectious conjunctivitis, keratitis, scleritis, or endophthalmitis in either eye 
9. Aphakia, ACIOL, or unstable PCIOL 
10. Uncontrolled glaucoma in the study eye (defined as intraocular pressure ≥30 mmHg despite 
treatment with anti-glaucoma medication) 
11. Pregnant or breast-feeding women 
12. Sexually active men4 or women of childbearing potential5 who are unwilling to practice adequate 
contraception during the study (adequate contraceptive measures include stable use of oral 
contraceptives or other prescription pharmaceutical contraceptives for 2 or more menstrual cycles 
prior to screening; intrauterine device [IUD]; bilateral tubal ligation; vasectomy; condom plus 
contraceptive sponge, foam, or jelly, or diaphragm plus contraceptive sponge, foam, or jelly) 
13. Any other condition that the investigator believes would pose a significant hazard to the patient if 
the investigational therapy were initiated  
 
*Contraception is not required for men with documented vasectomy. 
**Postmenopausal women must be amenorrheic for at least 12 months in order not to be considered of 
child bearing potential.  Pregnancy testing and contraception are not required for women with 
documented hysterectomy or tubal ligation. 
 
11. 
RECRUITMENT AND PROCEDURES PREPARATORY TO RESEARCH 
Potential subjects will be identified through their routine appointments at the Shiley Eye Institute and 
at the VASDHS, at which the physicians also hold clinical privilege. They will be invited to participate 
by their physician during their appointment.  
 
 
Potential subjects will be identified through the same manner at the subsites participation in this 
study.  
 
12. 
INFORMED CONSENT 
A study consent form along with the HIPAA authorization that will be used is submitted with this 
application.  
 
Informed consent for the study proposed here will be obtained prior to subject participation by trained 
study coordinators. The subject will be given an opportunity to read the consent form and to have 
                                                          
4 Contraception is not required for men with documented vasectomy. 
5 Postmenopausal women must be amenorrheic for at least 12 months in order not to be considered of child-bearing potential. Pregnancy testing and 
contraception are not required for women with documented hysterectomy or tubal ligation. 

 
 
 
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their questions answered. The study and all its elements will be carefully described to the potential 
subject. The subject is asked if he/she assents to the study. Informed consent will be documented by 
the signatures of the subject, and the subject will receive a copy of the signed consent, the HIPAA 
authorization, and of the Human Subjects’ Bill of Rights. 
 
If the subject dissents, all potential participation is void.   
 
13. 
ALTERNATIVES TO STUDY PARTICIPATION 
The alternative to participating in the study is to not participate in this study. 
 
14. 
POTENTIAL RISKS 
Eye Examination 
The risks of the eye examination are no different than they would be on a routine visit to the 
ophthalmologist. The drops used to dilate the pupils may sting temporarily and cause blurry vision, 
increased light sensitivity and glare in bright light, allergic reaction, and may in rare instances, cause 
a type of glaucoma for which prompt treatment is needed. The pupils may remain dilated for 4-6 
hours. 
 
 
Intravitreal Injection  
The risks of receiving Eylea® treatment or eye exams during this study are no different than they 
would be if prescribed outside the study. The safety and tolerability of intravitreal Eylea® injections 
have been investigated in previous Phase I, I/II, III, and IIIb studies in AMD. Potential safety issues 
associated with the route of administration or the pharmacology of Eylea® in the study population 
include decreased BCVA, pain at the injection site, intraocular inflammation, intraocular infection, 
transient and/or sustained elevation of intraocular pressure (IOP), cataract development or 
progression, retinal or intravitreal hemorrhage, macular edema, retinal break or detachment, and 
arterial thromboembolic events (ATEs). Adverse events that should be considered ATEs include, but 
are not limited to, myocardial infarction and cerebrovascular accident (ischemic and hemorrhagic). 
 
Blood Draw and Fluorescein Angiography 
The blood draw may cause slight discomfort and may result in a temporary bruise at the needle site, 
and rarely the possibility of infection. Also, subjects may faint in response to blood draw. The same 
risks apply to fluorescein angiography, in which a dye is injected into a patient’s vein. The most 
common side effects of this dye are nausea and vomiting; however, occasional allergic reactions and 
fainting may occur.  A severe allergic reaction would require immediate medical treatment and could 
result in permanent disability or death. Patients will be carefully observed during this procedure to 
minimize the risk to patient health. 
 
Confidentiality  
There is also the potential risk of loss of patient confidentiality. It is conceivable that patients may be 
placed at a disadvantage if employers or potential insurers gain access to genetic or other health 
information.  Many precautions will be taken to protect this information.   
 
15. RISK MANAGEMENT PROCEDURES AND ADEQUACY OF RESOURCES 
Blood Draw  
Blood will be drawn by trained study personnel.  
 
Intravitreal Injection  

 
 
 
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In order to safely monitor these risks, the following procedures will be followed: Following each 
intravitreal injection of Eylea®, a finger counting test will be performed for each patient after each 
injection by the physician; hand motion and light perception will be tested when necessary. IOP will 
be measured 15-30 minutes after each injection. If post-injection IOP increases ≥ 10 mmHg 
compared with the pre-injection measurement, then the IOP measurement will be performed again at 
60 (±10) minutes. If there are no safety concerns up to 60 (±10) minutes following an injection, 
patients will be allowed to leave the clinic. If any safety concern or immediate toxicity is noted, the 
patient will remain at the clinic and will be treated according to the designated physician’s clinical 
judgment. 2-7 days after each study drug treatment, the patient will be contacted by telephone by 
study staff and asked whether or not any eye pain, unusual redness, a decrease in vision, or other 
new eye problems have occurred. If any of these symptoms have occurred, the study 
ophthalmologist may decide that the patient should come to the clinic for additional eye examinations 
and treatment, if necessary. 
 
Study drug administration will be held at the investigator’s discretion if he or she suspects any safety 
or other issues. If the investigator decides to hold a dose, the reason will be recorded on the source 
documents. In the event a subject experiences an adverse event in the study eye that is considered 
by the investigator to be severe in intensity or serious in nature, consideration should be given to 
holding treatment or discontinuing the patient from study treatment. This decision will be at the 
investigator’s discretion and should be recorded on the source documents. 
 
Early Withdrawal  
Patients withdrawn from the study prior to completion will be asked to return for an early termination 
evaluation 30 days ( ± 7 days) following their last injection for monitoring of all adverse events 
(serious and non-serious; ocular and non-ocular) as well as for final study visit assessments.  
 
  
16. PRIVACY AND CONFIDENTIALITY CONSIDERATIONS INCLUDING DATA ACCESS AND MANAGEMENT 
Patients are evaluated in a private room in regular clinic. Access to the patient is limited by the study 
physician. In order to maintain subject privacy, all study personnel will not share information with 
patients about their care or progress unless they are in a private, secure area.  Patient information in 
paper form is kept in locked filing cabinets. All electronic information is kept on password-protected 
computers. Patient identifiers are removed and arbitrary numbers are assigned to materials that are 
shared with sources involved in the study. In order to maintain patient confidentiality any person who 
has access to or maintains patient records will ensure that confidentiality will be maintained at all 
times by keeping all records under their control or in locked cabinets.  All study staff are HIPAA 
trained. 
 
 
17. POTENTIAL BENEFITS 
This study primarily benefit researchers and the field of Ophthalmology with a better understanding of  
AMD pathogenesis.  Patients who participate in the study will receive ophthalmological care and an 
investigational drug, which may or may not result in a benefit to their ocular health.  
 
18. RISK/BENEFIT RATIO 
The risks of receiving Eylea® treatment during this study are no different than they would be if your 
doctor prescribed it for you outside the study.  Soreness or bruising at the site of needle insertion 
may occur at the needle site, and rarely the possibility of infection.   
 

 
 
 
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19. EXPENSE TO PARTICIPANT 
This study will not involve any expense to the participant. 
 
20. COMPENSATION FOR PARTICIPATION 
This study will not involve any compensation for the participant. 
 
21. PRIVILEGES/CERTIFICATIONS/LICENSES AND RESEARCH TEAM RESPONSIBILITIES 
All clinical procedures will be performed by Shiley Eye Institute physicians (Drs. Goldbaum, Zhang 
and Ferreyra) and research/clinic staff who are licensed or certified to perform their applicable tasks 
(including visual acuity examiners and photographers).  Administrative tasks, blood draws and many 
other research-related tests will be performed by the trained research coordinators. 
 
At the subsite: Dr. Tornambe has a current medical license and privilege at his respective institution. 
 
Cindy Wen and Megan Lyons will be the study coordinators, at the Shiley Eye Institute with technical 
and administrative roles. 
 
22. BIBLIOGRAPHY 
1. 
Heier, J.S., et al., Intravitreal aflibercept (VEGF trap-eye) in wet age-related macular degeneration. 
Ophthalmology. 119(12): p. 2537-48. 
2. 
Lin, J.M., et al., Vascular endothelial growth factor gene polymorphisms in age-related macular 
degeneration. Am J Ophthalmol, 2008. 145(6): p. 1045-1051. 
3. 
Yu, Y., et al., Common variants near FRK/COL10A1 and VEGFA are associated with advanced age-
related macular degeneration. Hum Mol Genet. 20(18): p. 3699-709. 
4. 
McKibbin, M., et al., CFH, VEGF and HTRA1 promoter genotype may influence the response to 
intravitreal ranibizumab therapy for neovascular age-related macular degeneration. Br J Ophthalmol. 
96(2): p. 208-12. 
5. 
Yang, Z., et al., A variant of the HTRA1 gene increases susceptibility to age-related macular 
degeneration. Science, 2006. 314(5801): p. 992-3. 
6. 
Zhao, L, Grob, S, Avery, Kimura, Pieramici, D, Lee, J, Rabena, M, Hughes, G, Ortiz, S, Tornambe, P, 
Goldbaum, M, Ferreyra, H, Kozak, I, and Zhang, 
 K.(2013). Common Variant in VEGFA and Response 
to Anti-VEGF Therapy for Exudative Age-Related Macular Degeneration. Current Molecular Medicine, 
 2013 Jun 4. [Epub ahead of print]. 
 
 
 
23. FUNDING SUPPORT FOR THIS STUDY 
This is an investigator-initiated trial funded by Regeneron Pharmaceuticals, Inc. through UCSD Office 
of Contracts and Grants Administration (OCGA). 
 
24. BIOLOGICAL MATERIALS TRANSFER AGREEMENT 
Not applicable. 
 
25. INVESTIGATIONAL DRUG FACT SHEET AND IND/IDE HOLDER 
See attached investigational drug fact sheet and investigator brochure for study drug aflibercept.  
 
26. IMPACT ON STAFF 
The research staff, including the study coordinators, will perform the majority of tasks involved in 
clinical visits.  Ophthalmic technicians may assist with certain procedures, but not to the extent that 
regular clinics will be inconvenienced or delayed in any way. 

 
 
 
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27. CONFLICT OF INTEREST 
Conflict of interest forms have been submitted to the clinical trials office. Neither Dr. Goldbaum nor 
the co-investigators have financial relationships with the sponsor. 
 
28. SUPPLEMENTAL INSTRUCTIONS FOR CANCER-RELATED STUDIES 
Not applicable. 
 
29. OTHER APPROVALS/REGULATED MATERIALS 
Not applicable. 
 
30. PROCEDURES FOR SURROGATE CONSENT AND/OR DECISIONAL CAPACITY ASSESSMENT 
No surrogate consent will be sought for this study. 
 
 
 
Version date: May 11, 2011