Title: Gene therapy provides long-term visual function in a pre-clinical model of retinitis pigmentosa
Description: Retinitis pigmentosa (RP) is a photoreceptor neurodegenerative disease. Patients with RP present with the loss of their peripheral visual field, and the disease will progress until there is a full loss of vision. Approximately 36,000 cases of simplex and familial RP worldwide are caused by a mutation in the rod-specific cyclic guanosine monophosphate phosphodiesterase (PDE6) complex. However, despite the need for treatment, mouse models with mutations in the alpha subunit of PDE6 have not been characterized beyond 1 month of age or used to test the pre-clinical efficacy of potential therapies for human patients with RP caused by mutations in PDE6A. We first proposed to establish the temporal progression of retinal degeneration in a mouse model with a mutation in the alpha subunit of PDE6: the Pde6anmf363 mouse. Next, we developed a surgical technique to enable us to deliver therapeutic treatments into the mouse retina. We then hypothesized that increasing PDE6a levels in the Pde6anmf363 mouse model, using an AAV2/8 gene therapy vector, could improve photoreceptor survival and retinal function when delivered before the onset of degeneration.

Human RP patients typically will not visit an eye care professional until they have a loss of vision, therefore we further hypothesized that this gene therapy vector could improve photoreceptor survival and retinal function when delivered after the onset of degeneration, in a clinically relevant scenario. For each of these studies, we used histology, autofluorescence (AF) and infrared (IR) imaging to examine the appearance of the retinal cell layers and retinal pigment epithelium (RPE) that are affected in human RP patients. We also used electroretinograms (ERGs) to measure both photoreceptor-specific and global retinal visual function in the Pde6anmf363 mice. For our gene therapy experiments, we utilized a vector with the cell-type-specific rhodopsin (RHO) promoter: AAV2/8(Y733F)-Rho-Pde6a, to transduce Pde6anmf363 retinas after subretinal injection at either post-natal day (P) 5 or P21. We then monitored the effects of AAV2/8(Y733F)-Rho-Pde6a transduction over at least a quarter of the mouse lifespan.

In the Pde6anmf363 mutant mouse model of RP, we found that by 2 months of age the number of photoreceptor cell nuclei is roughly halved in comparison to the 1 month time-point, and this degeneration continues until all photoreceptor cell nuclei have undergone degeneration by 4 months of age. Additionally, both loss of cone cell function and RPE atrophy are present by 5 months of age in these mice. After the development of a subretinal injection surgical procedure, we delivered the AAV2/8(Y733F)-Rho-Pde6a to the Pde6anmf363 mice at either P5 or P21. We found that a single injection enhanced survival of photoreceptors and improved retinal function. At 6 months of age, the treated eyes retained photoreceptor cell bodies, while there were no detectable photoreceptors remaining in the untreated eyes. More importantly, the treated eyes demonstrated functional visual responses even after the untreated eyes had lost all vision. Despite focal rescue of the retinal structure adjacent to the injection site, global functional rescue of the entire retina was observed.

We have also determined that subretinal transduction of this rod-specific transgene at P21, when approximately half of the photoreceptor cells have undergone degeneration, has similar efficacy in rescuing cone cell function long-term as transduction before disease onset, at P5. Therefore, we concluded that the Pde6anmf363 mice mimic human RP caused by mutations in PDE6A. The establishment of the temporal and biochemical characteristics of photoreceptor neurodegeneration in the Pde6anmf363 mice allows for future studies to test therapeutic options using this animal model, since the progression of RP can be compared to the established time-course of degeneration. Additionally, the development of a standard method for performing subretinal injections allows for comparable results after this surgical technique is used to deliver gene therapy vectors into the perinatal mouse eye. Our gene therapy studies suggest that RP due to PDE6a deficiency in humans, in addition to PDE6b deficiency, is also likely to be treatable by gene therapy.

Furthermore, AAV2/8(Y733F)-Rho-Pde6a is an effective gene therapy treatment that can be utilized in the clinical setting, in human patients who have lost portions of their peripheral visual field and are in the mid-stage of disease when they first present to an eye-care professional.