Abstract

Age-related macular degeneration (AMD) remains a major cause of blindness, with dysfunction and loss of retinal pigment epithelium (RPE) central to disease progression. We engineered an RPE patch comprising a fully differentiated, human embryonic stem cell (hESC)–derived RPE monolayer on a coated, synthetic basement membrane. We delivered the patch, using a purpose-designed microsurgical tool, into the subretinal space of one eye in each of two patients with severe exudative AMD. Primary endpoints were incidence and severity of adverse events and proportion of subjects with improved best-corrected visual acuity of 15 letters or more. We report successful delivery and survival of the RPE patch by biomicroscopy and optical coherence tomography, and a visual acuity gain of 29 and 21 letters in the two patients, respectively, over 12 months. Only local immunosuppression was used long-term. We also present the preclinical surgical, cell safety and tumorigenicity studies leading to trial approval. This work supports the feasibility and safety of hESC-RPE patch transplantation as a regenerative strategy for AMD.

Access optionsAccess options

Rent or Buy article

Get time limited or full article access on ReadCube.

from$8.99

All prices are NET prices.

References

  1. 1.

    Human embryonic stem cells: early hints on safety and efficacy. Lancet 379, 689–690 (2012).

  2. 2.

    et al. Development of human embryonic stem cell therapies for age-related macular degeneration. Trends Neurosci. 36, 385–395 (2013).

  3. 3.

    et al. Stem cell based therapies for age-related macular degeneration: The promises and the challenges. Prog. Retin. Eye Res. 48, 1–39 (2015).

  4. 4.

    et al. Developing cellular therapies for retinal degenerative diseases. Invest. Ophthalmol. Vis. Sci. 55, 1191–1202 (2014).

  5. 5.

    & Understanding age-related macular degeneration (AMD): relationships between the photoreceptor/retinal pigment epithelium/Bruch's membrane/choriocapillaris complex. Mol. Aspects Med. 33, 295–317 (2012).

  6. 6.

    et al. Ranibizumab for neovascular age-related macular degeneration. N. Engl. J. Med. 355, 1419–1431 (2006).

  7. 7.

    et al. Adaptive optics imaging shows rescue of macula cone photoreceptors. Ophthalmology 121, 430–431.e3 (2014).

  8. 8.

    et al. Human embryonic stem cell-derived retinal pigment epithelium in patients with age-related macular degeneration and Stargardt's macular dystrophy: follow-up of two open-label phase 1/2 studies. Lancet 385, 509–516 (2015).

  9. 9.

    et al. Autologous induced stem-cell-derived retinal cells for macular degeneration. N. Engl. J. Med. 376, 1038–1046 (2017).

  10. 10.

    et al. Elucidating the phenomenon of HESC-derived RPE: anatomy of cell genesis, expansion and retinal transplantation. Exp. Neurol. 214, 347–361 (2008).

  11. 11.

    et al. In vitro and in vivo characterization of pigment epithelial cells differentiated from primate embryonic stem cells. Invest. Ophthalmol. Vis. Sci. 45, 1020–1025 (2004).

  12. 12.

    International Stem Cell Initiative. et al. Characterization of human embryonic stem cell lines by the International Stem Cell Initiative. Nat. Biotechnol. 25, 803–816 (2007).

  13. 13.

    et al. Derivation and comparative assessment of retinal pigment epithelium from human embryonic stem cells using transcriptomics. Cloning Stem Cells 6, 217–245 (2004).

  14. 14.

    et al. Directed differentiation of human embryonic stem cells into functional retinal pigment epithelium cells. Cell Stem Cell 5, 396–408 (2009).

  15. 15.

    , & The derivation of clinical-grade human embryonic stem cell lines. FEBS Lett. 580, 2875–2878 (2006).

  16. 16.

    et al. Restriction landmark genome scanning identifies culture-induced DNA methylation instability in the human embryonic stem cell epigenome. Hum. Mol. Genet. 16, 1253–1268 (2007).

  17. 17.

    et al. Human embryonic stem cell-derived cells rescue visual function in dystrophic RCS rats. Cloning Stem Cells 8, 189–199 (2006).

  18. 18.

    & Fundus autofluorescence and RPE lipofuscin in age-related macular degeneration. J. Clin. Med. 3, 1302–1321 (2014).

  19. 19.

    , , & (eds.) The Atlas of Fundus Autofluorescence Imaging (Springer, 2007).

  20. 20.

    et al. Submacular Surgery Trials (SST) Research Group. Surgery for hemorrhagic choroidal neovascular lesions of age-related macular degeneration: ophthalmic findings: SST report no. 13. Ophthalmology 111, 1993–2006 (2004).

  21. 21.

    , & The effect of injection using narrow-bore needles on mammalian cells: administration and formulation considerations for cell therapies. J. Pharm. Pharmacol. 67, 640–650 (2015).

  22. 22.

    , & Reengineering of aged Bruch's membrane to enhance retinal pigment epithelium repopulation. Invest. Ophthalmol. Vis. Sci. 45, 3337–3348 (2004).

  23. 23.

    et al. Subretinal implantation of retinal pigment epithelial cells derived from human embryonic stem cells: improved survival when implanted as a monolayer. Invest. Ophthalmol. Vis. Sci. 54, 5087–5096 (2013).

  24. 24.

    et al. Retinal pigment epithelium translocation after choroidal neovascular membrane removal in age-related macular degeneration. Ophthalmology 109, 1492–1498 (2002).

  25. 25.

    , , , & A free retinal pigment epithelium-choroid graft in patients with exudative age-related macular degeneration: results up to 7 years. Am. J. Ophthalmol. 153, 120–7 e2 (2012).

  26. 26.

    et al. Long-term visual and microperimetry outcomes following autologous retinal pigment epithelium choroid graft for neovascular age-related macular degeneration. Clin. Experiment. Ophthalmol. 37, 275–285 (2009).

  27. 27.

    , , , & Retinal pigment epithelium-choroid graft with a peripheral retinotomy for exudative age-related macular degeneration: long-term outcome. Retina doi: 10.1097/IAE.0000000000001945 (2017).

  28. 28.

    , , & Surgery for CNV and autologous choroidal RPE patch transplantation: exposing the submacular space. Graefes Arch. Clin. Exp. Ophthalmol. 248, 37–47 (2010).

  29. 29.

    et al. New algorithm for assessing patient suitability for macular translocation surgery. Clin. Experiment. Ophthalmol. 35, 448–457 (2007).

  30. 30.

    , & Long-term outcome of RPE allografts in non-immunosuppressed patients with AMD. Eur. J. Ophthalmol. 9, 217–30 (1999).

  31. 31.

    et al. Morphological and functional rescue in RCS rats after RPE cell line transplantation at a later stage of degeneration. Invest. Ophthalmol. Vis. Sci. 49, 416–421 (2008).

  32. 32.

    et al. Long-term safety and function of RPE from human embryonic stem cells in preclinical models of macular degeneration. Stem Cells 27, 2126–2135 (2009).

  33. 33.

    & Macular translocation with 360 degree retinotomy for management of age-related macular degeneration with subfoveal choroidal neovascularization. Am. J. Ophthalmol. 134, 560–565 (2002).

  34. 34.

    et al. A comparison of macular translocation with patch graft in neovascular age-related macular degeneration. Invest. Ophthalmol. Vis. Sci. 50, 1848–1855 (2009).

  35. 35.

    , & Derivation of GMP raw materials for use in regenerative medicine: hESC-based therapies, progress toward clinical application. Clin. Pharmacol. Ther. 82, 448–452 (2007).

  36. 36.

    et al. Molecular characterization and functional analysis of phagocytosis by human embryonic stem cell-derived RPE cells using a novel human retinal assay. Mol. Vis. 15, 283–295 (2009).

  37. 37.

    & Analysis of photoreceptor outer segment phagocytosis by RPE cells in culture. Methods Mol. Biol. 935, 285–295 (2013).

  38. 38.

    et al. Rescue of the MERTK phagocytic defect in a human iPSC disease model using translational read-through inducing drugs. Sci. Rep. 7, 51 (2017).

Download references

Acknowledgements

We acknowledge H. Moore, Stem Cell Derivation Facility, Centre for Stem Cell Biology (CSCB), University of Sheffield for derivation of the original SHEF-1 hESC line and P. Keane and M. Cheetham for comments on the paper. We thank R. McKernan for support and input throughout the project. L.d.C. and P.J.C. received the following grants and donations and would like to acknowledge that they were used to fund the studies reported in this article: Anonymous Donor, USA, Establishment of The London Project to Cure Blindness - Donation. Lincy Foundation, USA, The London Project To Cure Blindness: Funding Towards The Production Of A Cell Based Therapy For Late Stage Age-Related Macular Degeneration - P12761. Macular Disease Society Studentship – Donation. MRC, Stem Cell Based Treatment Strategy For Age-Related Macular Degeneration (AMD) - G1000730. CIRM (California Institute of Regenerative Medicine) LA1_C2-02086. Pfizer Inc, The Development Plan For A Phase I/IIa Clinical Trial Implanting HESC Derived RPE for AMD - PF-05406388. Moorfields Biomedical Research Centre, National Institute for Health Research (NIHR) - BRC2_011. The Michael Uren Foundation R170010A.

Author information

Affiliations

  1. The London Project to Cure Blindness, ORBIT, Institute of Ophthalmology, University College London (UCL), London, UK.

    • Lyndon da Cruz
    • , Kate Fynes
    • , Odysseas Georgiadis
    • , Yvonne H Luo
    • , Ahmad Ahmado
    • , Britta Nommiste
    • , Shazeen M Hasan
    • , Sakina B Gooljar
    • , Amanda-Jayne F Carr
    • , Anthony Vugler
    • , Conor M Ramsden
    •  & Peter J Coffey
  2. NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust, UCL Institute of Ophthalmology, London, UK.

    • Lyndon da Cruz
    • , Odysseas Georgiadis
    • , Yvonne H Luo
    • , Adnan Tufail
    • , Anthony G Robson
    • , Graham E Holder
    • , Mandeep S Sagoo
    •  & Peter J Coffey
  3. Moorfields Eye Hospital NHS Foundation Trust, London, UK.

    • Lyndon da Cruz
    • , Odysseas Georgiadis
    • , Yvonne H Luo
    • , Conor M Ramsden
    • , Adnan Tufail
    • , Anthony G Robson
    • , Graham E Holder
    •  & Mandeep S Sagoo
  4. Wellcome/EPSRC Centre for Interventional & Surgical Sciences (WEISS), Charles Bell House, London, UK.

    • Lyndon da Cruz
  5. Pfizer, Granta Park, Cambridge, UK.

    • Julie Kerby
    • , Magda Bictash
    • , Mike Fenster
    • , Juliette Steer
    • , Tricia Harbinson
    • , Anna Wilbrey
    • , Gang Feng
    • , Mark Whitlock
    • , Peter T Loudon
    •  & Paul Whiting
  6. Cell and Gene Therapy Catapult, London, UK.

    • Julie Kerby
  7. Cells for Sight, Transplantation & Research Program, UCL Institute of Ophthalmology, London, UK.

    • Amanda Vernon
    •  & Julie T Daniels
  8. UCL Institute of Neurology, Queen Square, London, UK.

    • Paul Whiting
  9. Center for Stem Cell Biology and Engineering, NRI, UC, Santa Barbara, California, USA.

    • Peter J Coffey

Authors

  1. Search for Lyndon da Cruz in:

  2. Search for Kate Fynes in:

  3. Search for Odysseas Georgiadis in:

  4. Search for Julie Kerby in:

  5. Search for Yvonne H Luo in:

  6. Search for Ahmad Ahmado in:

  7. Search for Amanda Vernon in:

  8. Search for Julie T Daniels in:

  9. Search for Britta Nommiste in:

  10. Search for Shazeen M Hasan in:

  11. Search for Sakina B Gooljar in:

  12. Search for Amanda-Jayne F Carr in:

  13. Search for Anthony Vugler in:

  14. Search for Conor M Ramsden in:

  15. Search for Magda Bictash in:

  16. Search for Mike Fenster in:

  17. Search for Juliette Steer in:

  18. Search for Tricia Harbinson in:

  19. Search for Anna Wilbrey in:

  20. Search for Adnan Tufail in:

  21. Search for Gang Feng in:

  22. Search for Mark Whitlock in:

  23. Search for Anthony G Robson in:

  24. Search for Graham E Holder in:

  25. Search for Mandeep S Sagoo in:

  26. Search for Peter T Loudon in:

  27. Search for Paul Whiting in:

  28. Search for Peter J Coffey in:

Contributions

L.d.C., P.T.L., P.W., and P.J.C. designed all of the animal studies and the clinical study, developed the methodology for these studies, collected the data, performed the analysis, and wrote the manuscript. L.d.C. performed the pig and human surgery. K.F., J.K., A.A., A.Ve., J.T.D., B.N., S.M.H., S.B.G., A.-J.F.C., A.Vu., C.M.R., M.B., M.F., J.S., T.H., and A.W. developed, isolated, and prepared the hESC-RPE and performed the engineering of the hESC-RPE patch; and assisted in designing and conducting the mouse and pig studies, collecting the data, performing the analysis, and writing the manuscript. A.A. and A.Vu. performed the mouse surgery. O.G., Y.H.L., A.A., A.T., G.F., M.W., A.G.R., G.E.H. and M.S.S. assisted in designing the clinical study, developing the methodology, collecting the data, performing the analysis, and writing the manuscript.

Competing interests

J.K., M.B., M.F., J.S., T.H., G.F., M.W., P.T.L., and P.W. were all employees of Pfizer during the period of this clinical trial. This study was sponsored by Pfizer Inc. L.d.C. and P.J.C. are named on two patents lodged by University College London Business. They are Patent Application No. PCT/GB2009/000917 (for the patch) and International Patent Application No. PCT/GB2011/051262 (for the surgical tool).

Corresponding author

Correspondence to Lyndon da Cruz.

Integrated supplementary information

Supplementary information

About this article

Publication history

Received

Accepted

Published

DOI

https://doi.org/10.1038/nbt.4114

Further reading