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It could be considered for the treatment of a young patient whose high IOP would be a considerable burden for the rest of his or her life and who would have a significant chance of become blind. Recent advances in the generation of transgenic mice with myocilin mutations and elevated pressure could permit the development of an assay to assess the safety and efficacy of such vectors in gene therapy. In addition to the few genetically linked genes, numerous sequencing and gene profile studies have identified a set of 50 potentially relevant genes that we have termed the biomarkers or the molecular signature of glaucoma in the TM.
A perfused organ culture comprehensive study involving human genes whose expression is altered by elevated IOP revealed that both an individual and a general response were present in the human eye. These categories may well be a representation of the genes most likely to succeed in a gene therapy effort. The encouraging results mentioned earlier from the studies of an MMP1 viral vector lowering elevated IOP in sheep 12 , 13 confer a degree of confidence regarding the success of the project.
The first question that can be posed is whether we are ready to take a gene therapy vector to clinical trial for lowering IOP and for glaucoma treatment. There are several types of glaucoma: primary including juvenile open-angle glaucoma, congenital, pseudoexfoliation, and steroid. We cannot address all of these at the same time. We will achieve better results if we focus first on a particular type of glaucoma. Selection of targets.
We have good candidates. Selection of vector pseudotype and route of administration.
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Pseudotyping of the same virus or the ability to incorporate different targeting proteins in its envelope can significantly affect the tropism of the virus for a given cell type. Now that the general safety of the AAV vector has been established in the human so far, up to 4 years , 2 , 21 a few pretrial studies are needed to determine which of the various virus pseudotypes would be more specific for the TM. Further, the route of administration for the TM, whether by intravitreal or intracameral injection, must be validated. Control of transgene expression by gene regulatory elements. A long-term constitutive expression of a gene inside a cell may not always be beneficial.
The ideal gene drug should have built-in signals that would allow a gene to be turned on and off as needed. Ideally, these signals would be automatic—that is, directly switched on by a glaucomatous insult. They could also be induced by the oral intake of the inducer. Reliable animal efficacy evaluation procedures. Assays to determine the effects of gene delivery as well as visual function in animal models are critical.
Fortunately, the past 5 years have produced several instruments that assess, for the first time, the physiological parameters and noninvasive imaging morphometric determinations in rodent eyes. Among them are the rebound tonometer, a very recent aqueous humor dynamics apparatus 33 ; a pattern electroretinogram to measure function in RGCs; visual evoked potentials; and optical coherence tomography.
Validation in different animal models. Testing of the effect of the gene therapy vector, as with any conventional drug, would require the confirmation of the effect in more than one animal species. Again, during the past 2 to 3 years, the availability of TM animal models has been improving. The advantage of these strategies is the possibility of generating large animal models without the expense required in the creation of transgenic animals. Validation in different laboratories.
It is essential that researchers in different laboratories independently validate results. From the discussion of this plan by the panel of glaucoma investigators emerged the idea of forming a consortium among a few centers with the focused goal of moving toward the treatment of glaucoma by gene therapy.
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Disclosure: T. The number of people with glaucoma worldwide in and Br J Ophthalmol. Age-dependent effects of RPE65 gene therapy for Leber's congenital amaurosis: a phase 1 dose-escalation trial.
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Molecular and cell-based approaches for neuroprotection in glaucoma. Optom Vis Sci.
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Baculoviral IAP repeat-containing-4 protects optic nerve axons in a rat glaucoma model. Mol Ther. Effect of CNTF on retinal ganglion cell survival in experimental glaucoma. Invest Ophthalmol Vis Sci. Mol Vis. Hum Gene Ther. Gene transfer of dominant-negative RhoA increases outflow facility in perfused human anterior segment cultures. Intraocular pressure-lowering effects and safety of topical administration of a selective ROCK inhibitor, SNJ, in healthy volunteers.
Arch Ophthalmol. J Clin Invest. Development of a gene therapy virus with a glucocorticoid-inducible MMP1 for the treatment of steroid glaucoma. Treatment of sheep steroid-induced ocular hypertension with a glucocorticoid-inducible MMP1 gene therapy virus. Human and monkey trabecular meshwork accumulate alpha B-crystallin in response to heat shock and oxidative stress. Ocular gene delivery using lentiviral vectors.
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Gene Ther. Pigment epithelium-derived factor gene therapy targeting retinal ganglion cell injuries: neuroprotection against loss of function in two animal models. Prostaglandin pathway gene therapy for sustained reduction of intraocular pressure. Nanotechnology for ocular therapeutics and tissue repair. Expert Rev Ophthalmol.
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Functional delivery of synthetic naked siRNA to the human trabecular meshwork in perfused organ cultures. AAV2 Gene therapy readministration in three adults with congenital blindness. Sci Transl Med. Gene therapy for leber congenital amaurosis caused by RPE65 mutations: safety and efficacy in 15 children and adults followed up to 3 years. Self-complementary recombinant adeno-associated virus scAAV vectors promote efficient transduction independently of DNA synthesis. Self-complementary AAV virus scAAV safe and long-term gene transfer in the trabecular meshwork of living rats and monkeys.