Andrew Stockman

Effect of Gene Therapy on Visual Function in Leber's Congenital Amaurosis

Early-onset, severe retinal dystrophy caused by mutations in the gene encoding retinal pigment epithelium-specific 65-kD protein (RPE65) is associated with poor vision at birth and complete loss of vision in early adulthood. We administered to three young adult patients subretinal injections of recombinant adeno-associated virus vector 2/2 expressing RPE65 complementary DNA (cDNA) under the control of a human RPE65 promoter. There were no serious adverse events. There was no clinically significant change in visual acuity or in peripheral visual fields on Goldmann perimetry in any of the three patients. We detected no change in retinal responses on electroretinography. One patient had significant improvement in visual function on microperimetry and on dark-adapted perimetry. This patient also showed improvement in a subjective test of visual mobility. These findings provide support for further clinical studies of this experimental approach in other patients with mutant RPE65. (ClinicalTrials.gov number, NCT00643747 [ClinicalTrials.gov].).

The spectral sensitivities of the middle- and long-wavelength-sensitive cones derived from measurements in observers of known genotype

The spectral sensitivities of middle- (M-) and long- (L-) wavelength-sensitive cones have been measured in dichromats of known genotype: M-cone sensitivities in nine protanopes, and L-cone sensitivities in 20 deuteranopes. We have used these dichromat cone spectral sensitivities, along with new luminous efficiency determinations, and existing spectral sensitivity and color matching data from normal trichromats, to derive estimates of the human M- and L-cone spectral sensitivities for 2 and 10 degrees dia. central targets, and an estimate of the photopic luminosity function [V(lambda)] for 2 degrees dia. targets, which we refer to as V(2)*(lambda). These new estimates are consistent with dichromatic and trichromatic spectral sensitivities and color matches.

Spectral sensitivities of the human cones

Transient chromatic adaptation produced by an abrupt change of background color permits an easier and closer approach to cone isolation than does steady-state adaptation. Using this technique, we measured middle-wave-sensitive (M)-cone spectral sensitivities in 11 normals and 2 protanopes and long-wavelength-sensitive (L-) cone spectral sensitivities in 12 normals and 4 deuteranopes. Although there is great individual variation in the adapting intensity required for effective isolation, there is little variation in the shape of the M- and L-cone spectral-sensitivity functions across subjects. At middle and long wavelengths, our mean spectral sensitivities agree extremely well with dichromatic spectral sensitivities and with the M- and L-cone fundamentals of Smith and Pokorny [Vision Res. 15, 161 (1975)] and of Vos and Walraven [Vision Res. 11, 799 (1971)], both of which are based on the CIE (Judd-revised) 2 degrees color-matching functions (CMFs). But the agreement with the M-cone fundamentals of Estévez [Ph.D. dissertation, Amsterdam University (1979)] and of Vos et al. [Vision Res. 30, 936 (1990)], which are based on the Stiles-Burch 2 degrees CMFs, is poor. Using our spectral-sensitivity data, tritanopic color-matching data, and Stiles pi 3, we derive new sets of cone fundamentals. The consistency of the proposed fundamentals based on either the Stiles-Burch 2 degrees CMFs or the CIE 10 degrees large-field CMFs with each other, with protanopic and deuteranopic spectral sensitivities, with tritanopic color-matching data, and with short-wavelength-sensitive (S-) cone spectral-sensitivity data suggests that they are to be preferred over fundamentals based on the CIE 2 degrees CMFs.

Long-term effect of gene therapy on Leber's congenital amaurosis.

BACKGROUND Mutations in RPE65 cause Lebers congenital amaurosis, a progressive retinal degenerative disease that severely impairs sight in children. Gene therapy can result in modest improvements in night vision, but knowledge of its efficacy in humans is limited. METHODS We performed a phase 1-2 open-label trial involving 12 participants to evaluate the safety and efficacy of gene therapy with a recombinant adeno-associated virus 2/2 (rAAV2/2) vector carrying the RPE65 complementary DNA, and measured visual function over the course of 3 years. Four participants were administered a lower dose of the vector, and 8 were administered a higher dose. In a parallel study in dogs, we investigated the relationship among vector dose, visual function, and electroretinography (ERG) findings. RESULTS Improvements in retinal sensitivity were evident, to varying extents, in six participants for up to 3 years, peaking at 6 to 12 months after treatment and then declining. No associated improvement in retinal function was detected by means of ERG. Three participants had intraocular inflammation, and two had clinically significant deterioration of visual acuity. The reduction in central retinal thickness varied among participants. In dogs, RPE65 gene therapy with the same vector at lower doses improved vision-guided behavior, but only higher doses resulted in improvements in retinal function that were detectable with the use of ERG. CONCLUSIONS Gene therapy with rAAV2/2 RPE65 vector improved retinal sensitivity, albeit modestly and temporarily. Comparison with the results obtained in the dog model indicates that there is a species difference in the amount of RPE65 required to drive the visual cycle and that the demand for RPE65 in affected persons was not met to the extent required for a durable, robust effect. (Funded by the National Institute for Health Research and others; ClinicalTrials.gov number, NCT00643747.).

The spectral sensitivity of the human short-wavelength sensitive cones derived from thresholds and color matches.

We used two methods to estimate short-wave (S) cone spectral sensitivity. Firstly, we measured S-cone thresholds centrally and peripherally in five trichromats, and in three blue-cone monochromats, who lack functioning middle-wave (M) and long-wave (L) cones. Secondly, we analyzed standard color-matching data. Both methods yielded equivalent results, on the basis of which we propose new S-cone spectral sensitivity functions. At short and middle-wavelengths, our measurements are consistent with the color matching data of Stiles and Burch (1955, Optica Acta, 2, 168-181; 1959, Optica Acta, 6, 1-26), and other psychophysically measured functions, such as pi 3 (Stiles, 1953, Coloquio sobre problemas opticos de la vision, 1, 65-103). At longer wavelengths, S-cone sensitivity has previously been over-estimated.

The temporal properties of the human short-wave photoreceptors and their associated pathways

Flicker modulation sensitivity measurements made on high intensity orange steady backgrounds indicate that signals from short-wavelength sensitive cones (S-cones) have access to two pathways. At low S-cone adaptation levels the frequency response falls quickly with increasing frequency, but at higher adaptation levels it extends to much higher frequencies. At these higher S-cone adaptation levels, the following procedures can selectively expose either a process sensitive to low frequencies or one more sensitive to higher frequencies: (1) at high flicker frequencies, the S-cone signal can be nulled by a long-wavelength sensitive cone (L-cone) signal of suitable amplitude and phase, but at low frequencies a residual flicker persists; the modulation sensitivity for the residual flicker is lowpass in shape with a rapid decline in sensitivity with increasing flicker frequency; (2) sensitivity to flicker in the presence of a 17 Hz S- or L-cone mask is also lowpass with a similarly steep loss of high frequency sensitivity; yet (3) sensitivity to flicker during transient stimulation of the S-cones at 0.5 Hz is comparatively wideband (and slightly bandpass) in shape. The S-cone signal produced by the high frequency process is almost as well-maintained towards high frequencies as M- and L-cone signals. Furthermore, it is capable of participating in flicker photometric nulls with M- and L-cone signals. At low frequencies, however, when the low frequency S-cone signal is also present, satisfactory nulls can not be found. From these and phenomenological considerations, we identify the low and high frequency S-cone processes as S-cone inputs to the chromatic and luminance pathways, respectively. The phase adjustments needed to optimize flicker photometric nulls reveal that the S-cone input to the luminance pathway is actually inverted, but this is demonstrable only at relatively low frequencies: at medium or high frequencies the S-cone influence can be synergistic with that of the other cone types because of a delay in the transmission of S-cone signals.

Into the twilight zone: the complexities of mesopic vision and luminous efficiency

Of all the functions that define visual performance, the mesopic luminous efficiency function is probably the most complex and hardest to standardise or model. Complexities arise because of the substantial and often rapid visual changes that accompany the transition from scotopic to photopic vision. These are caused not only by the switch from rod to cone photoreceptors, but also by switches between different post‐receptoral pathways through which the rod and cone signals are transmitted. In this review, we list several of the complexities of mesopic vision, such as rod–cone interactions, rod saturation, mixed photoreceptor spectral sensitivities, different rod and cone retinal distributions, and the changes in the spatial properties of the visual system as it changes from rod‐ to cone‐mediated. Our main focus, however, is the enormous and often neglected temporal changes that occur in the mesopic range and their effect on luminous efficiency. Even before the transition from rod to cone vision is complete, a transition occurs within the rod system itself from a sluggish, sensitive post‐receptoral pathway to a faster, less sensitive pathway. As a consequence of these complexities, any measure of mesopic performance will depend not only on the illumination level, but also on the spectral content of the stimuli used to probe performance, their retinal location, their spatial frequency content, and their temporal frequency content. All these should be considered when attempting to derive (or to apply) a luminous efficiency function for mesopic vision.

A luminous efficiency function, V*(λ), for daylight adaptation

We propose a new luminosity function, V*(lambda), that improves upon the original CIE 1924 V(lambda) function and its modification by D. B. Judd (1951) and J. J. Vos (1978), while being consistent with a linear combination of the A. Stockman & L. T. Sharpe (2000) long-wavelength-sensitive (L) and middle-wavelength-sensitive (M) cone fundamentals. It is based on experimentally determined 25 Hz, 2 degrees diameter, heterochromatic (minimum) flicker photometric data obtained from 40 observers (35 males, 5 females) of known genotype, 22 with the serine variant L(ser180), 16 with the alanine L(ala180) variant, and 2 with both variants of the L-cone photopigment. The matches, from 425 to 675 nm in 5-nm steps, were made on a 3 log troland xenon white (correlated color temperature of 5586 K but tritanopically metameric with CIE D65 standard daylight for the Stockman and Sharpe L- and M-cone fundamentals in quantal units) adapting field of 16 degrees angular subtense, relative to a 560-nm standard. Both the reference standard and test lights were kept near flicker threshold so that, in the region of the targets, the total retinal illuminance averaged 3.19 log trolands. The advantages of the new function are as follows: it forms a consistent set with the new proposed CIE cone fundamentals (which are the Stockman & Sharpe 2000 cone fundamentals); it is based solely on flicker photometry, which is the standard method for defining luminance; it corresponds to a central 2 degrees viewing field, for which the basic laws of brightness matching are valid for flicker photometry; its composition of the serine/alanine L-cone pigment polymorphism (58:42) closely matches the reported incidence in the normal population (56:44; Stockman & Sharpe, 1999); and it specifies luminance for a reproducible, standard daylight condition. V*(lambda) is defined as 1.55L(lambda) + M(lambda), where L(lambda) and M(lambda) are the Stockman & Sharpe L- & M-cone (quantal) fundamentals. It is extrapolated to wavelengths shorter than 425 nm and longer than 675 nm using the Stockman & Sharpe cone fundamentals.

Faster than the eye can see: blue cones respond to rapid flicker

Flickering lights that are detected by the blue cones of the human visual system fuse to yield a steady sensation at much lower rates of flicker than do lights that are detected by the red or green cones. Yet, although blue-cone-detected lights flickering at 30-40 Hz appear to be steady, they are still able to interact with red- or green-cone-detected flickering lights to produce clearly detectable beats in the form of an amplitude modulation of the red- or green-cone flicker. Thus the blue cones produce a viable high-frequency flicker signal, as do the red and green cones, but one that is normally lost before it reaches sensation. The temporal-frequency response for the blue-cone beat interaction is similar in shape to the temporal-frequency response for directly detected red- or green-cone flicker. When measured through the same pathway (which we identify as the luminance pathway, since it is able to transmit high-frequency flicker), the response of the blue cones seems to be as fast as that of the other cones.

Macular pigment densities derived from central and peripheral spectral sensitivity differences

Estimates of the density spectrum of the macular pigment (Wyszecki G, Stiles WS. Color Science: Concepts and Methods. Quantitative Data and Formulas. 1st ed. New York: Wiley, 1967); (Vos JJ. Literature review of human macular absorption in the visible and its consequences for the cone receptor primaries. Institute for Perception. Soesterberg, The Netherlands, 1972) are partially based on the difference between central and peripheral spectral sensitivities, measured under conditions chosen to isolate a single cone class (Stiles WS. Madrid: Union Internationale de Physique Pure et Appliquée, 1953;1:65-103). Such derivations assume that the isolated spectral sensitivity is the same at both retinal locations, save for the intervening macular pigment. If this is true, then the type of cone class mediating detection should not influence the calculated difference spectrum. To test this assumption, we measured central and peripheral spectral sensitivities in a deuteranope, a protanope and a normal trichromat observer: (a) for short-wave sensitive (S-) cone detection; and (b) for long-wave sensitive (L-) cone detection (deuteranope), for middle-wave sensitive (M-) cone detection (protanope) or for both L- and M-cone detection (normal trichromat). The difference spectra determined for L- or M-cone detection deviate significantly from those measured for S-cone detection, at wavelengths below 450 nm. A theoretical analysis suggests that the discrepancies are owing, in part, to regional variation in the optical density of the cone pigments; and that such receptor variation cannot be ignored when deriving the standard density spectrum of the macular pigment.