Long-Term Effect of Gene Therapy on Leber’s Congenital Amaurosis
Open accessAbstract
BACKGROUND: Mutations in RPE65 cause Leber's 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.).
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Ocular AAV treatments have caused permanent visual acuity loss after intraocular inflammation.
“ocular AAV therapies leading to a permanent reduction in visual acuity following intraocular inflammation (9–11)”
From Engineering adeno-associated viral vectors to evade innate immune and inflammatory responses (2021) · cites this paper as [9]
The Results (Inflammatory and Immune Responses; page unavailable) report that mild anterior uveitis in one participant was followed by a persistent 15-letter reduction in visual acuity. This supports a lasting loss after intraocular inflammation, but the paper reports persistence during follow-up, not that the loss was permanent or irreversible. (LLM, conf=0.82)
Experimental — accuracy not yet measuredClinical trials have reported AAV dose-dependent intraocular inflammation and persistent visual acuity loss after subretinal AAV despite prophylactic immunosuppression.
“AAV dose-dependent intraocular inflammation and a few instances of persistent loss of visual acuity have been independently reported in clinical trials following subretinal AAV administration despite prophylactic immunosuppression (9–11).”
From Engineering adeno-associated viral vectors to evade innate immune and inflammatory responses (2021) · cites this paper as [9]
The Results (Inflammatory and Immune Responses; page not provided) report inflammation in higher-dose recipients and a persistent 15-letter loss of visual acuity in one participant. The Adverse Events section mentions oral glucocorticoids, but the passages in our copy do not establish that immunosuppression was given prophylactically. (LLM, conf=0.86)
Experimental — accuracy not yet measuredIn phase 1/2 dose-escalation trials for RPE65-associated LCA, choroideremia, and RPGR-associated X-linked retinitis pigmentosa, patients receiving higher doses of AAV presented with signs of retinal inflammation including vitritis, retinitis, and choroiditis.
“In the phase 1/2 dose-escalation trials for RPE65-associated LCA, choroideremia, and retinitis pigmentosa GTPase regulator (RPGR)-associated X-linked retinitis pigmentosa, patients receiving higher doses of AAV have presented with various signs of retinal inflammation, including vitritis, retinitis, and choroiditis,2,6,7 implicating the presence of a cell-mediated immune response.”
From Characterizing the cellular immune response to subretinal AAV gene therapy in the murine retina (2021) · cites this paper as [2]
Split into 2 atoms — 1 confirmed, 1 partially supported, 0 disputed, 0 misattributed, 0 unverifiable. Expand the claim to see per-atom verdicts.
Experimental — accuracy not yet measuredDose-dependent retinal inflammation (GTAU) has been observed in many retinal gene therapy trials, limiting vector dose and therapeutic efficacy.
“Despite the perceived low immunogenicity of AAV and relative immune privilege of the intraocular environment,8 dose-dependent retinal inflammation, or gene therapy-associated uveitis (GTAU), has been observed in many retinal gene therapy trials, which limits the vector dose and therapeutic efficacy.”
From Characterizing the cellular immune response to subretinal AAV gene therapy in the murine retina (2021) · cites this paper as [2]
The Results (Inflammatory and Immune Responses) report inflammation or immune responses in five of eight higher-dose participants and none of four lower-dose participants; the Discussion describes these as dose-limiting toxic effects. The paper reports one trial, however, and does not establish that inflammation occurred in many retinal gene therapy trials or generally limited therapeutic efficacy. (LLM, conf=0.88)
Experimental — accuracy not yet measuredDespite a 28-day oral corticosteroid therapy started 2 days before the first IVT, 70.7% of lenadogene nolparvovec-treated eyes developed some degree of intraocular inflammation versus 10.2% of placebo-treated eyes.
“Despite a 28-day oral corticosteroid therapy started 2 days before the first IVT, a regimen similar to that provided in several other clinical studies using IVT or sub-retinal AAV-based gene therapies,41–45 70.7% of lenadogene nolparvovec-treated eyes developed some degree of intraocular inflammation versus 10.2% of placebo-treated eyes.”
From Randomized trial of bilateral gene therapy injection for m.11778G&gt;A <i>MT-ND4</i> Leber optic neuropathy (2023) · cites this paper as [45]
The Methods—Intervention section describes subretinal AAV-based gene therapy, and the Results—Adverse Events section refers to oral glucocorticoid use. Those passages support citing this paper as an example of a related study, but our copy does not establish that its corticosteroid regimen was similar in duration or timing. The 70.7% and 10.2% figures appear after the citation and are not attributed to this source. (LLM, conf=0.82)
Experimental — accuracy not yet measured
Intraocular inflammation could lead to irreversible loss of retinal cells, deterioration of visual function and reduced durability of treatment effect associated with a costly one-off treatment.
“This is clinically important as intraocular inflammation could lead to irreversible loss of retinal cells, deterioration of visual function and reduced durability of treatment effect associated with a costly one-off treatment.”
From Gene Therapy-Associated Uveitis (GTAU): Understanding and mitigating the adverse immune response in retinal gene therapy (2025) · cites this paper as Bainbridge et al., 2015
In Results > Inflammatory and Immune Responses (page unavailable), inflammation was followed by a persistent loss of visual acuity in one participant and temporarily attenuated retinal-sensitivity gains in another. The paper does not establish that inflammation caused irreversible retinal-cell loss or reduced the long-term durability of treatment; it discusses macular thinning and later sensitivity decline without attributing either to inflammation. It does not address treatment cost. (LLM, conf=0.86)
Experimental — accuracy not yet measuredIf uncontrolled, intraocular inflammation can lead to irreversible retinal structural damage and reduced visual function.
“The intraocular inflammation is dose-dependent and can sometimes last for months or even years following treatment, leading to irreversible retinal structural damage and reduced visual function if uncontrolled (Bainbridge et al., 2015).”
From Gene Therapy-Associated Uveitis (GTAU): Understanding and mitigating the adverse immune response in retinal gene therapy (2025) · cites this paper as Bainbridge et al., 2015
The Results (Inflammatory and Immune Responses; page not provided) report that inflammation or immune responses occurred in five of eight higher-dose participants and none of four lower-dose participants. One participant’s mild uveitis was followed by macular pigmentary changes and a persistent 15-letter loss of visual acuity. The paper does not establish that uncontrolled inflammation caused irreversible retinal damage or that inflammation lasted months or years; the Discussion instead attributes macular thinning most likely to temporary retinal detachment. (LLM, conf=0.87)
Experimental — accuracy not yet measuredThe intraocular inflammation is dose-dependent.
“The intraocular inflammation is dose-dependent and can sometimes last for months or even years following treatment, leading to irreversible retinal structural damage and reduced visual function if uncontrolled (Bainbridge et al., 2015).”
From Gene Therapy-Associated Uveitis (GTAU): Understanding and mitigating the adverse immune response in retinal gene therapy (2025) · cites this paper as Bainbridge et al., 2015
The Results (Inflammatory and Immune Responses; Adverse Events, page unavailable) report intraocular inflammation in three higher-dose participants and none in the lower-dose group, supporting a dose association. The paper describes the inflammation as mild or transient; it does not report inflammation lasting months or years or establish that uncontrolled inflammation causes irreversible retinal damage. It does report persistent visual-acuity loss and macular pigmentary changes after one episode of uveitis. (LLM, conf=0.86)
Experimental — accuracy not yet measuredOne participant developed anterior uveitis at 2 weeks, followed by CRA and reduced visual acuity by 6 months.
“Notably, one participant developed anterior uveitis at 2 weeks, followed by CRA and reduced visual acuity by 6 months.”
From Gene Therapy-Associated Uveitis (GTAU): Understanding and mitigating the adverse immune response in retinal gene therapy (2025) · cites this paper as Bainbridge et al., 2015
The Results section (Inflammatory and Immune Responses; page unavailable) reports that Participant 7 had mild anterior uveitis followed by focal pigmentary changes at the macula and a persistent reduction in visual acuity. It does not identify those changes as CRA or give the claimed 2-week and 6-month timing. (LLM, conf=0.86)
Experimental — accuracy not yet measuredTwo participants developed optic disc swelling, retinal vascular tortuosity/sheathing and mild vitritis.
“Two participants developed optic disc swelling, retinal vascular tortuosity/sheathing and mild vitritis.”
From Gene Therapy-Associated Uveitis (GTAU): Understanding and mitigating the adverse immune response in retinal gene therapy (2025) · cites this paper as Bainbridge et al., 2015
The Results section, “Inflammatory and Immune Responses” (page unavailable), reports that two participants (8 and 9) had episodes of posterior intraocular inflammation. Our copy does not specify optic disc swelling, retinal vascular tortuosity or sheathing, or mild vitritis in those participants. (LLM, conf=0.85)
Experimental — accuracy not yet measuredThree out of eight participants who received the higher dose of vector (1 × 10^12 vg/eye) but none in the lower dose cohort (1 × 10^11 vg/eye) developed intraocular inflammation despite prophylactic peri-operative immunosuppression.
“Three out of eight participants who received the higher dose of vector (1 × 10 12 vg/eye) but none in the lower dose cohort (1 × 10 11 vg/eye) developed intraocular inflammation despite prophylactic peri-operative immunosuppression.”
From Gene Therapy-Associated Uveitis (GTAU): Understanding and mitigating the adverse immune response in retinal gene therapy (2025) · cites this paper as Bainbridge et al., 2015
The Methods (Intervention) give the two dose levels and cohort sizes, while the Results (Adverse Events; Inflammatory and Immune Responses) report intraocular inflammation in three higher-dose participants and none in the lower-dose cohort. The Results mention oral glucocorticoids, but our copy does not establish that participants received prophylactic peri-operative immunosuppression. (LLM, conf=0.86)
Experimental — accuracy not yet measuredGTAU is often diagnosed shortly after withdrawal of systemic immunosuppression prophylaxis or when the dose reaches around 15-20 mg for slower tapers, and sometimes several weeks to months after vector administration.
“Consequently, GTAU is often diagnosed shortly after the withdrawal of systemic immunosuppression prophy laxis (Dimopoulos et al., 2018) or when the dose reaches around 15 -20 mg for slower tapers, and sometimes several weeks to months after vector administration (Bainbridge et al., 2015).”
From Gene Therapy-Associated Uveitis (GTAU): Understanding and mitigating the adverse immune response in retinal gene therapy (2025) · cites this paper as Bainbridge et al., 2015
The Results (Inflammatory and Immune Responses; Adverse Events, pages unavailable) report uveitis and other intraocular inflammation after vector administration. They do not establish that these episodes were diagnosed several weeks to months later or when an immunosuppression taper reached 15–20 mg; the week-4 finding concerns immune markers, not the date of uveitis diagnosis. The withdrawal clause is separately cited to Dimopoulos et al. (LLM, conf=0.78)
Experimental — accuracy not yet measuredAAV vector-mediated retinal gene therapies have demonstrated efficacy in clinical trials for inherited retinal dystrophies.
“Although adeno-associated viral (AAV) vector-mediated retinal gene therapies have demonstrated efficacy”
From Characterizing the cellular immune response to subretinal AAV gene therapy in the murine retina (2021) · cites this paper as [2]
The intraocular inflammation can sometimes last for months or even years following treatment.
“The intraocular inflammation is dose-dependent and can sometimes last for months or even years following treatment, leading to irreversible retinal structural damage and reduced visual function if uncontrolled (Bainbridge et al., 2015).”
From Gene Therapy-Associated Uveitis (GTAU): Understanding and mitigating the adverse immune response in retinal gene therapy (2025) · cites this paper as Bainbridge et al., 2015
The Results (Adverse Events and Inflammatory and Immune Responses; page unavailable) report intraocular inflammation after treatment, describing it as mild or transient and referring to episodes. They do not state how long the inflammation lasted or establish that it could persist for months or years; searches for persistent inflammation and its duration found no such passage. (LLM, conf=0.73)
Experimental — accuracy not yet measuredIn phase I/II clinical trials for RPE65-LCA at University College London, ocular inflammation was noted following SRI of 1 × 10^12 vg of AAV2-RPE65.
“In phase I/II clinical trials for RPE65-LCA at University College London (ClinicalTrials.gov: NCT00643747), ocular inflammation was noted following SRI of 1 × 1012 vg of AAV2-RPE65.71,99”
From Current clinical applications of in vivo gene therapy with AAVs (2021) · cites this paper as [99]
Subfoveal viral gene therapy has been associated with various adverse effects, such as RPE alterations, retinal thinning, foveal morphological changes, vision loss, and variable duration of clinical effects.
“subfoveal viral gene therapy has been associated with various adverse effects, such as RPE alterations, retinal thinning, foveal morphological changes, vision loss, and the variable duration of clinical effects [281,294,296,297,298].”
From Bruch’s Membrane: A Key Consideration with Complement-Based Therapies for Age-Related Macular Degeneration (2023) · cites this paper as [296]
Dose-dependent immune responses have been observed, with high doses potentially leading to persistent inflammation and clinically significant vision loss in patients receiving high-dose AAV2 vector-based subretinal RPE65 therapy.
“Dose-dependent immune responses have also been observed, with high doses potentially leading to persistent inflammation and clinically significant vision loss in patients receiving high-dose AAV2 vector-based subretinal RPE65 therapy [296].”
From Bruch’s Membrane: A Key Consideration with Complement-Based Therapies for Age-Related Macular Degeneration (2023) · cites this paper as [296]
Some adverse events linked to glucocorticoids themselves have already been described in retinal rAAV trials, pointing out the need for other alternatives to mitigate inflammation.
“However, some adverse events linked to the glucocorticoids themselves have already been described in retinal rAAV trials which point out the need for other alternatives to mitigate the inflammation [37].”
From Risk mitigation of immunogenicity: a key to personalized retinal gene therapy (2021) · cites this paper as [37]
In an LCA trial (NCT00643747, Phase 1/2), retinal sensitivity improved, but final transgene expression in the high dose group was adversely affected by ocular inflammation or immune responses.
“The results showed that retinal sensitivity was improved; however, the final transgene expression in the participants from the high dose group was adversely affected by ocular inflammation or immune responses [48].”
From Immune responses to gene editing by viral and non-viral delivery vectors used in retinal gene therapy (2022) · cites this paper as [48]
Inflammatory reactions to gene therapy in the eye have led to permanent vision loss for some patients.
“Nonetheless, inflammatory reactions to gene therapy in the eye have led to permanent vision loss for some patients7–9.”
From Investigation of Cas9 Antibodies in the Human Eye (2022) · cites this paper as [7]
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BackgroundReprogramming metabolism by targeting sirtuin 6 attenuates retinal degeneration
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Georgiadis, A., Duran, Y., Ribeiro, J., Abelleira-Hervas, L., Robbie, S. J., Sünkel-Laing, B., Fourali, S., Gonzalez-Cordero, A., Cristante, E., Michaelides, M., et al. (2016) · Gene Therapy · doi:10.1038/gt.2016.66 · Cited by 84 · see citing works
Self-citation
- Authors
- Bainbridge, J. W. B., Mehat, M. S., Sundaram, V., Robbie, S. J., Barker, S. E., Ripamonti, C., Georgiadis, A., Mowat, F. M., Beattie, S. G., Gardner, P. J., Feathers, K. L., Luong, V. A., Yzer, S., Balaggan, K., Viswanathan, A., de Ravel, T. J. L., Casteels, I., Holder, G. E., Tyler, N., Fitzke, F. W., Weleber, R. G., Nardini, M., Moore, A. T., Thompson, D. A., Petersen-Jones, S. M., Michaelides, M., van den Born, L. I., Stockman, A., Smith, A. J., Rubin, G., & Ali, R. R.
- Affiliations
- Moorfields Eye Hospital (GB)
- Michigan State University (US)
- University of Michigan (US)
- Rotterdam Eye Hospital (NL)
- Universitair Ziekenhuis Leuven (BE)
- Oregon Health & Science University (US)
- ORCID
- Bainbridge, James W.B.
- Sundaram, Venki
- Robbie, Scott J.
- Georgiadis, Anastasios
- Mowat, Freya M.
- Beattie, Stuart G.
- Yzer, Suzanne
- Balaggan, Kamaljit
- Viswanathan, Ananth
- Casteels, Ingele
- Holder, Graham E.
- Tyler, Nick
- Weleber, Richard G.
- Moore, Anthony T.
- Thompson, Debra A.
- Michaelides, Michel
- Smith, Alexander J.
- Rubin, Gary
- Ali, Robin R.
- Venue
- New England Journal of Medicine
- Publisher
- Massachusetts Medical Society
- Published
- 2015-05-14
- Volume
- 372
- Issue
- 20
- Pages
- 1887-1897
- ISSN
- 0028-4793 (ISSN-L)
- 1533-4406
- PMC
- PMC4497809
- OpenAlex
- W265142245
- Semantic Scholar
- 31832b3aa3500171fc5f2a951f0a4124bd40068d
- Cited by
- 743
- References
- 29
- Citations by year
- 2026: 36 · 2025: 36 · 2024: 46 · 2023: 44 · 2022: 63 · 2021: 92 · 2020: 81 · 2019: 68 · 2018: 79 · 2017: 97 · 2016: 72 · 2015: 27 · 2014: 1
- FWCI
- 39.82
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- New England Journal of Medicine (publishedVersion)
- PubMed (publishedVersion)
- Europe PMC (PubMed Central) (acceptedVersion)
- PubMed Central (acceptedVersion)
- Durham Research Online (Durham University) (acceptedVersion)
- Durham Research Online (Durham University) (submittedVersion, cc-by)
- Lirias (KU Leuven) (submittedVersion, other-oa)
- UCL Discovery (University College London) (submittedVersion)
- eScholarship (California Digital Library) (submittedVersion)
- Research Portal (King's College London) (submittedVersion, other-oa)
- VUBIR (Vrije Universiteit Brussel) (submittedVersion)
- Funders
- Research to Prevent Blindness
- Wellcome Trust
- Massachusetts Medical Society
- National Institute for Health and Care Research (NF-SI-0507-10204, NF-SI-0513-10074, NIHR-RP-011-003)
- Sir Jules Thorn Charitable Trust
- University College London
- European Commission
- Ulverscroft Foundation
- Durham University
- KU Leuven
- Moorfields Eye Hospital NHS Foundation Trust
- Directorate for Biological Sciences
- Medical Research Council (MR/K024000/1, MR/M015815/1, MR/J005215/1)
- Engineering and Physical Sciences Research Council (EP/J017698/1, EP/J005193/1)
- Biotechnology and Biological Sciences Research Council (BB/M00211X/1)
- Topics
- Life Sciences › Biochemistry, Genetics and Molecular Biology › Molecular Biology › Retinal Development and Disorders
- Life Sciences › Biochemistry, Genetics and Molecular Biology › Genetics › Virus-based gene therapy research
- Health Sciences › Medicine › Ophthalmology › Retinal Diseases and Treatments
- Keywords
- Leber congenital amaurosis, RPE65, gene therapy, retinal degeneration, visual function, retinal sensitivity, electroretinogram, vector dose, intraocular inflammation, visual acuity, canine model, species differences, long-term efficacy and safety
- MeSH terms
- Retinoid Isomerohydrolase, Dependovirus, Adolescent, Animals, Child, Disease Models, Animal, Dogs, Genetic Vectors, Humans, Mutation, Retina, Vision, Ocular, Genetic Therapy, DNA, Complementary, Disease Progression, cis-trans-Isomerases, Photoreceptor Cells, Vertebrate, Young Adult, Leber Congenital Amaurosis
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