Total Human Eye-allotransplantation Innovation Advancement (THEIA)

ISO number: 75N99224R0002 Washington, Kia ABSTRACT A. Cover Page 1. ISO number: 75N99224R0002 THEA 2. Technical area: Health Sciences Futures 3. Proposal title: THEIA: Total Human Eye-allotransplantation Innovation Advancement 4. Prime Awardee/entity submitting proposal: University of Colorado School of Medicine 5. Type of organization: Other Educational 6. Date of abstract submission: February 29, 2024 7. Other team members: Kia Washington, MD, FACS, University of Colorado Anschutz Medical Campus Christene A. Huang, PhD, University of Colorado Anschutz Medical Campus Chad Jackson, PhD, Foundation Fighting Blindness; Other Non-Profit Thomas V. Johnson, MD, PhD, Johns Hopkins University; Other Educational Jeffrey S. Mumm, PhD, Johns Hopkins University; Other Educational Donald J. Zack, MD, PhD, Johns Hopkins University; Other Educational David Gamm, MD, PhD, University of Wisconsin-Madison; Other Educational Lucas Chase, PhD, Fujifilm Cellular Dynamics Inc. / Opsis Therapeutics; Large Business Jason Meyer, PhD, Indiana University School of Medicine; Other Educational Kapil Bharti, PhD, National Eye Institute; Other Non-Profit Kimberly Gokoffski, MD, PhD, University of Southern California; Other Educational Curtis L. Cetrulo, Jr., MD, FACS, FAAP, Cedars-Sinai Medical Center, Other Educational 8. Technical point of contact (POC): Salutation: Dr.; Last name: Washington First name: Kia Street address: University of Colorado Denver | Anschutz Medical Campus Mail Stop F428, Bldg. 500, W1131C 13001 E. 17th Place City: Aurora State: CO Zip Code: 80045 Telephone: (412) 638-7160 Email: [email protected] 9. Administrative POC: Salutation: Mr. Last name: Thomas First name: Keith Street Address: University of Colorado Denver | Anschutz Medical Campus Office of Grants and Contracts, Mail Stop F428, Bldg. 500, W1131C 13001 E. 17th Place City: Aurora State: CO Zip code: 80045 Telephone: (303)724-0489 Email: [email protected] 10. Total Funds Requested from ARPA-H: $166,696,702 1 ISO number: 75N99224R0002 Washington, Kia B. Concept Summary: Team THEIA (Total Human Eye-allotransplantation Innovation Advancement) is a multi-disciplinary consortium of globally-recognized experts in Vascular Composite Allotransplantation (VCA), reconstructive microsurgery, craniofacial surgery, ophthalmology, neurosurgery, otolaryngology, electrical engineering, material science, immunology, neurobiology, electrophysiology, and stem cell biology whose collective goal is to fast-track convergent technologies to carry out ARPA-H’s mission of curing blindness within 6 years. Specifically, THEIA’s team of experts will develop a platform to harvest and preserve human donor eyes, advance and synergize cellular, molecular, and electrical retinal and optic nerve interventions to enable survival and synaptic integration of donor optic nerves, establish immunosuppressive protocols permitting long-term graft survival, and pioneer innovative surgical techniques to implant donor eyes into recipients, allowing for functional vision recovery. C. Innovation and Impact: Enabling THEA to restore vision requires overcoming the following major barriers: 1) organ procurement while preserving ocular tissues with special emphasis on the neurosensory retina; 2) reattachment and repair of the optic nerve; 3) vascular reperfusion of the transplanted organ; and 4) targeted immunosuppression. Novel donor procurement (surgical and eye perfusion) and recipient eye surgical techniques and protocols will be established for TA1 and TA3. TA2’s novel and synergistic approaches are to: 1) confer resilience and enhanced regenerative capacity in mammalian retinal ganglion cells (RGCs) by developing gene therapies that promote regenerative transcriptional networks and new drug-dispensing biomaterials to reverse the inhibitory microenvironment for RGC growth; 2) facilitate bridge therapies between the transected area from donor to recipient through the use of a novel multi-cellular microfluidic optic nerve-on- a-chip platform; and 3) apply electric field (EF) stimulation to drive RGC axon growth and steer RGC axons to grow towards correct brain targets (e.g., lateral geniculate nucleus)1. This effort best aligns with ARPA-H’s Health Science Futures focus area as it will treat a broad range of blindness disorders if successful. THEIA provides insights into eye and nerve healing and brings us one step closer to potential vision restoration. D. Proposed Work: By the end of Year 6 (2030), we will deliver: 1) novel surgical techniques and Preservation Eye-Extracorporeal Membrane Oxygenation (PRE-ECMO) technology enabling preservation of ocular tissues with special attention to the neurosensory retina, viable for up to 48 hours, while avoiding disfigurement of donors; 2) molecular strategies to promote RGC resilience (survival following axotomy and ischemia/reperfusion) and regenerative capacity (axonal extension, axonal remyelination, and synaptogenesis); 3) cellular strategies to develop a bioengineered, human pluripotent stem cell (PSC)-based optic nerve “bridge” product; and 4) exogenous electrical field stimulation to drive target-specific axon regeneration and integration with the diencephalon. Each subgroup of experts within THEIA will work together to develop a unified approach to enable whole eye transplantation to restore vision to patients blinded by retinal and optic nerve disease. Technical Area 1: The rat eye globe with surrounding tissues will be procured according to the previous whole eye transplant experience2. Pig eyes and fresh human eyes procured from brain- dead organ donors (Donor Alliance Inc.) prior to cross-clamping will be evaluated to assess novel strategies for eye preservation and optic nerve viability including ex vivo non-ischemic eye preservation with a combination of Necrostatin-1 (Receptor interacting protein 1 inhibitor of necroptosis), FAS-1 siRNA (apoptosis inhibitor), and Gal3 siRNA (a proinflammation inhibitor) in UW® or CUSTODIOL® preservation solutions for 24h and 48h. We plan to meet and exceed 2 ISO number: 75N99224R0002 Washington, Kia the 48h preservation target set by THEA program by combining perfusion protocols and subzero storage techniques. Subzero temperature will promote deep metabolic stasis, mitigating ischemic injury during the storage period3. These approaches aim to maintain eye cell oxygen level, eliminate ischemia-reperfusion injury, reduce cell apoptosis and necrosis, and decrease post- transplant inflammation. Ocular anatomy and cellular viability will be assessed at UCAMC using IHC and flow cytometry. Spatial transcriptomics, single cell RNA sequencing and TotalSeqTM will be used to quantify apoptosis and necrosis markers in specific cell types and identify new therapeutic targets for cell specific therapy in different eye layers. Successful THEA (TA1, Phase 1) requires technologies that will support storage (> 24 hours) and transportation from the harvesting institution to the transplant institution. To demonstrate translatability, a separate set of eyes procured at the UCAMC will be shipped to USC to undergo confirmational electrophysiological testing (e.g., ERG)4. Technical Area 2: We propose three complementary but not exclusive approaches (shots on goal) to achieve functional optic nerve integration following THEA. 1) To promote axonal regeneration from donor RGCs, the Johns Hopkins University (JHU) REGROW team will leverage existing pharmacological approaches to neuro-protect and augment regeneration in RGCs while, in parallel, conducting a comparative evolutionary approach to identify master gene regulatory networks that confer RGC resilience and reinnervation of the brain5,6. In addition, we will develop nanomedicine-based approaches to modulate gene expression in a cell-type specific manner and suppress microenvironmental inhibitory cues within the retina and throughout white matter tracts within the visual pathways7,8,9,10. 2) Using fit-for-purpose PSC derivatives (e.g., RGCs, excitatory CNS neurons, and/or glia), the UW-IU-NEI-Opsis EYE BRIDGE team will develop a cellular matrix that facilitates functional reconnection of the donor and recipient optic nerves by (a) creating a direct neuronal relay connection11,12,13,14,15 or (b) providing a local environment that promotes RGC regrowth from the donor globe. The team will test and refine this strategy using a novel optic nerve-on-a-chip microfluidics platform and an ideally suited preclinical pig model16,17,18,19. 3) The ITEMS Institute at USC will adapt their electric field (EF) based- engineered systems into a technology that will safely drive long-distance regeneration to and synaptic connectivity of donor RGC axons with subcortical targets in the diencephalon20,21,22,23. Efficacy of implanted “shrink wrap” nerve cuffs versus surface contact lens electrodes will be compared in small animals before development of wireless portable stimulators. Functional recovery will be ensured by pairing EF stimulation with existing medical therapies to promote axon remyelination and vision therapy to drive neuronal integration. Critically, advances made through each approach are designed in a way to synergize with other approaches in a complementary yet independent manner, in which strategies devised in one approach will augment other approaches. We anticipate developing a convergent, multivariate strategy (encompassing molecular targeting, inhibitory signal suppression, electrical field stimulation and/or optic nerve relays) to ensure survival of ≥90% of RGCs in donor eyes and subcortical target reinnervation at ≥50% of normal levels in rats, pigs, and rhesus macaques to support restoration of visual functions to levels ≥10% of healthy eyes. Technical Area 3: Cedars-Sinai''s Organ Procurement Organization, in collaboration with UCAMC and NEI, will optimize two approaches for eye transplantation, one with and the other without surrounding tissues (eyelid, conjunctiva, extraocular muscles, vasculature), with the goal 3 ISO number: 75N99224R0002 Washington, Kia of maximizing optic nerve length. During TA3 Phase 1, we will build on our small-animal expertise to develop a porcine orthotopic protocol. Eye exam, FA and ERG will be performed to demonstrate perfusion and preservation of outer retina function. During TA3 Phase 1 and 2, robotic deceased donor dissections on 20 cadavers will be performed to optimize our two surgical approaches in humans. This will include preparation of the superficial temporal artery and vein. Practice recovery surgeries will be conducted on 4 brain-dead donors which will allow us to optimize our transplantation workflow. Intraoperative indocyanine green (ICG) angiography will be used to demonstrate collateral perfusion of the orbit and periorbita in the donor eye. Simultaneously, we will establish protocols for local immunosuppression of the eye and orbit to decrease the need for systemic immunosuppression and techniques to mitigate ischemia-reperfusion injury using large animal models. In Phase 2, we will begin the patient selection process. Recipient matching and preparation will be performed using a novel non-HLA matching strategy to reduce rejection of the allograft and minimize the level of immunosuppression required. Cedar-Sinai’s Center for Bioethics and Humanities will ensure equitable healthcare access and diversity in clinical trial populations. Demonstration of > 10% functional recovery will be demonstrated via full ophthalmologic exam (visual acuity, pupillary exam, contrast sensitivity, color vision, IOP, sensorimotor exam, pachymetry, SD-OCT, perimetry, FA, ICG, ERG, pERG, and VEP). Patients will also undergo functional MRI imaging with a 7T MRI at USC. E. Team Organization and Capabilities: University of Colorado School of Medicine Anschutz Medical Campus (Lead Institution): Dr. Kia Washington (Professor of Surgery with an appointment in the Department of Ophthalmology) is the Principal Investigator. Dr. Washington is a pioneer in the field of whole eye 4 ISO number: 75N99224R0002 Washington, Kia transplantation and will oversee all scientific and surgical efforts for TA1 - TA3. Dr. Christene Huang (Professor of Surgery) brings immunology expertise relevant for TA1 and TA3. She has over 25 years of experience in immunology, transplant immunology, strategies for tolerance induction, tissue preservation, and the study of ischemia-reperfusion injury in VCA. The University of Colorado team will partner with Donor Alliance Inc., Rocky Mountain Lions Eye Bank, and Rocky Mountain Lions Eye Institute Foundation. Cedars-Sinai Medical Center VCA Clinical Program (Role: Co-Investigator; TA3 focused) is UNOS- approved for eye transplantation and is the only active program in the Western U.S. The team is led by Dr. Curtis L. Cetrulo, Jr., who has a track record of successful VCA innovation (first penis transplant successfully performed in U.S.) and of experience in the postoperative immunosuppression management of VCA patients. JHU REGROW (Role: Co-Investigator; TA2 focused) is led by Drs. Thomas Johnson (Professor of Ophthalmology), Jeff Mumm (Professor in Ophthalmology), and Donald Zack (Co- Director, Center for Stem Cells and Ocular Regenerative Medicine) will develop molecular and biomaterial tools to facilitate coaptation of the donor and host optic nerve and ensure donor RGCs survive transplantation within an eye allograft and regenerate axons to subcortical visual centers. The team brings expertise in cross-species visual pathway multiomics; viral & nonviral gene delivery; biomedical engineering, materials science, and nanomedical therapeutics. The EYE BRIDGE team (Role: Co-Investigator; TA2 focused) is led by Dr. David Gamm (Director, McPherson Eye Research Institute, and Professor, Ophthalmology and Visual Science, University Wisconsin-Madison), who has expertise in translational ocular regenerative medicine and cell-based therapies. Dr. Jason Meyer (Associate Professor and Director of the Stem Cell Research Group at Indiana University School of Medicine) is a leader in induced PSC-derived RGCs and glia models. Dr. Lucas Chase (Senior Director, FCDI/Opsis Therapeutics, Madison, WI) will optimize and develop clinical grade iPSC-RGCs and/or other cell products. Opsis Therapeutics has expertise in manufacturing clinical-grade iPSC-derived retinal cells and IND- enabling studies, including small and large animal preclinical studies led by Dr. Joe Phillips. Dr. Kapil Bharti (Scientific Director, National Eye Institute, NIH) has extensive experience with ocular cell transplantation and first-in-human trials for ocular cell therapies. University of Southern California Team (Role: Co-Investigator; TA2-3 focused) is led by Dr. Kimberly Gokoffski, a board-certified Neuro-Ophthalmologist. As Director of Research for the Institute for Technology and Medical Systems at USC, Dr. Gokoffski will leverage her multi- disciplinary consortium to develop exogenous electric field application into a technology that drives target-specific regeneration of RGC axons and restore vision to patients blinded by optic nerve disease. Dr. Gokoffski is supported by the team of electrical engineers, neurosurgeons, electrophysiologists, and material scientists who pioneered the production of the Argus-II implant, the first FDA-approved retinal prosthesis. Foundation Fighting Blindness (Role: Project Management and Site Coordinator) is the world’s leading foundation advancing treatments and cures for blinding retinal diseases. Led by Dr. Chad Jackson (Sr. Director, Translational Research), the Foundation will use its experience in managing complex, multi-institution programs and multi-million-dollar budgets to lead reporting and monitor and effectively align Team THEIA’s progress with ARPA-H’s mission and requirements. The Foundation has played a major role in the development of 88% of treatments in clinical trials for inherited retinal diseases and dry AMD. 5 ISO number: 75N99224R0002 Washington, Kia F. Rough Order of Magnitude (ROM): • Budget includes GMP production of cellular therapies and clinical trial costs 6 ISO number: 75N99224R0002 Washington, Kia References: 1. Kim T et al. Target Specific Axon Regeneration and Restoration of Vision with Electric Field Stimulation Nature Neuroscience under review. 2. Komatsu C, van der Merwe Y, He L, Kasi A, Sims JR, Miller MR, Rosner IA, Khatter NJ, Su AA, Schuman JS, Washington KM, Chan KC. 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