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`Clinical science
`
`See Editorial, p 135
`
`1 The Wilmer Eye Institute, The
`Johns Hopkins University School
`of Medicine, Baltimore,
`Maryland, USA; 2 Charlotte Eye
`Ear Nose & Throat Associates,
`P.A., Charlotte, North Carolina,
`USA; 3 Regeneron
`Pharmaceuticals, Inc.,
`Tarrytown, New York, USA;
`4 Elan Pharmaceuticals, Inc.,
`South San Francisco, California,
`USA
`
`Correspondence to:
`Dr P A Campochiaro, The Wilmer
`Eye Institute, 600 North Wolfe
`Street, Maumenee #719,
`Baltimore, MD 21287, USA;
`pcampo@jhmi.edu
`
`Accepted 25 April 2008
`
`An exploratory study of the safety, tolerability and
`bioactivity of a single intravitreal injection of vascular
`endothelial growth factor Trap-Eye in patients with
`diabetic macular oedema
`
`D V Do,1 Q D Nguyen,1 S M Shah,1 D J Browning,2 J A Haller,1 K Chu,3 K Yang,3
`J M Cedarbaum,3,4 R L Vitti,3 A Ingerman,3 P A Campochiaro1
`
`ABSTRACT
`Aim: The aim of the study was to assess the safety and
`bioactivity of a single intravitreal injection of vascular
`endothelial growth factor (VEGF) Trap-Eye in subjects with
`diabetic macular oedema (DMO).
`Methods: Five subjects with DMO, foveal thickness
`>250 mm measured by optical coherence tomography
`(OCT), and best-corrected visual acuity (BCVA) between
`20/40 and 20/320, were enrolled. Each participant
`received a single intravitreal injection of 4.0 mg of VEGF
`Trap-Eye followed by a 6-week observation period.
`Outcome measures included safety and biological activity,
`including changes in BCVA and excess retinal thickness
`assessed by OCT.
`Results: Injections of VEGF Trap-Eye were well tolerated
`with no ocular toxicity. One patient had an unrelated
`serious adverse event: hospitalisation for cellulitis of the
`left foot 27 days after injection of VEGF Trap-Eye. Median
`baseline BCVA was 36 ETDRS letters read at 4 m (not
`ETDRS visual acuity score; Snellen equivalent: 20/50) and
`median baseline excess central 1 mm foveal thickness
`(FTH) was 108 mm. At 4 weeks after injection, the
`median excess FTH was 59 mm and the median
`improvement in BCVA was nine letters. At 6 weeks after
`injection, four of the five patients showed improvement in
`excess FTH (median 74 mm; 31% reduction from baseline,
`p = 0.0625) and four of the five showed improvement in
`BCVA (median improvement of three letters).
`Conclusions: A single intravitreal injection of 4.0 mg of
`VEGF Trap-Eye was well tolerated and preliminary
`evidence of bioactivity was detected. These findings
`support additional studies investigating multiple injections
`of VEGF Trap-Eye in patients with DMO.
`
`the leading cause of
`Diabetic retinopathy is
`blindness in adults of working age and diabetic
`macular oedema (DMO) is the most frequent cause
`of visual loss among individuals with non-prolif-
`erative diabetic retinopathy.1 The Early Treatment
`Diabetic Retinopathy Study (ETDRS) demon-
`strated a 32% risk of moderate visual loss with
`untreated DMO over a 3-year period and a
`significant reduction in visual loss by focal/grid
`laser photocoagulation.2 3 The mechanism by
`which macular photocoagulation provides benefit
`in patients with DMO is unknown; however, a
`reasonable hypothesis is that it reduces retinal
`hypoxia. The basis of this hypothesis is the
`demonstration that retinal hypoxia contributes to
`DMO4 and that laser photocoagulation reduces
`
`retinal hypoxia in an animal model of retinal vein
`occlusion.5
`The level of vascular endothelial growth factor
`(VEGF) is increased in hypoxic retina6 and causes
`in animal models.7 8
`retinal vascular
`leakage
`Recently,
`intravitreal
`injections of ranibizumab
`(Lucentis, Genentech,
`Inc.,
`San
`Francisco,
`California, USA), a humanised Fab that binds all
`isoforms of VEGF-A, were shown to reduce excess
`retinal thickness (ERT) and improve visual acuity
`in ten patients with chronic DMO, demonstrating
`that VEGF is a critical stimulus for excessive
`vascular permeability in DMO.9
`VEGF Trap is a 115 kDa recombinant fusion
`protein consisting of the VEGF binding domains of
`human VEGF receptors 1 and 2 fused to the Fc
`domain of human IgG1.10 VEGF Trap strongly
`inhibits choroidal neovascularisation (CNV) and
`VEGF-induced breakdown of
`the blood–retinal
`barrier.11 Compared with ranibizumab, animal stu-
`dies have shown that VEGF Trap has a longer half-
`life in the eye after intraocular injection, a higher
`binding affinity to VEGF-A, and it binds other
`members of the VEGF family including placental
`growth factors 1 and 2, which have been shown to
`contribute to retinal neovascularisation and exces-
`sive vascular permeability.10 12 13 Systemic adminis-
`tration of VEGF Trap reduces leakage, subretinal
`fluid and ERT in patients with CNV secondary to
`age-related macular degeneration (AMD), but higher
`doses induced hypertension and proteinuria.14 In
`order to avoid systemic toxicity, VEGF Trap-Eye
`(Regeneron Pharmaceuticals, Inc., Tarrytown, New
`York, USA) has been formulated for intravitreal
`injections; in early phase trials, intravitreal injections
`of VEGF Trap-Eye have caused substantial reduc-
`tions in ERT in patients with CNV due to AMD
`(reported at the Association for Research in Vision
`and Ophthalmology Annual Meeting, May 2007,
`Fort Lauderdale, Florida, USA, abstract #2868). The
`highest dose tested, 4.0 mg, showed a substantial
`effect by reducing subretinal and intraretinal fluid
`with no adverse effects identified. In this pilot study,
`we have tested the effect of a single intravitreal
`injection of 4.0 mg of VEGF Trap-Eye in patients
`with DMO.
`
`MATERIALS AND METHODS
`This study was conducted in compliance with the
`Declaration of Helsinki, US Code of Federal
`Regulations Title
`21,
`and the Harmonized
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`Tripartite Guidelines for Good Clinical Practice (1996). All
`subjects gave informed written consent before enrolment into
`this clinical trial, and it was conducted at two participating
`centres: the Wilmer Eye Institute of the Johns Hopkins
`University School of Medicine (Baltimore, Maryland, USA);
`and the Charlotte Eye Ear Nose & Throat Associates, P.A.
`(Charlotte, North Carolina, USA).
`
`Study population
`Participants aged >18 years with type 1 or type 2 diabetes and
`relatively good renal function, including serum creatinine (132.6
`mmol/l (upper limit of normal) and urine protein:creatinine ratio
`,0.11 mg/mmol, were eligible to participate if the study eye met
`the following criteria: (1) best-corrected ETDRS visual acuity
`(BCVA) score >24 letters (approximately 20/320 or better) and
`(73 letters (approximately 20/40 or worse); (2) retinal thicken-
`ing involving the foveal centre due to DMO (and not primarily
`because of vitreomacular interface disease); (3) optical coherence
`tomography (OCT)
`retinal
`thickness at
`the centre point
`>250 mm. Eyes were not eligible if they needed or had received
`panretinal scatter photocoagulation within the prior 4 months,
`focal/grid macular photocoagulation or periocular corticosteroids
`within the prior 4 months,
`intraocular treatment (such as
`intravitreal corticosteroids or VEGF inhibitors) within the prior
`6 months, major ocular surgery, including cataract extraction,
`within the prior 6 months, yttrium–aluminium–garnet capsulot-
`omy within the prior 2 months, history of prior pars plana
`vitrectomy, substantial cataract that in the opinion of the
`investigator was decreasing visual acuity by three lines or more,
`or aphakia. Eyes were also excluded if there was an ocular
`abnormality other than DMO that in the investigator’s judge-
`ment was contributing to a decrease in visual acuity (ie, vein
`occlusion, age-related macular degeneration, Irvine–Gass syn-
`drome, uveitis, vitreomacular
`traction syndrome, clinically
`significant epiretinal membrane). Subjects were excluded if
`they had the following systemic conditions: (1) blood pressure
`.150/90 mmHg; (2) history of myocardial infarction or transient
`ischaemic attack or cerebrovascular accident within the prior
`6 months; (3) New York Heart Association (NYHA) class II, III, or
`IV disease; (4) symptomatic peripheral vascular disease; (5)
`current pregnancy; or (6) malignancy other than basal cell
`carcinoma of the skin or in situ carcinoma of the cervix diagnosed
`and treated within the last 2 years.
`
`Study procedures
`The study was designed as an open-label, prospective clinical
`trial to evaluate the safety, tolerability and bioactivity of a
`single intravitreal injection of 4.0 mg of VEGF Trap-Eye in five
`subjects with DMO. Subjects were observed for 6 weeks
`following the intravitreal injection for assessments of ocular
`and systemic safety as well as biological activity. Safety was
`monitored by ophthalmological examination, tonometry and
`vital sign observation, and adverse event reporting at weekly
`study visits through to week 6, which was the primary endpoint
`of the study. Clinical laboratory tests, including measurements
`of haemoglobin A1c, haematological and chemistry panels, and
`urinalysis, were performed at baseline and at week 6. Additional
`safety assessments were also performed at days 155, 267 and
`380. The biological activity of VEGF Trap-Eye was evaluated by
`monitoring BCVA and two variables of thickness in the centre
`of the macula, central 1 mm foveal thickness (FTH), which is
`calculated from 128 measurements within the central 1 mm,
`and excess centre point thickness (CPT), which is a mean of six
`
`Clinical science
`
`measurements at the centre of fixation. Since many more
`measurements are used to compute FTH, it is less prone to
`sampling error than CPT, but at the outset of this study CPT
`was also commonly used and was included in the protocol;
`therefore, both variables are provided for each patient at each
`time point as excess FTH followed by excess CPT in
`parentheses. Excess FTH and CPT refer to the amount above
`normal and hence the amount of oedema, and they are
`calculated by subtracting normal values determined in popula-
`tion studies, 212 mm for FTH and 182 mm for CPT,15 from the
`measured values. Stereoscopic fundus photographs and fluor-
`escein angiography were obtained at baseline and at week 6.
`
`Administration of VEGF Trap-Eye
`After sterile draping of the study eye, topical anaesthesia was
`applied. Povidone iodine was used to clean the eyelid margins
`and eyelashes, and a sterile lid speculum was inserted. The
`conjunctiva was irrigated with 5% povidone iodine. A sterile
`caliper was used to measure 4.0 mm posterior to the limbus.
`VEGF Trap-Eye (4.0 mg in a volume of 100 ml) was injected into
`the vitreous cavity through a 30-gauge needle.
`Indirect
`ophthalmoscopy was used to verify perfusion of the central
`retinal artery immediately after the injection. Subjects were
`observed for 1 h after the injection and intraocular pressure was
`measured 30 min following the injection.
`
`Reading centre
`The Retinal Imaging Research and Reading Center (RIRRC) at
`the Wilmer Eye Institute (Baltimore, MD, USA) served as the
`centralised reading centre. All images were obtained according
`to a standardised protocol that included stereoscopic pairs of
`photographs of the study eye with transit of the study eye
`during fluorescein angiography. All images were evaluated by
`masked graders. All OCT imaging was performed using Stratus
`OCT (Carl Zeiss Meditec, Dublin, CA, USA) according to a
`standardised protocol that included 6 mm fast macular scans
`and 6 mm cross-hair scans centred on the fovea of the study
`eye. The FTH and CPT were computed by the Stratus OCT
`software (version 4.0). Digital fluorescein angiograms obtained
`at baseline and 6 weeks after injection of VEGF Trap-Eye were
`graded for area of perifoveal capillaries (in clock hours) that
`showed non-perfusion and/or leakage. The severity of fluor-
`escein leakage on late frames of the angiograms was graded as
`none, mild, moderate or severe. Grading was done by two of the
`investigators with experience grading fluorescein angiograms
`and then any differences were discussed and adjudicated to
`arrive at the final grading results.
`
`Statistical analysis
`Statistical analyses were performed using Statistical Package for
`the Social Sciences (SPSS Inc., Chicago, IL, USA). The likelihood
`that the change in excess retinal thickness or visual acuity from
`baseline to week 6 was due to VEGF Trap-Eye rather than
`chance was determined by the Wilcoxon signed-rank test.
`
`RESULTS
`Patient population
`Five participants (two men, three women) were enrolled and
`the mean age was 65.2 (range 56–75) years. Four subjects had
`type 1 diabetes and the mean duration of diabetes was 25.8
`(range 20–41) years. The median haemoglobin A1c at baseline
`was 7.7% and the median haemoglobin A1c at week 6 was 6.8%.
`Four of the five participants had received previous treatment in
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`Clinical science
`
`the study eye: one eye had prior intravitreal corticosteroid and
`two eyes had received focal laser photocoagulation, and one eye
`had received both focal
`laser and intraocular steroid. The
`median BCVA was 36 (range 29–44) letters; Snellen equivalent
`20/50+1, median excess FTH was 108 (range 88–424) mm and
`median excess CPT was 150 (range 125–482) mm (table 1).
`
`Excess retinal thickness
`After a single injection of 4.0 mg of VEGF Trap-Eye, five of the
`five subjects showed reduction in excess FTH (CPT) at 4 weeks,
`and four subjects maintained a reduction at 6 weeks. OCT scans
`with corresponding measurements of excess FTH (CPT) and
`BCVA for all five subjects are shown in fig 1. Subject 3 had cystic
`oedema with excess FTH (CPT) of 235 (235) mm at baseline. One
`week after injection of VEGF Trap-Eye, excess FTH (CPT)
`decreased to 55 (50) mm with fewer and smaller cysts. The excess
`FTH (CPT) continued to decline to 34 (14) mm at 2 weeks, 22
`(29) mm at 4 weeks, and –1 (5) mm at 6 weeks with return of a
`normal-appearing foveal pit. Subject 5 showed a similar course
`with reduction in excess FTH (CPT) from 97 (150) mm at baseline
`to 21(33) mm at 1 week and essentially elimination at 6 weeks.
`Subject 4 had more severe oedema at baseline with excess FTH
`(CPT) of 424 (482) mm, which was reduced to 341(395) mm at 1
`week, 320 (370) mm at 2 weeks and 265 (320) mm at 4 weeks. The
`patient missed his 6-week visit; therefore with last observation
`carried forward (LOCF) a value of 265 (320) mm was used at
`6 weeks. Subject 1 showed only a modest, transient response and
`excess FTH (CPT) was 74 (129) mm at 6 weeks compared with 88
`(125) mm at baseline. Subject 2 also showed a transient response
`with the baseline excess FTH (CPT) of 108 (135) mm reduced at 1
`and 2 weeks to 65 (80) and 58 (69) mm, respectively, but with
`return to near-baseline levels of 81 (109) mm at 6 weeks. Thus,
`two patients showed a marked reduction in DMO that was
`sustained for at least 6 weeks after a single injection of VEGF
`Trap-Eye and three patients showed modest responses that were
`not sustained for 6 weeks. The median residual excess FTH was
`59 mm at 1 month and 74 mm at 6 weeks (fig 2).
`
`Visual acuity
`Given the small sample size, the short follow-up period and the
`inclusion of patients with chronic DMO, a significant change in
`BCVA was not anticipated; however, one of the subjects, patient
`
`5, showed an excellent anatomical response accompanied by some
`functional response with improvements in BCVA of nine letters at
`1 week and one letter at 6 weeks (fig 1). Subject 3, who also
`showed an excellent anatomical response, showed an improve-
`ment of nine letters at one month and three letters at 6 weeks.
`Although subject 4 had substantial reduction in oedema, there was
`still substantial oedema at 4 weeks, the last observation within the
`6 weeks span of the study, and no improvement in BCVA.
`Subjects 1 and 2 showed transient improvements in both oedema
`and BCVA; BCVA was improved by ten letters in both at 1 month
`and four and six letters, respectively, at 6 weeks. The median
`improvement in BCVA was nine letters at 1 month and three
`letters at 6 weeks (fig 2).
`
`Fluorescein angiography
`Grading of fluorescein leakage in the macula at baseline and
`6 weeks after injection of 4 mg of VEGF Trap-Eye showed that
`there was no identifiable change in three patients and reduction
`in leakage in two patients (table 2). All five patients showed
`improvement in excess FTH measured by OCT indicating that
`there was improvement in leakage at some time after leakage,
`but the fluorescein angiography results indicated that by
`6 weeks after injection leakage was back to baseline levels in
`three of the patients. Two of the five patients still showed
`reduced leakage 6 weeks after a single injection of 4 mg of VEGF
`Trap-Eye and one of these patients showed prominent leakage
`at baseline and no identifiable leakage at 6 weeks after injection
`(fig 3). This suggests that in some patients with DMO a single
`injection of 4 mg of VEGF Trap-Eye may cause a prominent,
`sustained reduction in leakage, while in most the effects are not
`sustained for 6 weeks after a single injection.
`
`Safety
`A single intravitreal injection of 4.0 mg VEGF Trap-Eye was well
`tolerated and there were no serious ocular adverse events through
`to 6 weeks of follow-up. One patient was hospitalised for cellulitis
`of the left foot 27 days after intraocular injection of VEGF Trap-
`Eye and this was graded as an unrelated systemic serious adverse
`event. The patient had debridement, which was complicated by
`acute renal failure post-operatively, which resolved. Subsequently
`osteomyelitis was diagnosed and resolved after treatment with
`antibiotics. The most common ocular adverse events were mild
`
`Table 1 Baseline characteristics of five patients with diabetic macular oedema
`
`Characteristic
`
`Age (years)
`Duration of disease (years)
`Systemic disease
`Hypertension
`Hyperlipidaemia
`Lens status
`Phakic
`Pseudophakic
`Prior treatment for proliferative diabetic retinopathy
`Scatter photocoagulation
`Prior treatment for diabetic macular oedema*
`Steroids
`Laser
`Visual acuity (ETDRS letters read at 4 m)
`Excess central 1 mm foveal thickness (mm)
`Excess centre point thickness (mm)
`
`n
`
`5
`4
`
`4
`1
`
`1
`
`2
`4
`
`Mean (SD)
`
`Median
`
`65 (7)
`9 (8)
`
`62
`6
`
`Range
`
`57–75
`1–22
`
`37 (6)
`190 (143)
`225 (150)
`
`38
`108
`150
`
`*Intravitreal steroid injection was administered .9 months before VEGF Trap-Eye (Regeneron Pharmaceuticals, Inc., Tarrytown,
`New York, USA) study enrolment. Focal laser photocoagulation was performed .6 months before VEGF Trap-Eye study enrolment.
`
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`Table 2
`Fluorescein angiographic characteristics (clock hours) before and after a single intraocular injection
`of 4 mg of VEGF Trap-Eye for diabetic macular oedema
`
`Subject
`
`Baseline
`Non-perfused perifoveal capillaries
`Leakage
`Severity of leakage
`Week 6
`Non-perfused perifoveal capillaries
`Leakage
`Severity of leakage
`
`1
`
`3
`6
`Mild
`
`3
`6
`Mild
`
`2
`
`3
`
`4*
`
`5
`
`0
`12
`Moderate
`
`0
`12
`Mild
`
`2
`12
`Moderate
`
`2
`0
`Absent
`
`2
`12
`Moderate
`
`2
`12
`Moderate
`
`10
`2
`Mild
`
`10
`2
`Mild
`
`Four patients had digital, stereoscopic fluorescein angiograms at baseline and 6 weeks after intraocular injection of 4 mg of VEGF
`Trap-Eye (Regeneron Pharmaceuticals, Inc., Tarrytown, New York, USA).
`*Subject 4 missed the 6-week visit and had a fluorescein angiogram at 14 weeks after injection of VEGF. Trap-Eye and no
`additional treatments. Two physician graders at the Retinal Imaging Research and Reading Center of the Wilmer Eye Institute
`determined the number of clock hours of non-perfused perifoveal capillaries and flurorescein leakage and any differerences were
`discussed and adjudicated. The severity of leakage was graded as mild, moderate or severe on late frames of the fluorescein
`angiograms. The fluorescein angiograms at baseline and 6 weeks were unchanged in three patients, while two patients showed
`reduced leakage. The fluorescein angiograms for subject 3 are shown in fig 3.
`
`and related to the injection procedure: subconjunctival haemor-
`rhage in three eyes, increased lacrimation in one eye, itching in one
`eye, and transient post-injection increase in IOP to 30 mmHg in
`one eye that did not require medical treatment. There was no
`intraocular inflammation.
`
`DISCUSSION
`It has been shown that VEGF is an important stimulator of
`excessive vascular permeability in patients with DMO; five
`intraocular injections of 0.5 mg of ranibizumab over the course
`of 6 months caused resolution of 85% of excess FTH and mean
`
`Figure 1 Changes in central retinal thickness and best-corrected visual acuity (BCVA) after a single intraocular injection of 4 mg of VEGF Trap-Eye
`(Regeneron Pharmaceuticals, Inc., Tarrytown, New York, USA) in five patients with diabetic macular oedema. The subject number is listed at the top of
`each column. The top six rows show horizontal cross-sections obtained using optical coherence tomography at baseline (BL), day 3 (D3), week 1, week
`2, week 4 and week 6. Row 7 shows bar graphs for the excess central 1 mm foveal thickness at each time point and row 8 shows line graphs of the
`number of letters read on an ETDRS visual acuity chart at 4 m (not the ETDRS visual acuity score) at each time point. Patient 4 missed the week 6 visit;
`therefore using last observation carried forward (LOCF) the week 4 values are used at week 6.
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`improvement in BCVA of 12.3 letters.9 Like ranibizumab, VEGF
`Trap-Eye is a potent antagonist of VEGF-A, providing strong
`rationale for testing its effects in patients with DMO. This is
`the first report of the effects of VEGF Trap-Eye in patients with
`DMO and the results are consistent with expectations. A single
`intraocular injection of 4 mg of VEGF Trap-Eye in five patients
`with DMO was well tolerated, caused at least transient
`reduction in central thickening in all
`five patients, with
`reduction into the normal range in two of the patients 6 weeks
`after the injection. Two of five patients showed a reduction in
`fluorescein leakage 6 weeks after injection of VEGF Trap-Eye,
`indicating that effects on leakage were still manifested at that
`time point in those two patients. It was not expected that a
`single injection would result in significant improvement in
`BCVA at 6 weeks in the group as a whole, but there was at least
`transient improvement in the four patients who showed
`reduction in excess central thickening to about 50 mm or below.
`The one patient who showed substantial residual oedema did
`not
`show any improvement
`in BCVA. Thus,
`this
`first
`experience with intraocular VEGF Trap-Eye in patients with
`DMO is encouraging.
`Compared with ranibizumab, VEGF Trap-Eye has some
`theoretical advantages. It is more potent, has a longer half-life
`in the eye after intraocular injection, and it binds other VEGF
`
`Figure 2 Median excess central 1 mm foveal thickness and change
`from baseline in median best-corrected visual acuity after intraocular
`injection of 4 mg of VEGF Trap-Eye (Regeneron Pharmaceuticals, Inc.,
`Tarrytown, New York, USA) in five patients with diabetic macular
`oedema. Each bar represents the median excess foveal thickness (ERT)
`(foveal thickness 212 mm) at each time point and the line represents the
`median change from baseline in the number of letters read on an ETDRS
`visual acuity chart at 4 m (not the ETDRS visual acuity score). VA, visual
`acuity.
`
`Figure 3
`Fluorescein angiograms (FAs) at baseline and 6 weeks after injection of 4 mg of VEGF Trap-Eye (Regeneron Pharmaceuticals, Inc.,
`Tarrytown, New York, USA) in patient 3. At baseline the colour photograph shows hyperpigmented spots from prior focal laser therapy, thickening in
`the centre of the macula and surrounding exudates. The optical coherence tomography (OCT) shows severe thickening and cystic change in the macula.
`The FA shows moderate leakage from perifoveal capillaries resulting in pooling of dye in the macula in the late phase. Six weeks after injection of VEGF
`Trap-Eye the colour photograph shows a slight increase in exudates, which often occurs when oedema begins to resolve. The OCT shows marked
`improvement and there is no identifiable leakage throughout all phases of the FA.
`
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`family members in addition to VEGF-A that might contribute to
`excessive vascular permeability in patients with DMO. Also, the
`preliminary evidence suggesting that injections of 4 mg are well
`tolerated is encouraging, because a larger injected dose further
`increases the period that effective VEGF-neutralising levels are
`maintained in the eye. Two of
`four patients who were
`examined at the 6 week endpoint showed a persistent anti-
`permeability effect. One patient was not seen and the other two
`patients showed small increases in excess FTH (CPT) between 4
`and 6 weeks; in these patients it is not possible to determine if
`those small variations represent loss of VEGF-neutralising
`activity or random variation.
`The results of this study strongly support additional testing
`of VEGF Trap-Eye in patients with DMO in which repeated
`injections are given at an interval of every 6 weeks or longer.
`
`Funding: This study was funded by Regeneron Pharmaceuticals, Inc.
`
`Competing interests: D Do, Q Nguyen, S Shah, D Browning and J Haller have no
`conflicts of interest. P Campochiaro serves on a data and safety monitoring committee
`for a clinical trial for NVAMD sponsored by Regeneron. K Chu, K Yang, R Vitti and A
`Ingerman are employees of Regeneron. J M Cedarbaum is a former employee of
`Regeneron.
`
`Ethics approval: The study was approved by the Western Institutional Review Board.
`
`Patient consent: Obtained.
`
`REFERENCES
`Klein R. Retinopathy in a population-based study. Trans Am Ophthalmol Soc
`1.
`1992;90:561–94.
`
`2.
`
`3.
`
`5.
`
`6.
`
`7.
`
`Early Treatment Diabetic Retinopathy Study Research Group.
`Photocoagulation for diabetic macular edema. ETDRS report no. 4. Int Ophthalmol Clin
`1987;27:265–72.
`Early Treatment Diabetic Retinopathy Study Research Group.
`Photocoagulation for diabetic macular edema, ETDRS Report No. 1. Arch Ophthalmol
`1985;103:1644–52.
`4. Nguyen QD, Shah SM, Van Anden E, et al. Supplemental inspired oxygen improves
`diabetic macular edema; a pilot study. Invest Ophthalmol Vis Sci 2003;45:617–24.
`Pournaras CJ, Tsacopoulos M, Strommer K, et al. Scatter photocoagulation restores
`tissue hypoxia in experimental vasoproliferative microangiopathy in miniature pigs.
`Ophthalmology 1990;97:1329–33.
`Pierce EA, Avery RL, Foley ED, et al. Vascular endothelial growth factor/vascular
`permeability factor expression in a mouse model of retinal neovascularization. Proc
`Natl Acad Sci USA 1995;92:905–9.
`Ozaki H, Hayashi H, Vinores SA, et al. Intravitreal sustained release of VEGF causes
`retinal neovascularization in rabbits and breakdown of the blood–retinal barrier in
`rabbits and primates. Exp Eye Res 1997;64:505–17.
`8. Derevjanik NL, Vinores SA, Xiao W-H, et al. Quantitative assessment of the integrity
`of the blood-retinal barrier in mice. Invest Ophthalmol Vis Sci 2002;43:2462–7.
`9. Nguyen QD, Tatlipinar S, Shah SM, et al. Vascular endothelial growth factor is a
`critical stimulus for diabetic macular edema. Am J Ophthalmol 2006;142:961–9.
`Holash J, Davis S, Papadoupoulos N, et al. VEGF-Trap: a VEGF blocker with potent
`antitumor effects. Proc Natl Acad Sci U S A 2002;99:11393–8.
`Saishin Y, Saishin Y, Takahashi K, et al. VEGF-TRAPR1R2 suppresses choroidal
`neovascularization and VEGF-induced breakdown of the blood-retinal barrier. J Cell
`Physiol 2003;195:241–8.
`Rakic J-M, Lamber V, Devy L, et al. Placental growth factor, a member of the VEGF
`family, contributes to the development of choroidal neovascularization. Invest
`Ophthalmol Vis Sci 2003;44:3186–93.
`Gaudreault J, Fei D, Rusit J, et al. Preclinical pharmacokinetics of ranibizumab
`(rhuFabV2) after a single intravitreal administration. Invest Ophthalmol Vis Sci
`2005;46:726–33.
`14. Nguyen QD, Shah SM, Hafiz G, et al. A phase 1 trial of intravenously administered
`VEGF Trap-Eye for treatment in patients with choroidal neovascularization due to age-
`related macular degeneration. Ophthalmology 2006;113:1522e1521–1522e1514.
`Chan A, Duker JS, Ko TH, et al. Normal macular thickness measurements in healthy
`eyes using Stratus optical coherence tomography. Arch Ophthalmol 2006;124:193–8.
`
`10.
`
`11.
`
`12.
`
`13.
`
`15.
`
`Br J Ophthalmol 2009;93:144–149. doi:10.1136/bjo.2008.138271
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`An exploratory study of the safety, tolerability
`and bioactivity of a single intravitreal
`injection of vascular endothelial growth
`factor Trap-Eye in patients with diabetic
`macular oedema
`D V Do, Q D Nguyen, S M Shah, D J Browning, J A Haller, K Chu, K
`Yang, J M Cedarbaum, R L Vitti, A Ingerman and P A Campochiaro
`
`Br J Ophthalmol 
`2009 93: 144-149
`doi: 10.1136/bjo.2008.138271
`
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`References
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`This article cites 15 articles, 5 of which you can access for free at:
`http://bjo.bmj.com/content/93/2/144
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`#BIBL
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