tvst
`Bere
`VEGF: From Discovery to Therapy: The Champalimaud
`Award Lecture
`
`DOI: 10.1167/tvst.5.2.9
`
`Joan W.Miller!
`' Department of Ophthalmology, Harvard Medical School, Massachusetts Eye and Ear, Massachusetts General Hospital, Boston, MA, USA
`
`Correspondence: Joan W.Miller,
`Department of Ophthalmology,
`Harvard Medical School, Massachu-
`setts Eye and Ear, Massachusetts
`General Hospital, 243 Charles Street,
`Boston, MA 02114, USA. e-mail:
`Joan_Miller@meei.harvard.edu
`Received: 12 October 2015
`Accepted: 15 October 2015
`Published: 11 March 2016
`
`Keywords: age-related macular
`degeneration (AMD); angiogenesis;
`Antonio Champalimaud Vision
`Award; Factor X; vascular endo-
`thelial growth factor (VEGF)
`Citation: Miller JW. VEGF: from
`discovery to therapy: the Champali-
`maud Award Lecture. Trans Vis Sci
`Tech. 2016;5(2):9, doi:10.1167/tvst.5.
`2.9
`
`Purpose:Intraocular vascular diseases are leading causes of adult vision loss, and in
`the mid-1900s,I. C. Michaelson postulated that the retina releases a soluble, diffusible
`factor that causes abnormal vascular growth and leakage. What became known as
`“Factor X” eluded investigators for decades.
`
`Methods: Thefield of cancer research, where Judah Folkman pioneered the concept
`of angiogenesis, provided the inspiration for the work honored by the 2014
`Champalimaud Vision Award. Recognizing that tumors recruit their own blood supply
`to achieve critical mass, Dr Folkman proposed that angiogenic factors could be
`therapeutic targets in cancer. Napoleone Ferrara identified vascular endothelial
`growth factor (VEGF) as such an angiogenic agent: stimulated by hypoxic tumor
`tissue, secreted, and able to induce neovascularization. VEGF also was a candidate for
`Factor X, and the 2014 Champalimaud Laureates and colleagues worked individually
`and collaboratively to identify the role of VEGF in ocular disease.
`
`Results: The Champalimaud Laureates correlated VEGF with ocular neovascularization
`in animal models and in patients. Moreover, they showed that VEGF not only was
`sufficient, but it also was required to induce neovascularization in normal animal eyes,
`as VEGFinhibition abolished ocular neovascularization in key animal models.
`
`Conclusions: Theidentification of VEGF as Factor X altered the therapeutic paradigms
`for age-related macular degeneration (AMD), diabetic retinopathy,
`retinal vein
`occlusion, and other retinal disorders.
`
`Translational Relevance: The translation of VEGF from discovery to therapy resulted
`in the most successful applications of antiangiogenic therapy to date. Annually, over
`one million patients with eye disease are treated with anti-VEGF agents.
`
`
`
`translationalvisionscience&technology__iiie_*:@ —cqxr
`
`
`
`
`
`cancer care in its Centre for the Unknown in Lisbon.
`It is well worth a visit.
`I want to thank the other Champalimaud Laureates
`On behalf of the laureates, I want to thank the
`for allowing me to represent them. Weall are honored
`Champalimaud Foundation; in particular, its Presi-
`by the award, and recognize that the group involved in
`dent Leonor Beleza, who leads the foundation with
`translating the discovery of vascular endothelial
`such wisdom and grace, and the members of the
`growth factor (VEGF) to therapyis very muchlarger,
`Champalimaud Vision Award Jury. Of course, I also
`and includes many other investigators, a few of whom
`would like to acknowledge the vision and generosity
`I will mention. However,
`there also were many
`of its founder, Antonio Champalimaud. The Cham-
`postdoctoral fellows, students, and clinicians, as well
`palimaud Foundation challenges us to conquer the
`as industry scientists, and of course patients, whose
`unknown, muchlike the Portuguese explorers whoset
`important contributions I wish to acknowledge.
`sail from her shores. The Champalimaud Vision
`In the 1990s, the treatment of manyretinal diseases
`Award recognizes contributions in vision research,
`wasrather grim. For neovascular age-related macular
`andin alternate years, it is given to groups delivering
`degeneration (AMD), all we really had was a
`care in developing countries. However, the Founda-
`destructive laser treatment, which cauterized the
`tion also supports an internal research program in
`neuroscience and cancerresearch, as well as a clinical
`vessels but also caused destruction of the neurosen-
`
`
`TVST | 2016 | Vol. 5 | No.2 | Article 9
`co)OOS)
`This workis licensed under a Creative CommonsAttribution-NonCommercial-NoDerivatives 4.0 International License. oa
`
`IPR2023-00884
`Samsung etal. v. Regeneron
`Regeneron Pharmaceuticals, Inc.
`Exhibit2114
`Page 1
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`Miller
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`Figure 1. Researchers involved in the discovery of VEGF as Factor X and translation to therapy. Top row (left to right): Judah Folkman,
`Harold Dvorak, Napoleone Ferrara, Evangelos Gragoudas, Donald D’Amico, Lloyd Paul Aiello. Bottom row (left to right): George King, Lois
`Smith, Eric Pierce, Patricia D’Amore, David Shima, Anthony Adamis, and Joan Miller.
`
`sory retina, leading to scotomas, or blind spots, and
`often decreased vision. This was not very rewarding,
`either for the patient or the treating clinician. Diabetic
`retinopathy was better controlled with laser photoco-
`agulation, but even so, there were drawbacks and side
`effects. Treatment for retinal vein occlusion (RVO)
`also was of limited benefit.
`Early in the 1990s, there was a confluence of
`researchers, especially in Boston, who were interested
`in ocular neovascularization (Fig. 1). Together and
`separately, we investigated models of ocular neovascu-
`larization in human disease. We explored findings from
`tumor angiogenesis in ocular disease. Among these
`investigators, there was Dr Judah Folkman, who was,
`indeed, the ‘‘Father of Angiogenesis’’; and Harold
`Dvorak, who identified a soluble factor known as
`vascular permeability factor (VPF);1 Napoleone Fer-
`rara (Genentech), who isolated VEGF and recognized
`its role in angiogenesis;2 and Evangelos Gragoudas and
`Donald D’Amico (Massachusetts Eye and Ear), who
`
`insight and leadership. At
`provided great clinical
`Harvard Medical School, there were two primary
`groups investigating VEGF and ocular angiogenesis.
`One was led by Lloyd Paul Aiello and George King at
`Joslin Diabetes Center, who later were joined by Lois
`Smith and Eric Pierce of Boston Children’s Hospital.
`Another group was led by Patricia D’Amore and her
`graduate student David Shima, along with Anthony
`Adamis and me, at Boston Children’s Hospital and
`Massachusetts Eye and Ear. Of course, we had many
`collaborators, postdoctoral fellows, and students who
`were instrumental in carrying out this work.
`that
`The search for a secreted ‘‘Factor X’’
`stimulated ocular neovascularization dates back at
`least to 1948, when Michaelson postulated that a
`soluble and diffusible growth factor was responsible
`for retinal vascular growth in development and
`disease.3 Clinicians recognized that damaged or
`ischemic retina secreted a factor that could leak out
`into other parts of the eye and cause new blood vessel
`
`The search for Factor X. Left: Fluorescein angiogram of the retina in a patient with diabetic retinopathy (JWM patient seen at
`Figure 2.
`Massachusetts Eye and Ear). Black area represents nonperfused, ischemic retina. Center: Proposed action of unidentified angiogenic
`factor(s) in ocular neovascularization. Image courtesy of Anthony Adamis, MD; reproduced with permission. Right: Color photo of iris
`neovascularization in a patient with neovascular glaucoma (JWM patient seen at Massachusetts Eye and Ear).
`
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`Miller
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`Left: Human retinal pigmented epithelial (hRPE) cells hybridized in situ with a VEGF sense riboprobe (control), showing
`Figure 3.
`nonspecific cellular labeling and low background levels. Right: hRPE hybridized in situ with a VEGF antisense riboprobe, showing strong
`labeling of all hRPE cells and indicating VEGF expression. Reprinted with permission from Adamis AP, Shima DT, Yeo KT, et al. Synthesis
`and secretion of vascular permeability factor/vascular endothelial growth factor by human retinal pigment epithelial cells. Biochem
`Biophys Res Commun. 1993;193:631–638. Copyright 1993 Elsevier.14
`
`growth, either in the retina, optic nerve, or on the iris
`(Fig. 2). However, the exact identity of Factor X
`would remain elusive for several decades.
`In the 1970s, Folkman’s laboratory identified tumor
`angiogenesis factor,4 and Folkman published his
`seminal theory of tumor angiogenesis in the November
`1971 issue of New England Journal of Medicine: that
`angiogenesis, or the recruitment and growth of new
`
`Figure 4. Northern analysis of total RNA extracted from rRPE cells
`grown under normoxic and hypoxic conditions for 6, 12, and 24
`hours, probed for VEGF (upper), bFGF (middle), and 28S RNA
`(lower). Reproduced with permission from Shima DT, Adamis AP,
`Ferrara N, et al. Hypoxic induction of endothelial cell growth
`factors in retinal cells:
`identification and characterization of
`vascular endothelial growth factor (VEGF) as the mitogen. Mol
`Med. 1995;1:182–193.15
`
`3
`
`blood vessels, was required for tumor growth.5
`However, Folkman’s theory was met with skepticism.
`In the 1980s, Pat D’Amore, Bert Glaser, Arnall
`Patz, and others looked for an angiogenic factor in
`the retina and vitreous. Fibroblast growth factors 1
`and 2 (FGF-1 and FGF-2) were identified as
`angiogenic factors and potential candidates for
`Factor X.6–10 Importantly, however, FGF did not
`meet all the criteria for Factor X; namely, it is not
`secreted. The identity of Factor X remained elusive.
`In 1983, Harold Dvorak and Don Senger at
`Harvard Medical School isolated VPF from ascites
`fluid and tumor cells, and they demonstrated that it
`was a very potent permeability factor: 50,000 more
`potent than histamine.1 In 1989, Napoleone Ferrara
`and others cloned, sequenced, and characterized
`VEGF,2 which turned out to be the same molecule
`as VPF.11 VEGF was a secreted endothelial cell
`mitogen and an angiogenesis factor that was regulated
`by hypoxia (a condition known to stimulate neovas-
`cularization in certain retinopathies). Ferrara identi-
`fied high-affinity tyrosine kinase receptors for
`VEGF,12 and demonstrated that heterozygous Vegf
`knockouts were embryonically lethal.13
`Intrigued by these findings, our groups set off in
`two directions to investigate the role of VEGF in
`ocular disease. First, Adamis et al.14 grew retinal
`pigment epithelium (RPE) cells in culture and showed
`that they indeed produced VEGF (Fig. 3), the first
`demonstration that ocular cells made this factor. They
`also demonstrated that this production was regulated
`by hypoxia (Fig. 4).15,16
`At the same time, we collected ocular fluid samples
`from a model of ischemic retinopathy in a nonhuman
`primate,
`in which experimental retinal
`ischemia
`following laser vein occlusion leads to iris neovascu-
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`Miller
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`Experimental iris neovascularization. (A) Fundus photograph immediately following laser vein occlusion. (B) Color photograph
`Figure 5.
`showing new vessels on the surface of the iris, which appear 4 to 7 days after laser vein occlusion. (C) Fluorescein angiography showing
`iris neovascularization with abundant leakage of fluorescein (grade 3). (D) Fundus photograph immediately following sham laser, aimed
`adjacent to the retinal vessels and producing retinal injury but preserving normal vasculature. (E) Color photograph of iris 12 days after
`sham laser, which appears normal. (F) Fluorescein angiography of the iris in (E), showing normal iris vessels with no fluorescein leakage
`(grade 0). Reproduced with permission from Miller JW, Adamis AP, Shima DT, et al. Vascular endothelial growth factor/vascular
`permeability factor is temporally and spatially correlated with ocular angiogensis in a primate model. Am J Pathol. 1994;145:574–584.
`Copyright 1994 Elsevier.17
`
`Figure 6. Correlation of VEGF levels in the aqueous (A) and grade of iris neovascularization (B) of four monkey eyes after laser vein
`occlusion. VEGF levels and neovascularization are represented as a scatterplot with best fit curves. Reproduced with permission from
`Miller JW, Adamis AP, Shima DT, et al. Vascular endothelial growth factor/vascular permeability factor is temporally and spatially
`correlated with ocular angiogensis in a primate model. Am J Pathol. 1994;145:574–584. Copyright 1994 Elsevier.17
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`Miller
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`In situ localization of VEGF mRNA in ischemic retinas. Left: Cellular localization of VEGF mRNA expression by hybridization with
`Figure 7.
`an antisense VEGF riboprobe 13 days after laser vein occlusion. Right: Sense (control) riboprobe hybridized in 13-day ischemic retina.
`Adapted with permission from Shima DT, Gougos A, Miller JW, et al. Cloning and mRNA expression of vascular endothelial growth factor
`in ischemic retinas of Macaca fascicularis. Invest Ophthalmol Vis Sci. 1996;37:1334–1340.18
`
`larization (Fig. 5). When we looked at VEGF/VPF
`levels with Dvorak, we saw that the protein was
`virtually nonexistent before neovascularization ap-
`peared, but rose very quickly to high levels that
`correlated closely with increasing severity of
`iris
`
`neovascularization, and levels decreased as the iris
`neovascularization regressed (Fig. 6).17 This was the
`first correlation of increased VEGF levels with ocular
`neovascularization in vivo. We also demonstrated
`that it was the ischemic retina that produced VEGF,
`
`Figure 8. VEGF concentrations in the aqueous (squares) and vitreous (diamonds) of patients undergoing intraocular procedures.
`Arrowheads indicate mean values. Reproduced with permission from Aiello LP, Avery RL, Arrigg PG, et al. Vascular endothelial growth
`factor in ocular fluid of patients with diabetic retinopathy and other retinal disorders. N Engl J Med. 1994;331:1480–1487. Copyright 1994
`Massachusetts Medical Society.20
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`Inhibition of neovascularization using soluble VEGF receptor-IgG chimeric proteins in a mouse model of retinal ischemia. Left:
`Figure 9.
`Retinal neovascularization extending into the vitreous is indicated by arrows in control-treated mice (upper panel), and absent in mice
`treated with human Flt-IgG chimeric proteins (lower panel). Right: Dose-dependent inhibition of retinal vascularization with human Flt-
`IgG chimeric proteins. Reproduced with permission from Aiello LP, Pierce EA, Foley ED, et al. Suppression of retinal neovascularization in
`vivo by inhibition of vascular endothelial growth factor (VEGF) using soluble VEGF-receptor chimeric proteins. Proc Natl Acad Sci U S A.
`1995;92:10457–10461. Copyright 1995 National Academy of Sciences.21
`
`Inhibition of iris neovascularization using anti-VEGF antibody. Left: Early-phase fluorescein angiogram of an eye treated with
`Figure 10.
`anti-gp120 mAb (control), showing new iris vessels filling with fluorescein dye. Right: Early-phase fluorescein angiograms of the
`contralateral eye, treated with anti-VEGF mAb, showing no neovascularization. Reproduced with permission from Adamis AP, Shima DT,
`Tolentino MJ, et al. Inhibition of vascular endothelial growth factor prevents retinal ischemia-associated iris neovascularization in a
`nonhuman primate. Arch Ophthalmol. 1996;114:66–71. Copyright 1996 American Medical Association.22
`
`Figure 11. VEGF induces iris neovascularization and neovascular glaucoma. Left: Color iris photograph of an eye that received four 1.25-
`lg injections of VEGF, showing diffuse iris neovascularization and ectropion uveae (JWM image). Right: Histopathologic examination of
`the anterior chamber angle of an eye that received ten 1.25-lg injections of VEGF, showing a dense anterior fibrovascular membrane,
`ectropion uveae, and trabecular meshwork scarring. Reproduced with permission from Tolentino MJ, Miller JW, Gragoudas ES,
`Chatzistefanou K, Ferrara N, Adamis AP. Vascular endothelial growth factor is sufficient to produce iris neovascularization and neovascular
`glaucoma in a nonhuman primate. Arch Ophthalmol. 1996;114:964–970. Copyright 1996 American Medical Association.23
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`Miller
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`disease (such as proliferative diabetic retinopathy and
`iris neovascularization), whereas VEGF levels were
`low in eyes with quiescent disease or in normal
`control eyes (Fig. 8).
`Aiello then went on, collaborating with Lois Smith
`and Eric Pierce, to inhibit VEGF using soluble VEGF
`receptors in a murine model of retinopathy of
`prematurity, and found that blocking VEGF in this
`fashion led to a pronounced reduction in retinal
`neovascularization, the first time that VEGF inhibi-
`tion was shown to decrease neovascularization in the
`eye (Fig. 9).21
`Adamis and I and our group, working with
`Ferrara, used the ischemic retinopathy and iris
`neovascularization model
`to test
`the A461 full-
`length anti-VEGF antibody (essentially the precur-
`sor to Avastin), and we found that intravitreal
`injection of the antibody prevented any iris neovas-
`cularization, whereas a control antibody had no
`(Fig. 10).22 We also injected VEGF into
`effect
`normal eyes in our primate model, and found that
`this recapitulated all that we saw in neovascular eye
`disease, such as new blood vessels in the iris,
`neovascular glaucoma, retinal ischemia, and micro-
`angiopathy (Fig. 11).23,24
`At this point, in 1996, we were eager to develop a
`clinical treatment for patients. We had extensive
`evidence that VEGF had a key role in ischemic
`retinal disease in animal models and in humans. For
`neovascular AMD, there was perhaps less direct
`evidence for a causal role of VEGF, but there was
`definitely an unmet need, and Genentech (San
`Francisco, CA, USA) had a clear opportunity with
`several
`inhibitors of VEGF. Genentech, however,
`had many drugs in their pipeline at that time, and
`were perhaps influenced by Roche (Basel, Switzer-
`land), who had supported clinical trials in AMD
`using a-interferon, which had negative out-
`comes.25,26 Genentech,
`thus, was less driven to
`pursue ophthalmic targets. Genentech continued to
`develop anti-VEGF drugs, primarily for cancer
`indications, but its ophthalmology program lagged
`somewhat. After several employees left
`to form
`Eyetech Pharmaceuticals (New York, NY) and
`develop pegaptanib (Macugen), the newly competi-
`tive environment led to renewed interest at Genen-
`tech for AMD therapies.
`In the meantime, our group continued preclinical
`work with Ferrara et al. at Genentech, demonstrat-
`ing that VEGF,
`indeed, was upregulated in the
`model of laser-induced choroidal neovascularization
`(CNV), which was relevant to AMD. Since we were
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`
`Fluorescein angiogram of one eye after intravenous
`Figure 12.
`injection with fluoresceinated anti-VEGF antibody, demonstrating
`localization to experimental choroidal neovascularization.
`Hyperfluorescence noted 1 minute after injection (A), 20 minutes
`after injection (B), and with leakage noted one hour after injection.
`Reproduced with permission from Tolentino MJ, Husain D,
`Theodosiadis P, et al. Angiography of
`fluoresceinated anti-
`vascular endothelial growth factor antibody and dextrans in
`experimental choroidal neovascularization. Arch Ophthalmol.
`2000;118:78–84. Copyright 2000 American Medical Association.27
`
`specifically VEGF 121 and VEGF 165 (Fig. 7), which
`are the secreted isoforms.18
`In collaboration with D’Amico and Folkman,
`Adamis and I collected vitreous samples from
`patients, and found that VEGF levels were signifi-
`cantly increased in eyes with proliferative diabetic
`retinopathy.19 In a much larger study,20 Lloyd Paul
`Aiello, working with George King and Napoleone
`Ferrara, collected samples from patients with diabetic
`retinopathy and RVO, and found that
`increased
`VEGF levels were associated with active neovascular
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`Miller
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`Figure 13. VEGF blockade prevents CNV. Left: Fluorescein angiogram of control (A, C) and prevention (B, D) eyes with laser-induced
`lesions. (A) Early frame of the control eye, which received intravitreal vehicle injection. (B) Early frame of the prevention eye, injected with
`humanized monoclonal anti-VEGF antibody (rhuFab VEGF). (C) Late frame of the control eye (vehicle). (D) Late frame of the prevention
`eye (rhuFab VEGF). Late frames demonstrate presence of grade 4 lesions in the control eye but not in the prevention eye. Right: Total
`number of grade 4 CNV lesions in the control group (shaded bars) versus prevention group (empty bar) 2 weeks (day 35) and 3 weeks (day
`42) after laser induction. Injections of anti-VEGF or vehicle preceded laser induction of CNF. Reproduced with permission from Krzystolik
`MG, Afshari MA, Adamis AP, et al. Prevention of experimental choroidal neovascularization with intravitreal anti-vascular endothelial
`growth factor antibody fragment. Arch Ophthalmol. 2002;120:338–346. Copyright 2002 American Medical Association.29
`
`unsure whether an intravitreally injected antibody
`could reach CNV, we tested whether intravenous
`delivery of anti-VEGF antibodies might be effective,
`and demonstrated that it could, indeed, reach the
`CNV (Fig. 12) and persist for several days.27
`As described by Ferrara,28 the development of
`anti-VEGF agents continued, ultimately resulting in
`two molecules: bevacizumab (Avastin), the full-length
`antibody, and ranibizumab (Lucentis), the antibody
`fragment. Our group investigated intravitreal injec-
`tion of the anti-VEGF antibody fragment (essentially
`
`in the laser-induced CNV model, and
`Lucentis)
`showed it could prevent neovascularization (Fig.
`13), suggesting that this approach might be effective
`for neovascular AMD.29
`the founding of Eyetech
`As I hinted earlier,
`Pharmaceuticals led to some interesting outcomes.
`Its founders included former Genentech employees,
`Marty Glick and John McLaughlin, and three
`familiar ophthalmologists: David Guyer, Samir
`Patel, and Tony Adamis. They led the development
`of pegaptanib (Macugen) into clinical trials, and
`
`Figure 14. MARINA 2-year results: Mean changes in visual acuity from baseline to 24 months in patients injected with ranibizumab (0.3
`and 0.5 mg monthly) versus sham injections. Reproduced with permission from Rosenfeld PJ, Brown DM, Heier JS, et al. Ranibizumab for
`neovascular age-related macular degeneration. N Engl J Med. 2006;355:1419–1431. Copyright 1996 Massachusetts Medical Society.32
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`Miller
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`Figure 17. VEGF-induced blood-retinal breakdown. Fluorescein
`angiogram shows dilation, tortuosity, and leakage of temporal retinal
`vessels, 4 days after a single injection of 1.25 lg VEGF mixed with
`nonneutralizing antibody. Reproduced with permission from
`Tolentino MJ, Miller JW, Gragoudas ES, et al.
`Intravitreous
`injections of vascular endothelial growth factor produce retinal
`ischemia and microangiopathy in an adult primate. Ophthalmology.
`1996;103:1820–1828. Copyright 1996 Elsevier.24
`
`On the other hand, the Phase 3 results using
`ranibizumab for neovascular AMD were dramatic
`(Fig. 14). One-year results from the Minimally
`Classic/Occult Trial of the Anti-VEGF Antibody
`Ranibizumab in the Treatment of Neovascular Age-
`Related Macular Degeneration (MARINA)
`trial
`were presented in 2005, and 2-year results were
`published the following year,32 and showed for the
`first time that sustained vision improvement was
`possible, in patients given intravitreal injections with
`anti-VEGF therapy (0.3 mg or 0.5 mg ranibizumab),
`compared to gradual vision loss in sham-injected
`patients over the same course of time. Similar results
`obtained from after 1 year of treatment in the Anti-
`VEGF Antibody for the Treatment of Predominant-
`ly Classic Choroidal Neovascularization in Age-
`Related Macular Degeneration (ANCHOR) study,33
`which compared verteporfin photodynamic therapy
`
`Figure 15. Neovascular AMD showing improved OCT after
`intravitreal
`injection of approximately 1.0 mg Avastin.
`(A)
`Baseline,
`(B) 1 week postinjection,
`(C) 4 weeks postinjection.
`Reproduced with permission from Rosenfeld PJ, Moshfeghi AA,
`Puliafito CA. Optical coherence tomography findings after an
`intravitreal injection of bevacizumab (Avastin) for neovascular age-
`related macular degeneration. Ophthalmic Surg Lasers Imaging.
`2005;36:331–335. Copyright 2005 Slack, Inc.34
`
`Phase 3 data showed its efficacy in slowing vision
`loss in all forms of neovascular AMD.30 This was the
`first demonstration of efficacy of an antiangiogenic
`therapy in ophthalmology, and, thus, noteworthy.
`The vision outcomes with pegaptanib were not better
`than those achieved with verteporfin photodynamic
`therapy (Visudyne), a treatment developed earlier by
`our group,31 but were applicable to a broader range
`of neovascular AMD subtypes.
`
`Figure 16. OCT scans of a patient with RVO (JWM patient seen at Massachusetts Eye and Ear). The intraretinal cystic changes and
`subretinal fluid (left) completely resolved after treatment with anti-VEGF therapy (right).
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`Miller
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`Table 1. Anti-VEGF Therapy for AMD
` 2004: Pegaptanib (Macugen)
` 2005: Bevacizumab (Avastin), off label
` 2006: Ranibizumab (Lucentis)
` 2011: Aflibercept (Eylea)
` .90% of patients avoid moderate vision loss
` 1/3 achieve vision of 20/40 or better
` CATT, IVAN, and other trials demonstrate similar
`vision outcomes with a variety of anti-VEGF agents
`
`with the same dosing of ranibizumab as the
`MARINA trial.
`The same year that the ranibizumab results were
`presented (in fact, at
`the same meeting), Philip
`Rosenfeld presented optical coherence tomography
`(OCT) data showing improvement in OCT findings
`with stable vision in a patient with neovascular AMD
`after intravitreal injection of bevacizumab (Fig. 15).34
`This was dramatic and unexpected—we did not think
`that full-length antibody would be effective—but this
`stunning finding led to widespread off-label use of
`
`Avastin for neovascular AMD, which continues to
`this day.
`Today, clinicians have multiple anti-VEGF agents
`to use: pegaptanib, bevacizumab (off label), ranibizu-
`mab, and aflibercept (Eylea; Table 1). With these drugs,
`more than 90% of patients avoid moderate vision loss,
`and approximately a third of patients achieve vision of
`20/40 or better. More recently, the CATT, IVAN, and
`other trials have demonstrated similar vision outcomes
`with a variety of anti-VEGF agents.35,36
`What about anti-VEGF therapy beyond AMD?
`The earliest evidence of efficacy in the eye was
`achieved in a model of
`ischemic retinopathy,
`essentially a model of RVO.22 Therefore, it made
`sense to investigate anti-VEGF therapy for RVO.
`With the results of numerous Phase III studies of
`bevacizumab/ranibizumab and aflibercept, BRA-
`VO,37 CRUISE,38 COPERNICUS,39,40 GALI-
`LEO,41 and VIBRANT,42 we can conclude that
`anti-VEGF therapy is effective for RVO (Fig. 16);
`both branch retinal vein (BRVO) and central retinal
`vein (CRVO) occlusion.
`Additionally, we had shown that VEGF injected
`
`Left: Preretinal neovascularization in peripheral retina. Artery (‘‘a’’) and veins (‘‘v’’) in the peripheral retinal of an eye injected
`Figure 18.
`with VEGF. The artery displays tortuosity and dilation, with microaneurysmal-like formations at the levels of precapillary arterioles and
`capillaries. In the flat perspective (lower left), saccular neovascular buds obscure the parent veins (paired arrows). Right: Upper right shows
`a macula of a VEGF-injected eye with grotesquely dilated and saccular capillaries and veins. White arrowhead indicates microaneurysmal-
`like structure, and black arrow indicates arteriole. FAZ, foveal avascular zone. Lower: Section taken through the microaneurysmal-like
`structure (indicated by white arrowhead in the upper panel), showing endothelial cell hyperplasia (black arrowhead) and basement
`membrane material occluding the lumen. Reproduced with permission from Tolentino MJ, McLeod DS, Taomoto M, Otsuji T, Adamis AP,
`Lutty GA. Pathologic features of vascular endothelial growth factor-induced retinopathy in the nonhuman primate. Am J Ophthalmol.
`2002;133:373–385. Copyright 2002 Elsevier.43
`
`10
`
`TVST j 2016 j Vol. 5 j No. 2 j Article 9
`
`Samsung et al. v. Regeneron IPR2023-00884
`Regeneron Pharmaceuticals, Inc. Exhibit 2114 Page 10
`
`

`

`Miller
`
`into a normal eye causes breakdown of the blood
`retinal barrier (Figs. 17, 18), seen as fluorescein
`leaking out of retinal vessels and changes in the retinal
`vasculature that are reminiscent of
`the vascular
`aberrations in diabetic retinopathy and other ischemic
`retinopathies,24 as well as endothelial cell hyperpla-
`sia.43 Therefore, it is not surprising that anti-VEGF
`therapy also is successful for diabetic macular edema
`(DME), showing benefit
`in Phase III DRCRnet
`clinical trials,44,45 the RIDE/RISE trials,46 and more
`recently in the Protocol T study comparing ranibizu-
`mab, aflibercept, and bevacizumab.47
`The story of VEGF, from discovery to therapy,
`shows that we not only solved for Factor X, but also
`that we were able to develop treatments that
`dramatically improved outcomes for patients for
`AMD, diabetic retinopathy, RVO, and other retinal
`disorders. Today, we recognize the contributions of
`the 2014 Champalimaud Vision Award Laureates and
`their respective teams, but also the contributions of
`many other physicians, scientists, funding agencies,
`industry partners, and especially the patients who
`enrolled in the clinical trials.
`However,
`there is more to be done, and the
`research continues. We must improve our phenotyp-
`ing and develop biomarkers for AMD, diabetic
`retinopathy, and RVO. We must develop treatments
`for early AMD. Moreover, I believe that we must
`target other pathways beyond VEGF, particularly in
`DME and RVO.
`I would like to conclude with a quote from Leonor
`Beleza: ‘‘Now we start afresh every day with the sense
`that today is already past and tomorrow is the
`present. We honour [Antonio Champalimaud’s]
`philosophy of life: A search for excellence. . .out-
`comes. . .rigour. . .and knowledge.’’
`
`Acknowledgments
`
`Presented at the annual meeting of the Association
`for Research in Vision and Ophthalmology (ARVO),
`Denver, Colorado, May 5, 2015. Previously presented
`in part as The Harvard Angiogenesis Story: The Paul
`Henkind Memorial Lecture at
`the 34th annual
`meeting of
`the Macula Society in Boca Raton,
`Florida, March 11, 2011 (Miller JW. The Harvard
`Angiogenesis Story. Surv Ophthalmol. 2014;59:361–
`364).
`
`Disclosure: J.W. Miller, Alcon Research Council
`(C), Amgen (C), KalVista (C), Maculogix (C),
`
`11
`
`Valeant via Massachusetts Eye and Ear (P,R), ONL
`Therapeutics (C,P).
`
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