Photoreceptors (PRs), as the most abundant and light-sensing cells of the neuroretina, are responsible for converting light into electrical signals that can be interpreted by the brain. PR degeneration, including morphological and functional impairment of these cells, causes significant diminution of the retina’s ability to detect light, with consequent loss of vision. Recent findings in ocular regenerative medicine have opened promising avenues to apply neuroprotective therapy, gene therapy, cell replacement therapy, and visual prostheses to the challenge of restoring vision. However, successful visual restoration in the clinical setting requires application of these therapeutic approaches at the appropriate stage of the retinal degeneration. In this review, firstly, we discuss the mechanisms of PR degeneration by focusing on the molecular mechanisms underlying cell death. Subsequently, innovations, recent developments, and promising treatments based on the stage of disorder progression are further explored. Then, the challenges to be addressed before implementation of these therapies in clinical practice are considered. Finally, potential solutions to overcome the current limitations of this growing research area are suggested. Overall, the majority of current treatment modalities are still at an early stage of development and require extensive additional studies, both pre-clinical and clinical, before full restoration of visual function in PR degeneration diseases can be realized.Graphical Abstract

Photoreceptor degeneration is a major cause of untreatable blindness worldwide and has recently been targeted by emerging technologies, including cell- and gene-based therapies. Cell types of neural lineage have shown promise for replacing either photoreceptors or retinal pigment epithelial cells following delivery to the subretinal space, while cells of bone marrow lineage have been tested for retinal trophic effects following delivery to the vitreous cavity. Here we explore an alternate approach in which cells from the immature neural retinal are delivered to the vitreous cavity with the goal of providing trophic support for degenerating photoreceptors. Rat and human retinal progenitor cells were transplanted to the vitreous of rats with a well-studied photoreceptor dystrophy, resulting in substantial anatomical preservation and functional rescue of vision. This work provides scientific proof-of-principle for a novel therapeutic approach to photoreceptor degeneration that is currently being evaluated in clinical trials.

Objective: To assess the safety and tolerability of intravitreal injection of human retinal progenitor cells (RPCs) at multiple dose levels in adults with non-syndromic retinitis pigmentosa (RP).Design: A prospective, multicenter, open-label, single-arm, Phase I/IIa safety study of RPCs in adults with RP (n = 28). Two patient cohorts were studied: Cohort 1: BCVA no better than 20/200 and no worse than Hand Motions, and Cohort 2: BCVA no better than 20/40 and no worse than 20/200).Subjects: Adults (n = 28) with a clinical diagnosis of RP confirmed by electroretinogram, consenting to gene mutation typing for genes involved in inherited retinal degenerations and related disorders, and willing to undergo human leukocyte antigen (HLA) typing.Methods: Subjects, who were not selected for genotype, were divided across the two vision cohorts with each receiving a single intravitreal injection of one of: 0.5, 1.0, 2.0, or 3.0 × 10⁶ allogeneic RPCs. Initially, subjects received the lowest dose (0.5 × 10⁶ RPCs) in the worse-seeing eye. Each dose group contained equal numbers of subjects from Cohorts 1 and 2.Results: Intravitreal RPC injection was well tolerated and associated with mostly transient mild to moderate adverse events. There were no signs of graft rejection. While primarily a safety study, exploratory efficacy assessments suggested improved BCVA measurements at all doses, with a possible dose-response at the highest levels. Mean BCVA change from pre-treatment to Month 12 in the treated vs untreated eyes was 1.4 letters for the 0.5 × 10⁶ dose group, 1.0 letters for the 1.0 × 10⁶ group, 4.8 letters for the 2.0 × 10⁶ group, and 9.0 letters for the 3.0 × 10⁶ group. Additional patient-reported changes included increased light sensitivity, improved object recognition, color discrimination, and reading.Conclusion: A single intravitreal injection of RPCs was well tolerated in this safety study. The exploratory efficacy data suggest potential improvement of BCVA in some RP patients, particularly at the highest dose. While viewed cautiously, the possible treatment effect should be further investigated in larger controlled studies. The RPC technology has received FDA Regenerative Medicine Advanced Therapy designation. Later phase studies are ongoing.Clinical trial registration: https://clinicaltrials.gov/study/NCT02320812, NCT02320812.

Intravitreal transplantation of allogeneic human retinal progenitor cells (hRPCs) holds promise as a treatment for blinding retinal degenerations. Prior work has shown that neural progenitors are well-tolerated as allografts following single injections; however, sequential delivery of allogeneic cells raises the potential risk of host sensitization with subsequent immune rejection of grafts. The current study was designed to assess whether an immune response would be induced by repeated intravitreal transplants of allogeneic RPCs utilizing the mouse animal model. We injected murine retinal progenitor cells (gmRPCs), originally derived from donors with a C57BL/6 genetic background, into BALB/c recipient mice in order to provide safety data as to what might be expected following repeated treatment of patients with allogeneic human cell product. Immune responses to gmRPCs were mild, consisting of T cells, B cells, neutrophils, and natural killer cells, with macrophages clearly the predominating. Animals treated with repeat doses of gmRPCs did not show evidence of sensitization, nor was there immune-mediated destruction of the grafts. Despite the absence of immunosuppressive treatments, allogeneic gmRPC grafts survived following repeat dosing, thus providing support for the preliminary observation that repeated injection of allogeneic RPCs to the vitreous cavity is tolerated in patients with retinitis pigmentosa.

Photoreceptor degeneration is a major cause of untreatable blindness worldwide and has recently been targeted by emerging technologies, including cell- and gene-based therapies. Cell types of neural lineage have shown promise for replacing either photoreceptors or retinal pigment epithelial cells following delivery to the subretinal space, while cells of bone marrow lineage have been tested for retinal trophic effects following delivery to the vitreous cavity. Here we explore an alternate approach in which cells from the immature neural retinal are delivered to the vitreous cavity with the goal of providing trophic support for degenerating photoreceptors. Rat and human retinal progenitor cells were transplanted to the vitreous of rats with a well-studied photoreceptor dystrophy, resulting in substantial anatomical preservation and functional rescue of vision. This work provides scientific proof-of-principle for a novel therapeutic approach to photoreceptor degeneration that is currently being evaluated in clinical trials.