KOL EVENT MEETING MARCH 5, 2018 - An update on promising results with PRIMA in advanced dry-AMD - Pixium Vision
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KOL EVENT MEETING An update on promising results with PRIMA in advanced dry-AMD MARCH 5, 2018 KOL Meeting - Paris - March 5, 2019 1
Forward Looking Statements T his doc um ent c o nta in s inf or m at ion on P ix iu m Vis ion ’s m ark ets and c om peti t i ve pos i t ion , and m ore s pec if ic a l l y, on th e s i ze of its m ark ets . T his i nf orm atio n h a s been d ra wn f rom var io us s our c es o r f rom th e c om pani es o wn es t i m ates . In ves to rs s h ou ld not bas e the i r i n ve s tm ent dec is ion on th i s inf orm atio n . T h is d o c um ent als o c ont a ins c e rta i n f or ward - look ing s ta tem ents . T hes e s tatem ent s are not gua rantees of the Com pan y's f utu re pe rf orm ance . T hes e f or wa rd- l ook ing stat em ents r e late to th e Com pan y' s f utur e pr os pec ts , de ve lo pm ents and m ark etin g s trat eg y and are b as ed on an a l ys es of e arn ings f orec as ts and es tim ates of am ounts not ye t determ i nab le . For wa r d - look ing s t atem ents ar e s ubj ec t to a va r iet y of ris k s and unc erta i nt ies as t he y re la te to f uture e ve nts and a re dependen t on c irc um s tanc es that m a y o r m a y not m ater ia l i ze in the f uture . P ix i um V is ion dra ws yo u r a ttent i on to t he f ac t tha t as f or ward - loo k ing s ta tem ents c ann o t unde r a n y c i rc um s tanc e be c ons true d as a guar a n tee of the Com pan y's f uture perf orm anc e an d that the Com pan y’ s ac tua l f inanc i a l pos it i on, res u l ts and c as h f l o w, as we l l as the tre nds in the s ec t or in wh ic h th e C om pan y ope rate m a y d if f er m ater ia l l y f r om thos e p ropos ed o r ref l ec ted in the f or ward- lo ok ing s tatem ent s c onta in ed i n th i s do c um ent . Furth erm ore, e ve n if Pix ium V is ion ’s f inanc ia l pos i t ion, res u lts , c as h- f lo ws and de v e lopm ents in the s ec t or in w hic h the C om pan y op e rates were to c onf orm to the f or ward - look i ng s t ate m ents c onta ine d in th i s doc um ent, s uc h res u lts o r de v e lopm ents c a nnot b e c o ns tru ed as a re l i ab le ind ic a t ion of the C om pan y's f uture res u lt s or d e ve lopm ents . T he C om pan y does no t u ndertak e a n y o b l igat i on to up date or t o c o nf irm pr oj ec t ions o r e s tim ates m ade b y ana l ys ts o r t o m ak e pub l ic an y c orrec t i on to an y p r os pec t i ve inf or m at ion in orde r to ref lec t an e v ent or c irc um s tanc e t hat m a y oc c ur af ter th e date of th is pres e nt ati on . A des c r ipt io n of thos e even ts tha t m a y ha ve a m ater i a l ad ve rs e ef fec t on the b us ines s , f i nanc ia l pos it i on o r res ults of P ix ium V is ion, or on its a b i l it y t o m eet its ta rgets , appea rs in th e s ec ti ons " R is k Fac to r s " of its “ Doc um ent d e Bas e” f i led wi th th e F renc h Au tor i té de s Marc hés F inanc ie rs . B y at tend in g t h is p r es entat io n o r ac c ept i ng th is doc um ent, you agr ee to be bound by the f oregoing res tric tions s et out above . KOL Meeting - Paris - March 5, 2019 2
• A Bioelectronics company developing bionic vision systems to compensate for severe vision loss or blindness • PRIMA, miniaturized wireless implant, novel breakthrough technology to treating blindness • In clinical stage initially treating dry age-related macular degeneration (dry-AMD), a significant unmet medical need Corporate Presentation – February 2019 3
Agenda ▪ 8:30 Welcome & introduction K. Ishaque, CEO Pixium Vision ▪ 8:35 PRIMA inventor’s motivation Pr. D. Palanker ▪ 8:50 First in human study PRIMA in AMD Pr. J-A. Sahel ▪ 9:05 Real world unmet medical need: Atrophic dry-AMD Pr. F. Holz ▪ 9:20 Q&A ▪ 10:00 Close KOL Meeting - Paris - March 5, 2019 4
PRIMA inventor’s motivation Daniel Palanker, PhD Professor Department of Ophthalmology, School of Medicine, and Director Hansen Experimental Physics Laboratory, Stanford University, California, USA KOL Meeting - Paris - March 5, 2019 5
Photovoltaic Restoration of Sight in Age-Related Macular Degeneration Daniel Palanker Department of Ophthalmology and Hansen Experimental Physics Laboratory Stanford University, CA KOL Meeting - Paris - March 5, 2019 6
Subretinal Electrical Stimulation of the Bipolar Cells Electric current Neural signals KOL Meeting - Paris - March 5, 2019 7
Photovoltaic Retinal Prosthesis: System Design camera dichroic mirror Subretinal implant 880nm beam KOL Meeting - Paris - March 5, 2019 8
1 0.9 20 mm pixels, Restoration of central vision in AMD 0.8 8 levels of grey 0.7 0.6 acuity 0.5 0.4 0.3 0.2 0.1 0 0 10 20 30 40 eccentricity, degrees KOL Meeting - Paris - March 5, 2019 9
Operation of Subretinal Photovoltaic Prosthesis Advantages of the photovoltaic approach: 880 nm light • Simplicity of the PV implant allows its miniaturization and wireless operation. Neural signals • Small size and lack of wires enables minimally invasive surgery. • Modular design enables enlarging visual field GCL via small retinotomy. • Image projection is naturally linked to eye movements. • System enables image processing (autofocus, zoom, contrast enhancement, background removal, etc.). • System can be integrated with advanced INL computer vision for naming the people, reading the text and other advanced functions. • Image can be transferred directly from a computer to the video glasses for reading, watching TV, etc. KOL Meeting - Paris - March 5, 2019 100 mm 10
Photovoltaic Retinal Prosthesis: System Design KOL Meeting - Paris - March 5, 2019 11
Benefits of the network-mediated retinal stimulation RCS pON RCS pOFF • Flicker fusion at high (>20Hz) frequencies (now confirmed in patients). • Adaptation to static images. • Antagonistic center-surround organization of receptive fields. • ON and OFF responses. • Linear and non-linear summation of subunits in RGC receptive fields, which is essential for high acuity. Natural + Prosthetic, 48mm pitch • Spatial resolution matching the pixel pitch, at least up to 50 µm (equivalent of 20/200 acuity in a human eye). 17mm 48mm KOL Meeting - Paris - March 5, 2019 12
Pilot clinical trial of the PRIMA system in patients with geographic atrophy 2x2 mm array, 30 µm thick, 100 µm pixels 1 month post surgery Implant appears thicker in OCT due to refractive index difference All patients perceive bright white-yellow patterns of retinotopically correct shapes and locations. KOL Meeting - Paris - March 5, 2019 13
Tests of Prosthetic Vision • Patients preferred frequency: 10 Hz and above (30 Hz). • Minimum bar width: 1 pixel in all 4 patients with subretinal placement, 2 pixels in one patient with intra-choroidal placement of the implant. • Bar orientation: 88-96% correct in all 4 patients with subretinal placement. • Visual acuity measured with Landolt C is only 10-30% below the theoretical minimum for the 100 µm pixel size: Theoretical maximum with 100 µm pixels 20/420 (1.32 logMAR), 1.0 pixel Patient 2, pre-op: 20/800 (1.6 LogMAR) 20/550 (1.44 logMAR), 1.35 pixels Opaque video goggles Patient 3, pre-op: 20/1000 (1.7 LogMAR) 20/500 (1.40 logMAR), 1.23 pixels with a camera Patient 5, pre-op: 20/500 (1.4 LogMAR) 20/460 (1.37 logMAR), 1.15 pixels KOL Meeting - Paris - March 5, 2019 14
Smaller pixels enabled by honeycomb arrays 0.5 A/cm2 mm 40 INL INL 20 0 -50 0 50 mm • Stimulation thresholds greatly reduced • Penetration depth and stimulation threshold do not depend on pixel width! DV=E·l=j · r · l, j - current density, r - tissue resistivity, l – length of the cell. KOL Meeting - Paris - March 5, 2019 15
Honeycomb Arrays 40 mm 30 mm 20 mm 6 weeks post implantation in RCS rats DAPI – all nuclei, IBA1- microglia, GS -Müller glia RGC IPL INL Array KOL Meeting - Paris - March 5, 2019 16
Summary ✓ Subretinal pixels larger than 70 µm provide sufficient penetration of electric field into the inner retina. ✓ Clinical results with PRIMATM (100µm pix) are very encouraging. ✓ Pixels smaller than 50 µm will be based on honeycomb arrays. ✓ Ultimate goal: to achieve visual acuity >20/100 using 20 µm honeycomb pixels. About 10,000 pixels in a 2 mm array. KOL Meeting - Paris - March 5, 2019 17
First in human study PRIMA in AMD José-Alain Sahel, MD Professor and Chairman of the Department of Ophthalmology at University of Pittsburgh Medical Center (UPMC), USA Director of the Institut de la Vision (Sorbonne-Université/Inserm/CNRS), Paris Chairman of the Department of Ophthalmology at Centre Hospitalier National d’Ophtalmologie des XV-XX, and Fondation ophtalmologique Rothschild, Paris KOL Meeting - Paris - March 5, 2019 18
PRIMA System ▪ Designed to restore central vision within geographic atrophy. ▪ Wireless subretinal chip with photodiodes activated by near-infrared (NIR) light projected from video glasses, Invented by Daniel Palanker (Stanford) ▪ PRIMA chip replaces the lost photoreceptors and stimulates the bipolar cells in the INL. ▪ The remaining retinal network preserves many features of the natural signal processing. KOL Meeting - Paris - March 5, 2019 19
PRIMA system Images captured by the camera integrated into the augmented reality glasses are projected onto the retina using pulsed near- infrared (NIR) light. NIR beam Subretinal wireless photovoltaic chip converts pulsed light into pulsed electric current in each pixel to stimulate the adjacent inner retinal neurons. Subretinal implant KOL Meeting - Paris - March 5, 2019 20
Generating an ex vivo model of a degenerated primate retina Vibratome section of the retina ONL Implant INL GCL ? NF Multi-electrode array KOL Meeting - Paris - March 5, 2019 21
Surgical procedure Vitrectomy and Additional manual Sub-retinal BSS detachment, if injection needed Subretinal insertion Retinotomy outside of the 2x2mm wide of the atrophic area, chip using specially preserving the PRL designed forceps Positioning of the Exchange of the chip at the pre- PFCL with air and determined location final tamponade. under PFCL KOL Meeting - Paris - March 5, 2019 22
Early feasibility study design: safety and functionality FEASIBILITY STUDY Restoration of visual function in patients with advanced atrophic dry age related macular degeneration using the PRIMA system: open-label, non-randomized CRITERIA PRIMARY ENDPOINT Safety and elicitation of visual perception by • 5 eyes of 5 patients electrical stimulation of the PRIMA implant • VA < 20/400 measured by Octopus Visual Field. • GA of at least 3 Optic Disc Diameters without any other Microperimetry to : pathology – Confirm the absolute scotoma in the • No light perception in the atrophic area atrophic area • Fellow eye with useful vision – Identify the main PRL to ensure its preservation KOL Meeting - Paris - March 5, 2019 23
PRIMA implant in the atrophic macula PRIMA implant: 1 month post surgery 2x2 mm array, 30 µm thick, with 378 pixels of 100 µm Implant is located in the middle of the geographic atrophy area, in close proximity to the INL. KOL Meeting - Paris - March 5, 2019 24
Results ▪ 5 consecutive patients successfully implanted between December 2017 and June 2018 in Paris: – 3 with silicone oil removed at week 4 / 2 with gas (C2F6 and SF6). ▪ Surgery duration < 2 hours. ▪ Complications: – 1 intraoperative complication: movement of the patient head under local anesthesia during implantation led to thin subretinal bleeding, which resolved after 6 weeks. – 1 SAE at day 1 - acute hypertony resolved 2 days later without consequence. – 1 small migration of the chip due to early posture change after surgery. The chip remained within the atrophic area. – 1 retinal detachment one year after surgery, retina reattached, no impact on implant KOL Meeting - Paris - March 5, 2019 25
Anatomical Results P1 P4 6M 1M P2 P5 6M 6W P3 The implant appears in OCT twice thicker 6M due to higher refractive index of Si compared to that of the retinal tissue. Dashed line indicates position of the back side of the implant resting on Bruch’s membrane. KOL Meeting - Paris - March 5, 2019 26
Visual acuity (ETDRS) Pre vs. Post implantation Average VA without System - ETDRS Pre-op Baseline Post-op 1st measurement measurement after surgery PRIMA can be safely implanted under the atrophic macula while preserving the residual natural peripheral visual acuity, measured via ETDRS KOL Meeting - Paris - March 5, 2019 27
Results ▪ No other serious post-operative complications during the follow up currently ranging from 4 to 10 months. ▪ No decrease in natural vision compared to pre-operative acuity. ▪ Patients are trained to use the system and progress to describe patterns, objects, letters, etc. elicited via the PRIMA chip in atrophic areas of the macula. ▪ Objective vision tests were conducted using opaque glasses to prevent confusion with residual natural vision. KOL Meeting - Paris - March 5, 2019 28
PRIMA central visual perception at 6 Months • Octopus Visual Field Measurement* • Fully opaque glasses: light perception via PRIMA chip only P1 P2 P3 P4 P5 System ON System OFF *performance of the PRIMA chip and system without use of any peripheral remaining vision (only with fully opaque glasses) KOL Meeting - Paris - March 5, 2019 29
Tests of Prosthetic Vision Acuity measured with Landolt C Theoretical limit with 100 µm pixels 20/400 (1.30 logMAR), 1.0 pixel Subject A : PRE-OP : CF 20/550 (1.44 logMAR), 1.35 pixels Subject B : PRE-OP : HM 20/500 (1.40 logMAR), 1.23 pixels Subject C : PRE-OP LogMAR 1.4 20/460 (1.37 logMAR), 1.15 pixels 15-35% below the theoretical limit of resolution for 100 µm pixels KOL Meeting - Paris - March 5, 2019 30
Control: System ON vs OFF KOL Meeting - Paris - March 5, 2019 31
Conclusions ▪ Subretinal implantation of the wireless PRIMA chip in atrophic dry AMD is feasible and safe. ▪ No decrease in residual natural vision compared to pre-operative visual acuity. ▪ ALL 5 patients reached the functional primary end point of the feasibility study (visual perception in the former scotoma). ▪ PRIMA provided the best prosthetic visual acuity to date: 20/460 – only 15% below the theoretical limit for 100mm pixels. ▪ Most subjects recognize complex patterns close to the theoretical limit of the implant resolution. KOL Meeting - Paris - March 5, 2019 32
Next Steps ▪ Similar feasibility study initiated in Pittsburgh, USA (J. Martel, J.A. Sahel). ▪ European multicenter pivotal study is planned for 2019. ▪ Implants with smaller pixels are being developed and tested in preclinical studies (Palanker’s group at Stanford). KOL Meeting - Paris - March 5, 2019 33
Real world unmet medical need: Atrophic dry-AMD Frank G. Holz, MD Chairman and Professor, Department of Ophthalmology, University of Bonn, Germany President Elect of European Society of Retinal Specialists (EURETINA) KOL Meeting - Paris - March 5, 2019 34
Dry AMD /Geographic Atrophy Frank G. Holz University of Bonn, Germany KOL Meeting - Paris - March 5, 2019 35
AMD Progressive Visual Impairment Loss of High Contrast BCVA Metamorphopsia (distortion) Neovascular AMD Early AMD Intermediate AMD Scotoma Geographic (central blind spot) Atrophy » Late AMD severe loss of vision, independence, and quality of life, increased rates of falls, depression, and institutionalization KOL Meeting - Paris - March 5, 2019 36
Therapy neovascular AMD Introduction anti-VEGF-Therapy 10 years ago KOL Meeting - Paris - March 5, 2019 37
Age-related macular degeneration (AMD) Dry AMD – major unmet need • Leading cause of blindness • Even with effective treatments for neovascular AMD, atrophy is still the long-term outcome • Chronic progressive neurodegenerative disease • Many challenges including multifactorial pathogenesis KOL Meeting - Paris - March 5, 2019 38
Macular Function Courtesy S. Trauzettel-Klosinski KOL Meeting - Paris - March 5, 2019 39
KOL Meeting - Paris - March 5, 2019 40
“Dry” Age-related macular degeneration (AMD) “Geographic atrophy“ Drusen Pigment abnormalities Early/intermediate AMD Late-stage AMD KOL Meeting - Paris - March 5, 2019 41
Loss of RPE on FAF correlates with photoreceptor loss on SD-OCT S Schmitz-Valckenberg, M Fleckenstein, AP Göbel, TC Hohman, FG Holz. IOVS 52:1-6;2011 KOL Meeting - Paris - March 5, 2019 42
Loss of RPE in FAF images correlates with loss of photoreceptor function on microperimetry KOL Meeting - Paris - March 5, 2019 43
Spectri and Chroma Pooled Outcome: Change in Best-Corrected Visual Acuity from Baseline to Week 48 0 Mean Change From Baseline in ETDRS BCVA Letter Score ETDRS letter score ∆ from BL Lq4 −4.1 (n = 601) -5 Lq6 −4.9 (n = 604) ∆ Means vs Sham Pooled (95% CI) P value Sham −4.9 (n = 604) ▬ Lampalizumab 0.8 ETDRS letters (−0.4, q4w 2.1) 0.20 ▬ Lampalizumab 0.1 ETDRS letters (−1.2, q6w 1.3) 0.94 -10 0 12 24 36 48 Time Since Randomization, weeks Holz FG, Sadda SR, Busbee B, Chew EY, Mitchell P, Tufail A, Brittain C, Ferrara D, Gray S, Honigberg L, Martin J, Tong B, Ehrlich JS, Bressler NM; Chroma and Spectri Study Investigators. JAMA Ophthalmol. 2018 May 2 44
Structural Assessment - Imaging Modalities Colour fundus photography Fundus autofluorescence Near-infrared reflectance OCT-Angiography Fluorescein angiography SD-OCT/SS-OCT KOL Meeting - Paris - March 5, 2019 45
KOL Meeting - Paris - March 5, 2019 46
KOL Meeting - Paris - March 5, 2019 47
Geographic Atrophy Assessment Fundus Autofluoresence Imaging KOL Meeting - Paris - March 5, 2019 48
Geographic Atrophy – Disease progression KOL Meeting - Paris - March 5, 2019 49
Geographic atrophy - Prognostic markers for disease progression 1 mm²/year 2 mm²/year 5 mm²/year ➢High variability in GA progression rate AREDS Lindblad et al. 2009, BDES Klein et al. 2008, BMES Joachim et al. 2013, FAM Holz et al. 2007, GAIN Biarnes et al. 2015, GAP Schmitz-Valckenberg et al. 2016, GAS Sunness et al. 1999, KOL Meeting - Paris - March 5, 2019 50
Geographic Atrophy: Fundus Autofluorescence Automated Detection and Quantification Schmitz-Valckenberg S, Brinkmann CK, Alten F, Herrmann P, Stratmann NK, Göbel AP, Fleckenstein M, Diller M, Jaffe GJ, Holz FG. Invest Ophthalmol Vis Sci. 2011;52:7640-6 KOL Meeting - Paris - March 5, 2019 51
Geographic atrophy (GA) - Morphologic markers for disease progression ➢ Prognostic information for future disease progression ➢ Identification of patients at high risk loosing visual acuity / reading ability ➢ Unequal distribution of patients with risk-features in clinical trials may counterfeit / obscure a therapeutic effect Fleckenstein M, Mitchell P, Freund B, Sadda SR, Holz FG, Brittain C, Henry EC, Ferrara D. Review. Ophthalmology 2017 S0161-6420(17)30968-5 KOL Meeting - Paris - March 5, 2019 52
Geographic atrophy (GA) - Heterogeneity Fleckenstein M, Adrion C, Schmitz-Valckenberg S, Göbel AP, Bindewald-Wittich A, Scholl HP, Mansmann U, Holz FG, FAM-Study group. Invest Ophthalmol Vis Sci. 2010;50:3915-21 KOL Meeting - Paris - March 5, 2019 53
Visual Function Outcome Measures KOL Meeting - Paris - March 5, 2019 54
Interventional GA trials Oxidative stress Genetic predisposition Environment Brimonidine 2 α-Lipoic Acid 2 OT-551 Tandospirone 2 Phase 2 3 Phase 3 Accumulation of cellular by-products Emixustat MC-1101 2 GSK933776 Fenretinide ALK-001 RN6G Inflammation Complement Cascade RPE impairment Fluocinolone Metformin 2 APL-2 2 LFG316 CPCB-RPE1 2 MA09-hRPE Oracea 3 Minocycline 2 CLG561 2 Eculizumab CNTO 2476 2 HuCNS-SC Copaxone Sirolimus Zimura 2 Lampalizumab 3 NT-501 GA 55 FG Holz, EC Strauss, S Schmitz-Valckenberg, M van Lookeren Campagne. Ophthalmology 121:1079-1091;2014
Lampalizumab: Selective Inhibitor of Complement Factor D, the Rate-limiting Enzyme of the Alternative Complement Pathway Scientific rationale: genetic evidence implicates complement cascade dysregulation in GA/AMD1,2 Complement factor D: rate-limiting enzyme of the alternative complement pathway with lowest plasma concentration of Complement Factor D Lampalizumab complement proteins3,4 C3 Convertase Lampalizumab: an antigen-binding fragment of a humanized monoclonal antibody that inhibits complement factor D3,4 Phase 2 Mahalo: GA area progression from baseline to C5 Convertase 18 months was reduced by 20% in the monthly lampalizumab-treated group versus sham5 Membrane attack complex 56
GA Area Growth From Baseline Over Time to Week 48 2.5 Wk 48 ∆ from BL Pooled Lq4 2.06 mm2 2.5 Wk 48 ∆ from BL Mean Change from BL GA Area, mm2 Mean Change From Baseline GA Area, mm2 Lq6 2.05 mm2 Lq4 2.09 mm2 2.0 Lq6 2.02 mm2 2.0 Sham 1.98 mm2 Sham 1.93 mm2 1.5 1.0 0.5 1.5 0.0 0 12 24 36 48 Time Since Randomization, weeks 1.0 2.5 Wk 48 ∆ from BL Mean Change from BL GA Area, mm2 Lq4 2.02 mm2 ∆ Means Relative 2.0 Lq6 2.09 mm2 vs Sham Pooled (95% CI) Reduction P value Sham 2.04 mm2 0.5 1.5 ▬ Lampalizumab q4w 0.07 mm2 (−0.05, 0.19) −3.6% 0.247 1.0 ▬ Lampalizumab q6w 0.07 mm2 (−0.05, 0.19) −3.5% 0.255 0.5 0.0 0.0 0 12 24 36 48 0 12 24 36 48 Time Since Randomization, weeks Time Since Randomization, weeks FG Holz et al. JAMA Ophthalmol 2018, 136(6):666-77 57
Age-related macular degeneration (AMD) Dry AMD – how to proceed • See how C3-inhibition works in phase 3 • Role of the ARMS2/HTRA1 risk polymorphism? • Identify new targets • Restoring function with device • Define acceptable endpoints for earlier intervention KOL Meeting - Paris - March 5, 2019 58
KOL Meeting - Paris - March 5, 2019 59
Earlier Intervention? CFP FAF SD-OCT KOL Meeting - Paris - March 5, 2019 60
State of the Art 16 Mio € Text • oder • Aufzählungen 11
Thank you KOL Meeting - Paris - March 5, 2019 62
PRIMA device development plan in dry-AMD Feasibility study Pivotal study 6-m 1-y CE results follow-up Mark* 2018 2019 2020 2021 2022 US FIH Feasibility study Accelerated Access Program PMA** *CE Mark – EU regulatory approval to commercialize **PMA – US FDA regulatory approval to commercialize Corporate Presentation - February 2019 63
KOL EVENT MEETING An update on promising results with PRIMA in advanced dry-AMD MARCH 5, 2018 KOL Meeting - Paris - March 5, 2019 64
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