METHODS AND COMPOSITIONS FOR TREATING CONE-ROD RETINAL

DYSTROPHY

CROSS-REFERENCE TO RELATED APPLICATIONS This application claims the benefit of the filing dates of U.S. Provisional Application

No. 62/551,212 filed August 28, 2017 and U.S. Provisional Application No. 62/664,063 filed April 27, 2018, the entire contents of which are incorporated by reference.

BACKGROUND OF INVENTION

Mutations in GUCY2D, the gene encoding retinal guanylate cyclase-1 (retGCl), are the leading cause of autosomal dominant, cone-rod dystrophy (adCORD). GUCY2D- adCORD or cone -rod dystrophy type 6 (CORD6) account for 35% of adCORD cases.

Patients present with a loss of visual acuity, abnormal color vision, photophobia, visual field loss and macular atrophy within the first decade. In severe cases, rod degeneration and loss of peripheral visual field follow.

SUMMARY OF THE INVENTION

Aspects of the application relate to methods of treating a subject having a cone-rod dystrophy (CORD6, e.g. , autosomal dominant CORD6) by administering a first nucleic acid that encodes a guide RNA (gRNA) that targets a guanylate cyclase gene (e.g. , a GUCY2D gene) sequence, and a second nucleic acid that encodes an RNA-guided endonuclease. In some embodiments, the gRNA targets both an autosomal dominant allele of GUCY2 (e.g., GUCY2D) and a wild-type allele of GUCY2 (e.g., GUCY2D) in the subject. In some embodiments, the method further comprises administering a replacement nucleic acid to the subject, wherein the replacement nucleic acid encodes a replacement functional guanylate cyclase. In some embodiments, the gRNA specifically targets an autosomal dominant allele of GUCY2 (e.g., GUCY2D) relative to a wild-type allele of GUCY2 (e.g., GUCY2D). In some embodiments, the RNA-guided endonuclease is selective for the autosomal dominant allele of GUCY2 (e.g., GUCY2D). In some embodiments, the first and second nucleic acids are administered in rAAV particles.

In some embodiments, the replacement nucleic acid is administered in an rAAV particle. In some embodiments, the replacement nucleic acid comprises a functional GUCY2 gene (e.g., a functional GUCY2 cDNA, a functional GUCY2D cDNA or other guanylate cyclase coding sequence) that is hardened relative to the gRNA. In some embodiments, the replacement nucleic acid comprises a functional GUCY2 gene that is hardened such that the gRNA no longer recognizes the gene or the RNA guided endonuclease no longer recognizes the PAM site. In some embodiments, the replacement nucleic acid comprises a functional GUCY2D gene that is hardened such that the gRNA no longer recognizes the gene or the RNA guided endonuclease no longer recognizes the PAM site.

In some embodiments, the first nucleic acid comprises a first promoter operatively connected to a gene encoding the gRNA, and wherein the first promoter is selected from the group consisting of U6, HI, opsin, rhodopsin kinase, CRX, FIZ1, CMV, CBA, EFla, Nrl, IRBP, IRBP-GNAT2, and Cone Arrestin promoters. In some embodiments, the second nucleic acid comprises a second promoter operatively connected to a gene encoding the RNA-guided endonuclease, and wherein the second promoter is selected from the group consisting of U6, HI, opsin, rhodopsin kinase, CRX, FIZ1, CMV, CBA, EFla, Nrl, IRBP, IRBP-GNAT2, and Cone Arrestin promoters. In some embodiments, the replacement nucleic acid comprises a replacement promoter that is operatively connected to a replacement functional GUCY2 gene (e.g., GUCY2D), and wherein the replacement promoter is selected from the group consisting of U6, HI, opsin, rhodopsin kinase, CRX, FIZ1, CMV, CBA, EFla, Nrl, IRBP, IRBP-GNAT2, and Cone Arrestin promoters.

In some embodiments, the gRNA is encoded by a nucleic acid comprising a sequence of SEQ ID NO: 9. In some embodiments, the gRNA is encoded by a nucleic acid comprising a sequence of SEQ ID NO: 13. In some embodiments, an encoded gRNA comprises the corresponding RNA sequences to SEQ ID NO: 9 or SEQ ID NO: 13 in which Thymines (Ts) are replaced by Uracils (Us).

In some embodiments, the RNA-guided endonuclease is Cas9. In some embodiments, the selective RNA-guided endonuclease is a modified Cas9 that is selective for the autosomal dominant allele of GUCY2. In some embodiments, GUCY2 is GUCY2D.

In some embodiments, the subject has a symptom selected from the group consisting of loss of visual acuity, abnormal color vision, photophobia, visual field loss, macular atrophy, rod degeneration, loss of cones, and/or loss of peripheral visual field. In some embodiments, the replacement nucleic acid comprises a wild-type GUCY2D gene. In some embodiments, the replacement nucleic acid comprises a wild-type GUCY2D gene from a non-human primate species. In some embodiments, the rAAV capsid particles comprise rAAV capsid proteins of AAV5, AAV8, AAV9, rhlO, rh8, Anc80, AAV 44.9, AAV2(triple Y-F), AAV2(quad Y-F+T-V), AAV2(MAX)deltaHS, also known as AAV2(4pMut)deltaHS. In some embodiments, the rAAV particles comprises rAAV capsid proteins of serotype 5 or serotype 8. In some embodiments, the nucleic acids and/or rAAV particles are administered intravitreally to one or both eyes of the subject. In some embodiments, the nucleic acids and/or rAAV particles are administered subretinally to one or both eyes of the subject.

Aspects of the disclosure include an rAAV particle comprising an rAAV genome, wherein the rAAV genome comprises first nucleic acid that encodes a gRNA that targets a GUCY2 (e.g., GUCY2D) gene. In some embodiments, the rAAV genome also comprises a replacement nucleic acid that encodes a functional guanylate cyclase. In some embodiments, the gRNA is specific for a dominant mutant allele of GUCY2D. In some embodiments, the rAAV capsid particles comprise rAAV capsid proteins of AAV5, AAV8, AAV9, rhlO, rh8, Anc80, AAV 44.9, AAV2(triple Y-F), AAV2(quad Y-F+T-V), AAV2(MAX)deltaHS, also known as AAV2(4pMut)deltaHS. In some embodiments, the rAAV particle comprises AAV capsid proteins of serotype 5 or serotype 8. In some embodiments, the rAAV genome comprises a promoter operatively linked to a gene encoding the gRNA. In some

embodiments, the promoter is selected from the group consisting of U6, HI, opsin, rhodopsin kinase, CRX, FIZ1, CMV, CBA, EFla, Nrl, IRBP, IRBP-GNAT2, and Cone Arrestin promoters.

Aspects of the disclosure include an rAAV particle comprising an rAAV genome, wherein the rAAV genome comprises a nucleic acid that encodes a RNA-guided

endonuclease that is selective for an autosomal dominant GUCY2 gene (e.g., GUCY2D). In some embodiments, the RNA-guided endonuclease is a Cas9 that is selective for an autosomal dominant GUCY2 gene (e.g., GUCY2D). In some embodiments, the rAAV capsid particles comprise rAAV capsid proteins of AAV5, AAV8, AAV9, rhlO, rh8, Anc80, AAV 44.9, AAV2(triple Y-F), AAV2(quad Y-F+T-V), AAV2(MAX)deltaHS, also known as AAV2(4pMut)deltaHS. In some embodiments, the rAAV particle comprises AAV capsid proteins of serotype 5 or serotype 8. In some embodiments, the rAAV genome comprises a promoter operatively linked to a gene encoding the RNA-guided endonuclease. In some embodiments, the promoter is selected from the group consisting of U6, HI , opsin, rhodopsin kinase, CRX, FIZ1, CMV, CBA, EFla, Nrl, IRBP, IRBP-GNAT2, and Cone Arrestin promoters. In some embodiments, the RNA-guided endonuclease is a self-inactivating RNA- guided endonuclease. In some embodiments, the nucleic acid coding the RNA-guided endonuclease is inactivated in an inducible manner. In some embodiments, the nucleic acid coding the RNA-guided endonuclease is inactivated in an inducible manner with

doxycycline/tetracycline.

In some embodiments, the subject is a mammal. In some embodiments, the subject is a primate. In some embodiments, the subject is human. In some embodiments, the method reduces the severity of one or more of the following symptoms in the subject: loss of visual acuity, abnormal color vision, photophobia, visual field loss, macular atrophy, rod

degeneration, loss of cones, and/or loss of peripheral visual field.

Aspects of the disclosure include an rAAV particle comprising an rAAV genome, wherein the rAAV genome comprises a nucleic acid that encodes a RNA-guided

endonuclease that is selective for a GUCY2D gene, wherein the nucleic acid coding the RNA- guided endonuclease is inactivated in an inducible manner. In some embodiments, the RNA- guided endonuclease is inactivated in an inducible manner with doxycycline/tetracycline.

These and other aspects are described in more detail herein. BRIEF DESCRIPTION OF THE DRAWINGS

The following drawings form part of the present specification and are included to further demonstrate certain aspects of the present disclosure, which can be better understood by reference to one or more of these drawings in combination with the detailed description of specific embodiments presented herein.

FIG. 1 shows the regulation of wildtype and R838 adCORD retGCl in dark and light. ECD= extracellular domain; KHD= kinase homology; DD= dimerization; CAT= catalytic domains.

FIG. 2 shows Gucy2e and GUCY2D gRNAs screened for activity by plasmid transfection in mouse 3T3 and human HEK293 cells, respectively and indel rates determined by the T7E1 assay. GUCY2D gRNA27 has the highest editing efficiency (46% indels) in human cells, in vitro.

FIGs. 3A-3F show Gucy2e gRNA16- (FIG. 3A), GUCY2D gRNA27- (FIG. 3B), and SaCa9- (FIG. 3C) containing vector plasmids. Transcript analysis reveals expression of each gRNAs and Cas9 only in GFP+ cells from treated retinas of WT mice (FIG. 3D). AAV- mediated Cas9 expression was evident in WT retinas co-injected with gRNAs (FIG. 3E), but was absent from retinas treated with AAV-Cas9 alone (FIG. 3F).

FIGs. 4A-4C show representative fundus images of GCl ^+/~ :GC2 ^_/~ mice injected with either AAV5-Gucy2e gRNA 16-hGRK 1 -GFP or AAV5-GUCY2D gRNA27 -hGRK 1 -GFP (FIG. 4A). ERG analysis shows a loss of both rod and cone function 6 weeks post-treatment with AAV5-Gucy2e gRNA 16-hGRK 1 -GFP (FIGs. 4B and 4C).

FIG. 5 shows representative retinal cross sections from GCl ^+/~ :GC2 ^~/~ mice injected with either AAV5-Gucy2e gRNA 16-hGRK 1 -GFP or AAV5-GUCY2D gRN A27 -hGRK 1 - GFP, and AAV5-hGRKl-Cas9. ONL- outer nuclear layer; INL- inner nuclear layer;GCl- ganglion cell layer.

FIGs. 6A and 6B show fluorescent fundus images from macaque that reveal GFP expression in multiple blebs of AAV5-GUCY2D gRNA27-hGRKl-GFP- and AAW5-Gucy2e gRNA 16-hGRK 1 -GFP- treated eyes (FIG. 6A). OCT scans through macular blebs and mfERG measurements from central retina are shown at baseline and 2 months post-injection.

FIG. 7 shows Indel analysis in macaque cell populations. OD- right eye, OS- left eye, IT-inferior temporal retina.

FIG. 8 shows retGCl expression lost in photoreceptors of macaque injected with AAV5-GUCY2D gRN A27 -hGRK 1 - GFP + AAV5-hGRKl-Cas9. Conversely, retGCl is properly localized and expressed in AA Y5-Gucy2e gRNA16-hGRKl-GFP-treated photoreceptors.

FIG. 9 shows human GUCY2D gene (SEQ ID NO: 1) with the location of gRNA targets. The protospacer and PAM recognition sequence of allele specific guide, GUCY2D- gRNA838 and evolved Cas9 are included along with an alignment of the corresponding mouse (SEQ ID NO: 2) and human (SEQ ID NO: 3) R838S mutant sequence.

FIG. 10 shows a selection scheme for evolved, allele specific Cas9 and analysis of specificity in vitro for mutant versus WT allele.

FIGs. 11A-11B show two different approaches for limiting the duration of Cas9 expression. FIG. 11A is a construct design for a Tet-inducible self-inactivating Cas9 system. FIG. 1 IB is a construct design for a dual vector Tet-inducible self-inactivating system.

FIG. 12 shows AAV constructs containing gRNA targeted to Gucy2e and 'hardened' GUCY2D tagged with either GFP or HA at the C-terminus. Codon optimization adds Kpnl restriction site for easy identification. SEQ ID NOs: 4-6 are listed from top to bottom, respectively.

FIG. 13 shows a sequence encoding guide RNA (gRNA) 27 (SEQ ID NO: 9) and human GUCY2D gene antisense (SEQ ID NO: 10) with corresponding macaque (SEQ ID NO: 11) and mouse (SEQ ID NO: 12) gene antisense comparisons. It further shows a sequence encoding guide RNA (gRNA) 16 (SEQ ID NO: 13) and mouse Gucy2e gene antisense (SEQ ID NO: 14) with corresponding human (SEQ ID NO: 15) and macaque (SEQ ID NO: 16) gene antisense comparisons. Protospacer and PAM recognition sequences are shown in an alignment of corresponding mouse, human and macaque sequence. SEQ ID NOs: 9-16 are listed from top to bottom, respectively. FIG. 14 shows GFP expression from the Gucy2e gRNA 16 and GUCY2D gRNA 27 vectors, respectively in subretinally injected WT mice. gRNA expression was directly correlated with success of subretinal injection, as evidenced by GFP expression in fundus images.

FIGs. 15A-15C show that Gucy2e-gRNA and GUCY2D-gKNA were present in GFP+

PRs of left and right eyes, respectively 6 weeks post injection in WT mice.

FIG. 16 shows editing rates by indel sequencing.

FIGs. 17A-17I show 20-weeks post-injection results for treated GC1 ^+/" :GC2 ^~/_ mice. FIGs. 17A-17F show that AAV-CRISPR/Cas9- based editing of Gucy2e in photoreceptors of the eyes of GCl ^+/~ :GC2 ^_/~ mice alters retinal function and structure as a consequence of reduced retGCl expression.

FIGs. 18A-18H show that in AAW-Gucy2e gRNA + AAV-Cas9 injected eyes, ONL thinning was restricted to the region of the GFP+ injection bleb

FIGs. 19A-19D show 10 week post-injection results for GUCY2D editing in

GUCY2D(R838S) transgenic mice.

FIG. 20 shows Western blots of protein from macaque retinas treated with AAV- Cas9 plus either AAV-G£/CF2£>-gRNA27 or control AAV-Gac 2e-gRNA16 were probed for the presence of retGCl and its biochemical partner, GCAP1.

FIGs. 21A-21H show stained retinal cross sections from macular blocks of

GRl 14QB ' s right and left eyes, with focus placed on the edge of the bleb, where both GFP+ and GFP- PRs (those with and without gRNA) could be found.

FIG. 22 shows fundus images of WT mice 6 weeks post-injection with AA Y-Gucy2e gRNA-hGRKl-GFP vector alone (top). Exposure and gain settings were consistent throughout.

FIG. 23A-23C show the ELISPOT assay of T cell responses to SaCas9.

FIG. 24 shows ERG analysis performed at 4 and 6 weeks post- injection of GC1 ^+/" :GC2 ^_/" mice injected with AAV8(733)-hGRKl-/zdG«c;y2e + AAV5-hGRKl-Cas9 + AAV5- U6-G«c 2e-gRNA 16-GRK 1 -GFP vectors . FIG. 25 shows Sanger sequencing results in GC1 ^" :GC2 ^{" "} mice subretinally injected with AAV5-hGRKl-Cas9 + AAW5-Gucy2e gRNA- hGRKl-GFP vectors. Sequences from top to bottom correspond to SEQ ID NOs: 43-63.

FIG. 26 shows Sanger sequencing results in macaques subretinally injected with AAV5-hGRKl-Cas9 + AAV5-GUCY2D gRNA- hGRKl-GFP vectors. Sequences from top to bottom correspond to SEQ ID NOs: 64-82.

DETAILED DESCRIPTION OF THE INVENTION

Provided herein are methods and compositions for treating autosomal dominant eye disorders, for example an autosomal dominant cone-rod dystrophy (e.g., CORD6). In certain embodiments, a therapeutically effective amount of a composition is administered to a subject to treat and/or prevent an autosomal dominant disorder or condition as described herein. For example, the compositions herein can be used to treat diseases or conditions associated with mutations in a GUCY2D gene.

In some embodiments, an autosomal dominant allele associated with an eye disorder (e.g., a dominant allele of the GUCY2D gene) is knocked out in one or more cells of a subject (e.g., in one or more eye cells of the subject) having an autosomal dominant eye disorder. In some embodiments, the dominant allele is specifically knocked out and the remaining functional (e.g., wild-type) allele in a heterozygous subject is sufficient for eye function (e.g., for retinal or photoreceptor function). In some embodiments, both alleles of the gene (e.g., both the dominant allele and the corresponding wild type allele in a heterozygous subject) are knocked out and a separate copy of the gene (e.g., of a wild type allele of the gene) is provided to replace the function of the alleles that were knocked out.

In some embodiments, a CRISPR-based technique is used to knock out one or both alleles of a gene associated with an eye disorder. In some embodiments, an allele- specific, CRISPR-based technique is used to specifically knock out an autosomal dominant allele of a gene of interest. In some embodiments, an allele-non-specific, CRISPR-based technique is used to knock out both alleles of a gene of interest (e.g., both the autosomal dominant allele and the wild-type allele).

In some embodiments, an allele- specific, CRISPR-based technique involves delivering an allele-specific guide RNA (gRNA) and/or an allele- specific RNA-guided endonuclease (e.g., an allele-specific Cas9 protein) to target cells (e.g., disease-affected eye cells) in a subject.

In some embodiments, an allele-non-specific, CRISPR-based technique involves delivering an allele-non-specific guide RNA (gRNA) and an allele-non-specific RNA-guided endonuclease to target cells (e.g., disease-affected eye cells) in a subject.

In some embodiments, a gRNA and/or an RNA-guided endonuclease can be delivered by delivering a first nucleic acid encoding the gRNA and a second nucleic acid encoding the RNA-guided endonuclease to a subject. In some embodiments, the first and second nucleic acids are included on the same nucleic acid molecule. In some embodiments, the first and second nucleic acid are on separate nucleic acids. In some embodiments, the first and second nucleic acids are delivered using a recombinant adeno-associated virus (rAAV). In some embodiments, both nucleic acids are included on the same rAAV genome and delivered in the same rAAV particle comprising the rAAV genome. In some embodiments, the nucleic acids are included on separate rAAV genomes and provided in different rAAV particles.

In some embodiments, an rAAV particle comprising an rAAV genome, wherein the rAAV genome comprises a nucleic acid that encodes a RNA-guided endonuclease that is selective for a GUCY2D gene, wherein the nucleic acid coding the RNA-guided

endonuclease is inactivated in an inducible manner. In some embodiments, the RNA-guided endonuclease is inactivated in an inducible manner with doxycycline/tetracycline.

In some embodiments, other techniques can be used to knock out one or both alleles of a gene of interest (e.g., of GUCY2D). In some embodiments, other gene-targeting approaches (e.g., using TALENS, meganucleases, or other suitable gene-targeting techniques) can be used to knock out one or both alleles of a gene of interest. However, in some embodiments RNA-targeting approaches (e.g., using RNAi or other suitable RNA- targeting techniques) can be used to knock down or silence expression (e.g., to reduce RNA expression levels partially or completely) of one or more alleles of a target gene.

In some embodiments, when both alleles of a target gene (e.g., both GUCY2D alleles in a subject) are knocked out or knocked down in a subject, a replacement nucleic acid is provided to provide a functional variant of the target gene (e.g., a wild-type GUCY2D gene). In some embodiments, a replacement allele of a gene of interest comprises one or more nucleotide substitutions relative to the target allele(s) of the gene of interest to avoid being targeted by the gene-targeting molecules (e.g., the CRISPR gRNA and/or RNA-guided endonucleases) and/or the RNA-targeting molecules. In some embodiments, one or more (or all) of the nucleotide substitutions are silent (they don't alter the amino acid sequence of the protein encoded by the gene). In some embodiments, 1 or more, for example 2, 3, 4, 5, 6, 7, 8, 9, or 10 nucleotide substitutions are included in the replacement gene. In some embodiments, the portion of the gene in which the substitutions are made is located within the region recognized the gRNA or is within the PAM site of the Cas9 endonuclease. In some embodiments, the replacement gene or allele is referred to as a "hardened" gene or allele, because it is not targeted by the gene-targeting or RNA-targeting molecules used to knock out or knock down the target allele(s) of interest, and/or the Cas9 endonuclease (e.g., the autosomal dominant and/or wild-type alleles of GUCY2D). In some embodiments, the replacement nucleic acid comprises a functional GUCY2D gene that is hardened such that the gRNA no longer recognizes the gene or the RNA guided endonuclease no longer recognizes the PAM site.

In some embodiments, a replacement nucleic acid is delivered by administering the replacement nucleic acid to one or both eyes (e.g., to one or more cell types in one or both eyes) of a subject. In some embodiments, the replacement nucleic acid is delivered using a recombinant adeno-associated virus (rAAV) comprising an rAAV genome that includes the replacement gene of interest.

In some embodiments, the replacement nucleic acid is included on the same rAAV genome as the first and/or the second CRISPR nucleic acids (e.g., encoding the gRNA and/or RNA-guided endonuclease, respectively). In some embodiments, the RNA-guided endonuclease is a self-inactivating RNA-guided endonuclease. In some embodiments, the nucleic acid coding the RNA-guided endonuclease is inactivated in an inducible manner. In some embodiments, the nucleic acid coding the RNA-guided endonuclease is inactivated in an inducible manner with doxycycline/tetracycline.

5 In some embodiments, the replacement nucleic acid is included on the same rAAV genome as the first nucleic acid encoding the gRNA and both are delivered in the same rAAV particle, and the second nucleic acid encoding the RNA-guided nuclease is included on a separate rAAV genome and delivered in a different rAAV particle. In some embodiments, the replacement nucleic acid is included on the same rAAV genome as the second nucleic o acid encoding the RNA-guided nuclease, and both are delivered in the same rAAV particle, and the first nucleic acid encoding the gRNA is included on a separate rAAV genome and delivered in a different rAAV particle. In some embodiments, the replacement nucleic acid, and the first and second nucleic acids (encoding the gRNA and RNA-guided nuclease, respectively) are all included on the same rAAV genome and delivered in the same rAAV5 particle. In some embodiments, the replacement nucleic acid, and the first and second

nucleic acids are each on a different rAAV genome and delivered in a different rAAV particle.

A composition comprising one or more recombinant nucleic acids and/or rAAV particles comprising the recombinant nucleic acids (e.g., one or more of the replacement o nucleic acid, the first and/or second CRISPR nucleic acids) can be delivered to target cells using any appropriate technique. In some embodiments, the composition is delivered via injection, for example via injection into one or more target loci in one or both eyes of a subject. In some embodiments, an injection is an intravitreal injection. In some

embodiments, an injection is a subretinal injection. In some embodiments, an injection is a 5 sub Dinner limiting membrane (subILM) injection (e.g., Boye SE, Alexander JJ, Witherspoon CD, Boye SL, Peterson JJ, Clark ME, Sandefer KJ, Girkin CA, Hauswirth WW, Gamlin PD. Highly Efficient Delivery of Adeno-Associated Viral Vectors to the Primate Retina. Hum Gene Ther. 2016 Aug;27(8):580-97. doi: 10.1089/hum.2016.085, incorporated herein by reference). In some embodiments, an injection is a suprachoroidal injection. In some embodiments, an injection is an intravascular injection.

In some embodiments, target cells in a subject are one or more of the following non- limiting types of eye cells, including photoreceptors, cone cells, rod cells, retinal epithelial cells, retinal bipolar cells, retinal ganglion cells and RPE cells.

In some embodiments, a subject is a patient (e.g., a human patient) that has an autosomal eye or retinal disease. Eye and retinal diseases vary widely, but most of them cause visual symptoms. Retinal diseases can affect any part of the retina. In some embodiments, a subject is a patient that has an autosomal dominant cone-rod dystrophy (e.g., CORD6). In some embodiments, a patient has one or more signs or symptoms, and methods and compositions described in this application can be used to alleviate or correct one or more of these signs or symptoms and/or restore (e.g., partially or completely) one or more aspects of normal eye function. In some embodiments, the replacement nucleic acid comprises a wild-type GUCY2D gene. In some embodiments, signs or symptoms can include one or more of loss of visual acuity, abnormal color vision, photophobia, visual field loss, macular atrophy, rod degeneration, loss of cones, and/or loss of peripheral visual field. In some embodiments, signs or symptoms can include reduced cone function. Cone function can be measured by ERG or multi-focal ERG (mfERG) or other electrophysiological testing.

Accordingly, in some embodiments aspects of the application relate to knocking out a dominant mutant form of GUCY2D. GUCY2D (e.g., NCBI Reference Sequence:

NG_009092.1) encodes retinal guanylate cyclase- 1 (retGCl), a protein expressed exclusively in the outer segments of photoreceptors (PRs) in the vertebrate retina (predominantly cones). Upon light stimulation, cGMP hydrolysis by cGMP phosphodiesterase (PDE) leads to closure of cGMP-gated channels, a reduction in intracellular Ca2+ and hyperpolarization of PRs. Through its activation by Ca2+-sensitive guanylate cyclase activating protein- 1 (GCAP1), retGCl plays a role in the recovery phase of phototransduction by producing cGMP within outer segments. This increase in cGMP re-opens cGMP-gated channels leading to an increase in intracellular Ca2+. Thus, the physiological link between GC1, GCAP1 and intracellular Ca2+ affects the polarization state of the PR.

Autosomal recessive, loss of function mutations in GUCY2D, can cause Leber congenital amaurosis-1 (LCAl). Subretinally delivered AAY-Gucy2e (murine homologue of GUCY2D) is capable of restoring retinal function and visually guided behavior over the long term in three different mouse models of LCAl. In contrast, autosomal dominant cone-rod dystrophy type 6 (CORD6) results from over- activity of retGCl, rather than loss of function. Its biochemical basis is as follows. The dimerization domain of wild type retGCl is predicted to form an a-helical coiled-coil structure with four turns that are broken at residue R838. In CORD6, mutations at residue R838 are predicted to cause this structure to continue for additional turns (FIG. 1). As a result, CORD6 mutants have increased affinity for activation by GCAP1 and require much higher concentrations of Ca2+ in order to be suppressed. It is predicted that PR cell death follows due to overproduction of cGMP by the cyclase which leads to a larger influx of Ca2+ into the PR, disruption of mitochondrial outer membrane, caspase activation and ultimately apoptosis. Mutations in GUCY2D are a leading cause of adCORD, accounting for -35% of cases. Patients present with a loss of visual acuity, abnormal color vision, photophobia, visual field loss and macular atrophy within the first decade. In severe cases, rod degeneration and loss of peripheral visual field follow loss of cones. Electroretinography reveals cone dysfunction with variable levels of rod involvement. There are no therapies currently available for treating CORD6. Notably, the vast majority of CORD6-causing mutations are located in the same residue (838).

In some embodiments, aspects of the disclosure relate to knocking out a dominant mutation in GUCY2D. In some embodiments, CORD6 can be treated using a gene editing approach and/or a gene silencing approach. In some embodiments, CORD6 can be treated using CRISPR/Cas9 as the gene editing approach. In some embodiments, CORD6 can be treated using an allele- specific gene editing approach. In some embodiments, allele- specific guide RNAs (gRNAs) and/or allele- specific Cas9 variants are used for allele specific gene editing. In some embodiments, CORD6 can be treated using an allele-non-specific gene editing approach. In some embodiments, the allele-non-specific gene editing approach also includes providing a functional replacement of GUCY2D. In some embodiments, Cas9 can be deactivated by Dox induction. In some embodiments, the Tet repressor is co-expressed from the same peptide as Cas9 {e.g. , by way of a P2A self-cleaving site).

In some embodiments, one or more different recombinant viral vectors are used to deliver one or more genes encoding one or more CRISPR/Cas9 components for allele- specific gene editing. In some embodiments, one or more different recombinant viral vectors are used to deliver one or more genes encoding one or more CRISPR/Cas9 components for allele-non-specific gene editing. In some embodiments, recombinant viral vectors are used to deliver a functional replacement GUCY2D gene or a functional portion thereof.

In some embodiments, separate recombinant viral vectors are used to deliver different genes encoding different CRISPR/Cas9 components and/or a replacement gene (e.g., a hardened replacement gene). The separate recombinant viral vectors can be administered to a subject simultaneously or at different times.

In some embodiments, the recombinant viral vectors are rAAV particles comprising rAAV genomes encoding the one or more genes of interest (e.g., genes encoding gRNA, an RNA-guided nuclease, and/or a replacement gene such as a hardened replacement gene).

In some embodiments, the rAAV particles comprise wild type capsid proteins of any suitable serotype. In some embodiments, the rAAV particles comprise variant capsid proteins of any suitable serotype, wherein the variant capsid proteins comprise one or more amino acid substitutions relative to a corresponding wild-type sequence. In some

embodiments, the rAAV capsid proteins are rAAVs of AAV5, AAV8, AAV9, rhlO, rh8, Anc80, AAV 44.9, AAV2(triple Y-F), AAV2(quad Y-F+T-V), AAV2(MAX)deltaHS, also known as AAV2(4pMut)deltaHS. In some embodiments, the rAAVs are of rAAV serotype 5 or rAAV serotype 8.

In some embodiments, different rAAV genomes encoding different genes of interest are provided in rAAV particles having the same serotype (or with capsid proteins having the same amino acid substitutions). However, in some embodiments different rAAV genomes encoding different genes of interest are provided in different rAAV particles (e.g., of different serotypes and/or comprising mutant capsid proteins having different amino acid

substitutions).

In some embodiments, each gene of interest (e.g., the gRNA gene, the RNA-guided nuclease gene, the functional GUCY2 and/or the functional GUCY2D gene) is operably linked to a promoter. In some embodiments the genes are all under control of the same promoter. In some embodiments, each gene is under the control of a separate promoter. In some embodiments, the separate promoters are of the same type. In some embodiments, the separate promoters are different. In some embodiments, each promoter is independently selected from the group consisting of promoters that are active in one or more photoreceptor cell types. In some embodiments, a promoter is active in both rod and cones cells. In some embodiments, a promoter is rod cell specific. In some embodiments, a promoter is cone cell specific.

In some embodiments, a promoter is a human promoter (e.g., a human promoter of any of the promoter types described in this application). In some embodiments, a promoter is a non-human primate promoter (e.g., a non-human primate promoter of any of the promoter types described in this application). In some embodiments, a promoter is from another mammal (e.g., a mouse) or a non-mammalian species (e.g., a virus). In some embodiments, a promoter is a truncated natural promoter, a chimeric promoter, or a synthetic promoter.

In some embodiments, a promoter or fragment thereof is selected from the group consisting of U6 (e.g., human U6 small nuclear promoter), HI (e.g., human HI promoter), opsin (e.g., human opsin), rhodopsin kinase (e.g., human rhodopsin kinase), CRX (e.g., a cone-rod homeobox), FIZ1 (e.g., a FLT3 interacting zinc finger 1), CMV (e.g., a

cytomegalovirus), CBA (e.g., a chicken beta actin), EFla (e.g., an elongation factor- 1 alpha), Nrl (e.g., a neural retina- specific leucine zipper protein), IRBP (e.g., an interphotoreceptor retinoid-binding protein), IRBP-GNAT2 (e.g., a chimeric promoter comprising portions of the IRBP and G protein subunit alpha transducin 2 promoter sequences), and Cone Arrestin promoters (including, for example, the corresponding human promoter sequences) Gene Editing

Aspects of the application relate to the delivery of nucleic acids and proteins, such as genome editing nucleic acids and proteins, to target GUCY2D. In some embodiments, components of gene/genome editing are provided by AAV.

In some embodiments, one or more complexes, compositions, and/or preparations, a provided for the delivery of one or more functional effector proteins, e.g., nucleases, recombinases, and/or Cas9 proteins (including variants and fusions thereof), and/or nucleic acids (e.g., guide RNAs (gRNAs)) to a cell (e.g., in vitro or in vivo). In some embodiments, the genome editing proteins include Zinc Finger Nucleases (ZFNs), TALENs, CRISPR/Cas proteins, and/or meganucleases. In some embodiments, the cell is associated with the eye. In some embodiments, the cell is a retinal cell. In some embodiments, the biological effect exerts a therapeutic benefit to a subject in which the cell is found. In some embodiments, the complexes, compositions, preparations, systems, kits, and related methods for delivery of functional effector proteins are useful for introducing an effector protein into a cell, e.g., in the context of manipulating the cell for a research or therapeutic purpose. Delivery of site- specific proteins, such as TALENs or Cas9 proteins (or variants or fusions thereof) using the compositions, preparations, systems, kits, and related methods provided herein allows for the targeted manipulation/modification of the genome of a host cell, e.g., in GUCY2D, in vitro or in vivo.

Methods described in this application can be used to deliver proteins and/or nucleic acids into cells for a variety of purposes, such as delivery of therapeutic proteins, or genome editing. As used herein, "genome editing" refers to the adding, disrupting or changing the sequence of specific genes by insertion, removal or mutation of DNA from a genome using artificially engineered proteins and related molecules. For example, genome editing proteins, such as TALENS, may be delivered to a cell using a method described herein. The TALEN can introduce double stranded breaks at a target locus in the host cell genome, resulting in altered gene function and/or expression. TALENS can also promote DNA repair (e.g., non- homologous end joining or homology-directed repair), which is useful for rescue construct- mediated stable integration of foreign genetic material into the genome of a host cell. Rescue constructs, comprising a polynucleotide encoding a desired insertion or mutation, can be delivered before, after, or simultaneously to a genome editing protein in order to introduce a mutation or other alteration at the target locus. A rescue construct can be single- stranded polynucleotide or a double- stranded polynucleotide. In some embodiments, a rescue construct is a single- stranded oligonucleotide DNA (ssODN). In some embodiments, a rescue construct is a plasmid, viral vector, or other nucleic acid.

In some embodiments, a CRISPR/Cas9-based gene editing approach can be used. The CRISPR (clustered regularly interspaced short palindromic repeats)/Cas9 gene editing system can efficiently disrupt genes at desired loci, enabling either complete gene knockout or homology directed repair. In the former, and more commonly used system, a guide RNA (gRNA) directs the Cas9 endonuclease to specific sites in the genome proximal to a protospacer adjacent motif (PAM), causing a double-strand break (DSB). Host cell machinery efficiently repairs the DNA damage via the non-homologous end joining (NHEJ) pathway, and during this process introduce insertions or deletions (indels) at the target site. Gene disruption can thus be achieved if the target site is within the coding sequence and indels lead to frameshifts. Notably, CRISPR/Cas9 has higher targeting efficiency than other gene targeting strategies like zinc finger nucleases (ZFNs) or Transcription Activator-Like Effector Nucleases (TALENs), and is unaffected by DNA methylation status. Despite its widespread use for creating gene knockouts in vitro and in animal models, the use of CRISPR/Cas9 in retina is extremely limited. Only a handful of studies have been published to date. The first targeted a specific form of retinitis pigmentosa by evaluating the ability of electroporated gRNA- and Cas9- containing plasmids in postnatal day 0 (P0) rats to selectively ablate the dominant S334 Rhodopsin mutation. Translational limitations of this study included treatment age, and inefficiency of PR transduction with plasmid DNA. The second study used intravitreally injected AAV2 encoding gRNA and Cas9 to target the YFP locus in postmitotic ganglion cells of the Thy-1 -YFP transgenic mouse. While this study provided a means to rapidly quantify CRISPR/Cas9 efficiency in vivo, it did not target a specific disease locus. The third study took a more generalized approach by asking whether phenotypic conversion of rods into cones could offer protection in the presence of rod- mediated disease. AAVs encoding gRNA and Cas9 were subretinally injected at P14 to target the rod-fate-determinant gene, neural retina leucine zipper (Nrl) in postmitotic mouse PRs. Disruption of Nrl resulted in rods assuming some cone features, and an increased resistance to death in the presence of rod-specific disease causing mutations. However, naturally occurring mutations in the NRL locus are known to cause human disease, calling into question the applicability of this approach. AAV-mediated gRNA and Cas9 were used to induce a targeted deletion in Cep290 in wild type mice. While this study demonstrated the feasibility of creating a genomic deletion in PRs, it was performed in wild type mice and thus no measurable downstream phenotype was produced.

In some embodiments of the present methods and compositions, components of CRISPR/Cas9 are provided to as subject using a recombinant AAV (rAAV) as a delivery vector.

In some embodiments, an rAAV can be used to deliver an sgRNA (single-guide RNA) that combines the tracrRNA and crRNA, which are separate molecules in the native CRISPR/Cas9 system in S. pyogenes, into a single RNA construct, simplifying the components needed to use CRISPR/Cas9 for genome editing (for plasmid or IVT

expression).

In some embodiments, an rAAV can be used to deliver one or more genome editing proteins and/or nucleic acids that are designed to target a sequence in a gene that encodes guanylate cyclase (e.g., a GUCY2D gene, e.g., a protein coding sequence of SEQ ID NO: 7).

In some embodiments, similar methods and compositions can be adapted for treating dominant cone-rod dystrophy due to mutations in guanylate cyclase-activating protein 1 (GCAP1), the accessory protein to GC1. For example, CRISPR/Cas9 components for targeting a gene encoding GCAP1 in a subject (e.g., in a subject, such as a human subject, having one or more mutant alleles, for example a dominant allele, of a gene encoding GCAP1) can be administered to the subject (e.g., using one or more AAV vectors encoding the one or more components). In some embodiments, a replacement copy of a gene encoding a normal GCAP1 protein can be provided to the subject (e.g., using one or more AAV vectors encoding the GCAP1 protein). A non-limiting example of a GCAP1 gene is GUCA1A (see, e.g., SEQ ID NO: 8; Michaelides M, Wilkie SE, Jenkins S, Holder GE, Hunt DM, Moore AT, Webster AR, Mutation in the gene GUCA1A, encoding guanylate cyclase -activating protein 1, causes cone, cone-rod, and macular dystrophy, Ophthalmology 112(8): 1442-7 (2005)). Guanylyl cyclase-activating protein 1 stimulates retinal guanylyl cyclase when free calcium ion concentration is low and inhibits guanylyl cyclase when free calcium ions concentration is elevated. This Ca2+- sensitive regulation of retinal guanylyl cyclase is a key event in recovery of the dark state of rod photoreceptors following light exposure. Accordingly, in some embodiments one or more genome editing proteins and/or nucleic acids are designed to target a sequence in a gene that encodes guanylate cyclase (e.g., GUCA1A, e.g., a protein coding sequence from SEQ ID NO: 8 for example).

Recombinant adeno-associated virus (rAAV) particles and Nucleic Acids

Aspects of the application relate to recombinant AAV (rAAV) particles and nucleic acids. In some embodiments, compositions comprising rAAV particles described in this application are administered to subjects having an eye disorder (e.g., an inherited eye disorder) to treat or help treat the eye disorder (for example, alone or in conjunction with one or more additional therapies).

In some embodiments, a nucleic acid is provided, the nucleic acid comprising an expression construct containing a promoter operably linked to a coding sequence of one or more genes of interest. In some embodiments, a promoter is a natural promoter. In some embodiments, a promoter can be a truncated natural promoter. In some embodiments, a promoter can include an enhancer and/or basal promoter elements from a natural promoter.

In some embodiments, an expression construct including a promoter and a gene of interest is flanked on each side by an inverted terminal repeat sequence. In some embodiments, the expression construct comprises one or more regions comprising a sequence that facilitates expression of the coding sequence of the gene of interest, e.g., expression control sequences operably linked to the coding sequence. Non- limiting examples of expression control sequences include promoters, insulators, silencers, response elements, introns, enhancers, initiation sites, termination signals, and poly(A) tails. Any combination of such control sequences is contemplated herein (e.g., a promoter and an enhancer). In some embodiments, the expression construct includes other regulatory elements including WPRE or a miRNA target sequence (to restrict expression of the vector mediated mRNA in a tissue specific manner, for example miRNA 181c, see Kay et al. Figure 7, Targeting Photoreceptors via Intravitreal Delivery Using Novel, Capsid-Mutated AAV Vectors, PLoS One, 8(4): e62097 (2013)).

In some embodiments, the nucleic acid is a plasmid (e.g., a circular nucleic acid comprising one or more of an origin of replication, a selectable marker, and a reporter gene). In some embodiments, a nucleic acid described herein, such as a plasmid, may also contain marker or reporter genes, e.g., LacZ or a fluorescent protein, and an origin of replication. In some embodiments, the plasmid is transfected into a producer cell that produces AAV particles containing the expression construct.

In some embodiments, the nucleic acid is a nucleic acid vector such as a recombinant adeno-associated virus (rAAV) genome. Exemplary rAAV nucleic acid vectors useful according to the application include single- stranded (ss) or self-complementary (sc) AAV nucleic acid vectors.

In some embodiments, a recombinant rAAV particle comprises a nucleic acid vector, such as a single-stranded (ss) or self-complementary (sc) AAV nucleic acid vector. In some embodiments, the nucleic acid vector contains an expression construct as described herein and one or more regions comprising inverted terminal repeat (ITR) sequences (e.g., wild-type ITR sequences or engineered ITR sequences) flanking the expression construct. In some embodiments, the nucleic acid is encapsidated by a viral capsid.

Accordingly, in some embodiments, a rAAV particle comprises a viral capsid and a nucleic acid vector as described herein, which is encapsidated by the viral capsid. In some embodiments, the viral capsid comprises 60 capsid protein subunits comprising VPl, VP2 and VP3. In some embodiments, the VPl, VP2, and VP3 subunits are present in the capsid at a ratio of approximately 1: 1: 10, respectively.

The ITR sequences of a nucleic acid or nucleic acid vector described herein can be derived from any AAV serotype (e.g., 1, 2, 3, 4, 5, 6, 7, 8, 9, or 10) or can be derived from more than one serotype. In some embodiments of the nucleic acid or nucleic acid vector provided herein, the ITR sequences are derived from AAV2. In some embodiments of the nucleic acid or nucleic acid vector provided herein, the ITR sequences are derived from one or more other serotypes. ITR sequences and plasmids containing ITR sequences are known in the art and commercially available (see, e.g., products and services available from Vector Biolabs, Philadelphia, PA; Cellbiolabs, San Diego, CA; Agilent Technologies, Santa Clara, Ca; and Addgene, Cambridge, MA; and Gene delivery to skeletal muscle results in sustained expression and systemic delivery of a therapeutic protein. Kessler PD, Podsakoff GM, Chen X, McQuiston SA, Colosi PC, Matelis LA, Kurtzman GJ, Byrne BJ. Proc Natl Acad Sci U S A. 1996 Nov 26;93(24): 14082-7; and Curtis A. Machida. Methods in Molecular Medicine™. Viral Vectors for Gene Therapy Methods and Protocols. 10.1385/1-59259-304-6:201 © Humana Press Inc. 2003. Chapter 10. Targeted Integration by Adeno- Associated Virus. Matthew D. Weitzman, Samuel M. Young Jr., Toni Cathomen and Richard Jude Samulski; U.S. Pat. Nos. 5,139,941 and 5,962,313, all of which are incorporated herein by reference).

In some embodiments, the expression construct is no more than 7 kilobases, no more than 6 kilobases, no more than 5 kilobases, no more than 4 kilobases, or no more than 3 kilobases in size. In some embodiments, the expression construct is between 4 and 7 kilobases in size.

The rAAV particle may be of any AAV serotype (e.g., 1, 2, 3, 4, 5, 6, 7, 8, 9, or 10), including any derivative (including non-naturally occurring variants of a serotype) or pseudotype.

In some embodiments, the rAAV particle is an rAAV5 particle. In some embodiments, the rAAV particle is an rAAV8 particle. In some embodiments, the rAAV particle is selected from the group consisting of rAAV2, rAAV9, rhlO, rh8, and Anc80 particles. In some embodiments, the rAAV particle is an rAAV particle comprising one or more amino acid substitutions. Non-limiting examples of derivatives and pseudotypes include AAV2-AAV3 hybrid, AAVrh.10, AAVhu.14, AAV3a/3b, AAVrh32.33, AAV- HSC15, AAV-HSC17, AAVhu.37, AAVrh.8, CHt-P6, AAV2.5, AAV6.2, AAV2i8, AAV- HSC15/17, AAVM41, AAV9.45, AAV6(Y445F/Y731F), AAV2.5T, AAV-HAE1/2, AAV clone 32/83, AAVShHIO, AAV2 (Y->F), AAV8 (Y733F), AAV2.15, AAV2.4, AAVM41, and AAVr3.45. Such AAV serotypes and derivatives/pseudotypes, and methods of producing such derivatives/pseudotypes are known in the art (see, e.g., Mol Ther. 2012

Apr;20(4):699-708. doi: 10.1038/mt.2011.287. Epub 2012 Jan 24. The AAV vector toolkit: poised at the clinical crossroads. Asokan Al, Schaffer DV, Samulski RJ.).

In some embodiments, the rAAV particles comprise capsid proteins having one or more amino acid substitutions (e.g., AAV2(tripleY-F) (Y444F+Y500F+Y730F), see Petrs- Silva et al., Novel Properties of Tyrosine -mutant AAV2 Vectors in the Mouse Retina, Mol. Ther. 19(2): 293-301 (2011); AAV2(quadY-F+T-V)

(Y272F+Y444F+Y500F+Y730F+T491V), see Kay et al., Targeting Photoreceptors via Intravitreal Delivery Using Novel, Capsid-Mutated AAV Vectors, PLoS One, 8(4): e62097 (2013); or AAV2(MAX)deltaHS, also known as AAV2(4pMut)deltaHS

(Y444F+Y500F+Y730F+T491V+R585S+R588T+R487G), see Boye et al., Impact of

Heparan Sulfate Binding on Transduction of Retina by Recombinant Adeno-Associated Virus Vectors, J. Virol. 90(8): 4215-4231 (2016)).

In some embodiments, serotypes of and capsid variants include AAV5, AAV8, AAV9, rhlO, rh8, Anc80, AAV 44.9 (ott.nih.gov/technology/e-175-2015), AAV2(triple Y-F), AAV2(quad Y-F+T-V), AAV2(MAX)deltaHS, also known as AAV2(4pMut)deltaHS. In some embodiments, the Cas9 and gRNA vectors are delivered in the same vectors. In some embodiments, the Cas9 and gRNA vectors are delivered in separate capsids with non- overlapping primary receptors. In some embodiments, the Cas9 and gRNA vectors are delivered in separate capsids to increase co-transduction efficiencies.

In some embodiments, the rAAV particle comprises a capsid that includes modified capsid proteins (e.g., capsid proteins comprising a modified VP3 region). Methods of producing modified capsid proteins are known in the art (see, e.g., U.S. Patent Publication Number US20130310443, which is incorporated herein by reference in its entirety). In some embodiments, the rAAV particle comprises a modified capsid protein comprising a (e.g., at least one) non-native amino acid substitution at a position that corresponds to a surface- exposed amino acid (e.g., a surface exposed Tyrosine) in a wild-type capsid protein. In some embodiments, the rAAV particle comprises a modified capsid protein comprising a non- tyrosine amino acid (e.g., a phenylalanine) at a position that corresponds to a surface-exposed tyrosine amino acid in a wild-type capsid protein, a non-threonine amino acid (e.g., a valine) at a position that corresponds to a surface-exposed threonine amino acid in the wild-type capsid protein, a non-lysine amino acid (e.g., a glutamic acid) at a position that corresponds to a surface-exposed lysine amino acid in the wild-type capsid protein, a non-serine amino acid (e.g., a valine) at a position that corresponds to a surface-exposed serine amino acid in the wild-type capsid protein, or a combination thereof.

In some embodiments, a rAAV particle (e.g., a rAAV2 or other rAAV serotype particle) comprises a capsid that includes modified capsid proteins having one or more, for example two or more (e.g., 2, 3, 4, 5, or more) amino acid substitutions.

Methods of producing rAAV particles and nucleic acid vectors are also known in the art and commercially available (see, e.g., Zolotukhin et al. Production and purification of serotype 1, 2, and 5 recombinant adeno-associated viral vectors. Methods 28 (2002) 158— 167; and U.S. Patent Publication Numbers US20070015238 and US20120322861, which are incorporated herein by reference; and plasmids and kits available from ATCC and Cell Biolabs, Inc.). For example, the nucleic acid vector (e.g., as a plasmid) may be combined with one or more helper plasmids, e.g., that contain a rep gene (e.g., encoding Rep78, Rep68, Rep52 and Rep40) and a cap gene (encoding VP1, VP2, and VP3), and transfected into a producer cell line such that the rAAV particle can be packaged and subsequently purified.

In some embodiments, the one or more helper plasmids include a first helper plasmid comprising a rep gene and a cap gene and a second helper plasmid comprising other genes that assist in AAV production, such as a Ela gene, a Elb gene, a E4 gene, a E2a gene, and a VA gene. In some embodiments, the rep gene is a rep gene derived from AAV2 and the cap gene is derived from AAV5. Helper plasmids, and methods of making such plasmids, are known in the art and commercially available (see, e.g., pDM, pDG, pDPlrs, pDP2rs, pDP3rs, pDP4rs, pDP5rs, pDP6rs, pDG(R484E/R585E), and pDP8.ape plasmids from

PlasmidFactory, Bielefeld, Germany; other products and services available from Vector Biolabs, Philadelphia, PA; Cellbiolabs, San Diego, CA; Agilent Technologies, Santa Clara, Ca; and Addgene, Cambridge, MA; pxx6; Grimm et al. (1998), Novel Tools for Production and Purification of Recombinant Adenoassociated Virus Vectors, Human Gene Therapy, Vol. 9, 2745-2760; Kern, A. et al. (2003), Identification of a Heparin-Binding Motif on Adeno- Associated Virus Type 2 Capsids, Journal of Virology, Vol. 77, 11072-11081.; Grimm et al. (2003), Helper Virus-Free, Optically Controllable, and Two-Plasmid-Based Production of Adeno-associated Virus Vectors of Serotypes 1 to 6, Molecular Therapy, Vol. 7, 839-850; Kronenberg et al. (2005), A Conformational Change in the Adeno- Associated Virus Type 2 Capsid Leads to the Exposure of Hidden VPl N Termini, Journal of Virology, Vol. 79, 5296- 5303; and Moullier, P. and Snyder, R.O. (2008), International efforts for recombinant adenoassociated viral vector reference standards, Molecular Therapy, Vol. 16, 1185-1188).

An exemplary, non-limiting, rAAV particle production method is described next. One or more helper plasmids are produced or obtained, which comprise rep and cap ORFs for the desired AAV serotype and the adenoviral VA, E2A (DBP), and E4 genes under the transcriptional control of their native promoters. HEK293 cells (available from ATCC®) are transfected via CaP04-mediated transfection, lipids or polymeric molecules such as

Polyethylenimine (PEI) with the helper plasmid(s) and a plasmid containing a nucleic acid vector described herein. Alternatively, in another example, Sf9-based producer stable cell lines are infected with a single recombinant baculovirus containing the nucleic acid vector. As a further alternative, in another example HEK293 or BHK cell lines are infected with a HSV containing the nucleic acid vector and optionally one or more helper HSVs containing rep and cap ORFs as described herein and the adenoviral VA, E2A (DBP), and E4 genes under the transcriptional control of their native promoters. The HEK293, BHK, or Sf9 cells are then incubated for at least 60 hours to allow for rAAV particle production. The rAAV particles can then be purified using any method known in the art or described herein, e.g., by iodixanol step gradient, CsCl gradient, chromatography, or polyethylene glycol (PEG) precipitation.

The disclosure also contemplates host cells that comprise at least one of the disclosed rAAV particles, expression constructs, or nucleic acid vectors. Such host cells include mammalian host cells, with human host cells being preferred, and may be either isolated, in cell or tissue culture. In the case of genetically modified animal models (e.g., a mouse), the transformed host cells may be comprised within the body of a non-human animal itself.

Compositions

Aspects of the disclosure relate to compositions comprising rAAV particles or nucleic acids described herein. In some embodiments, rAAV particles described herein are added to a composition, e.g., a pharmaceutical composition.

In some embodiments, the composition comprises a pharmaceutically acceptable carrier. The term "carrier" refers to a diluent, adjuvant, excipient, or vehicle with which the rAAV particle is administered. Such pharmaceutical carriers can be sterile liquids, such as water and oils, including those of petroleum oil such as mineral oil, vegetable oil such as peanut oil, soybean oil, and sesame oil, animal oil, or oil of synthetic origin. Saline solutions and aqueous dextrose and glycerol solutions can also be employed as liquid carriers. Non- limiting examples of pharmaceutically acceptable carriers include lactose, dextrose, sucrose, sorbitol, mannitol, starches, gum acacia, calcium phosphate, alginates, tragacanth, gelatin, calcium silicate, microcrystalline cellulose, polyvinylpyrrolidone, cellulose, water, saline, syrup, methylcellulose, ethylcellulose, hydroxypropylmethylcellulose, polyacrylic acids, lubricating agents (such as talc, magnesium stearate, and mineral oil), wetting agents, emulsifying agents, suspending agents, preserving agents (such as methyl-, ethyl-, and propyl-hydroxy-benzoates), and pH adjusting agents (such as inorganic and organic acids and bases). Other examples of carriers include phosphate buffered saline, HEPES -buffered saline, and water for injection, any of which may be optionally combined with one or more of calcium chloride dihydrate, disodium phosphate anhydrous, magnesium chloride

hexahydrate, potassium chloride, potassium dihydrogen phosphate, sodium chloride, or sucrose. Other examples of carriers that might be used include saline (e.g., sterilized, pyrogen-free saline), saline buffers (e.g., citrate buffer, phosphate buffer, acetate buffer, and bicarbonate buffer), amino acids, urea, alcohols, ascorbic acid, phospholipids, proteins (for example, serum albumin), EDTA, sodium chloride, liposomes, mannitol, sorbitol, and glycerol. USP grade carriers and excipients are particularly useful for delivery of rAAV particles to human subjects. Such compositions may further optionally comprise a liposome, a lipid, a lipid complex, a microsphere, a microparticle, a nanosphere, or a nanoparticle, or may be otherwise formulated for administration to the cells, tissues, organs, or body of a subject in need thereof. Methods for making such compositions are well known and can be found in, for example, Remington: The Science and Practice of Pharmacy, 22nd edition, Pharmaceutical Press, 2012.

Typically, such compositions may contain at least about 0.1% of the therapeutic agent (e.g., rAAV particle) or more, although the percentage of the active ingredient(s) may, of course, be varied and may conveniently be between about 1 or 2% and about 70% or 80% or more of the weight or volume of the total formulation. Naturally, the amount of therapeutic agent(s) (e.g., rAAV particle) in each therapeutically-useful composition may be prepared ins such a way that a suitable dosage will be obtained in any given unit dose of the compound. Factors such as solubility, bioavailability, biological half-life, route of administration, product shelf life, as well as other pharmacological considerations will be contemplated by one skilled in the art of preparing such pharmaceutical formulations, and as such, a variety of dosages and treatment regimens may be desirable. The term "therapeutically effective amount" as used herein refers to that amount of active composition that elicits the biological or medicinal response in a tissue, system, animal, or human that is being sought by a researcher, veterinarian, medical doctor, or other clinician. In some embodiments, a composition described herein may be administered to a subject in need thereof, such as a subject having an eye disorder such as a cone-rod retinal dystrophy. In some embodiments, a method described herein may comprise administering a composition comprising rAAV particles as described herein to a subject in need thereof. In some embodiments, the subject is a primate. In some embodiments, the subject is a human subject. In some embodiments, the subject has or is suspected of having an eye disorder. In some embodiments, the subject has been diagnosed with an eye disorder. In some embodiments, the subject is known to be at risk of having or developing an eye disorder.

Methods

Aspects of the disclosure relate to methods of delivering a nucleic acid (e.g., in an rAAV particle described herein) to a subject to treat an eye disorder. In some embodiments, a composition described herein is administered to a subject with CORD6.

In some embodiments, the method comprises administering a rAAV particle as described herein or a composition as described herein to a subject via a suitable route to treat CORD6.

In some embodiments, a subject is a mammal. In some embodiments, a subject is a human subject. In some embodiments, a subjects is a companion animal (e.g., a dog, a cat, or other companion animal). In some embodiments, a subject is a farm animal (e.g., a horse, cow, sheep, or other farm animal). However, aspects of the disclosure can be used to treat other animals (e.g., other mammals).

To "treat" a disease as the term is used herein, means to reduce the frequency or severity of at least one sign or symptom of a disease or disorder experienced by a subject. The compositions described above or elsewhere herein are typically administered to a subject in an effective amount, that is, an amount capable of producing a desirable result. The desirable result will depend upon the active agent being administered. For example, in some embodiments an effective amount of rAAV particles may be an amount of the particles that is capable of knocking-out a CORD6 mutation. In some embodiments, an effective amount of rAAV particles may be an amount of the particles that can replace one or more functions of a guanylate cyclase protein in a cell.

A therapeutically acceptable amount may be an amount that is capable of treating an eye disorder, e.g., CORD6 (e.g., alone or in combination with one or more additional therapies).

As is well known in the medical and veterinary arts, dosage for any one subject depends on many factors, including the subject's size, body surface area, age, the particular composition to be administered, the active ingredient(s) in the composition, time and route of administration, general health, and other drugs being administered concurrently.

The rAAV particle or nucleic acid vector may be delivered in the form of a composition, such as a composition comprising the active ingredient, such as a rAAV particle described herein, and a pharmaceutically acceptable carrier as described herein. The rAAV particles or nucleic acid vectors may be prepared in a variety of compositions, and may also be formulated in appropriate pharmaceutical vehicles for administration to human or animal subjects.

In some embodiments, the number of rAAV particles administered to a subject may be provided in a composition having a concentration on the order ranging from 10 ⁶ to 10 ¹⁴ particles/ml or 10 3 to 1015 particles/ml, or any values therebetween for either range, such as for example, about 10 ⁶ , 10 ⁷ , 10 ⁸ , 10 ⁹ , 10 ¹⁰ , 10 ¹¹ , 10 ¹² , 10 ¹³ , or 10 ¹⁴ particles/ml. In one embodiment, rAAV particles of higher than 10 13 particles/ml are administered. In some embodiments, the number of rAAV particles administered to a subject may be on the order ranging from 10 to 10 vector genomes(vgs)/ml or 10 to 10 vgs/ml, or any values

therebetween for either range, such as for example, about 10 ⁶ , 10 ⁷ , 10 ⁸ , 10 ⁹ , 10 ¹⁰ , 10 ¹¹ , 10 ¹² ,

10 13 , or 101 ¹ 4" vgs/ml. In one embodiment, rAAV particles of higher than 1013 vgs/ml are administered. The rAAV particles can be administered as a single dose, or divided into two or more administrations as may be required to achieve therapy of the particular disease or disorder being treated. In some embodiments, 0.0001 ml to 10 mis are delivered to a subject. In some embodiments, the number of rAAV particles administered to a subject may be on the order ranging from 10 ⁶ -10 ¹⁴ vg/kg, or any values therebetween, such as for example, about 10 ⁶ , 10 ⁷ , 10 ⁸ , 10 ⁹ , 10 ¹⁰ , 10 ¹¹ , 10 ¹² , 10 ¹³ , or 10 ¹⁴ vgs/kg. In some embodiments, the number of rAAV particles administered to a subject may be on the order ranging from 10 ¹² -10 ¹⁴ vgs/kg.

If desired, rAAV particles may be administered in combination with other agents as well, such as, e.g., proteins or polypeptides or various pharmaceutically-active agents, including one or more systemic or topical administrations of therapeutic polypeptides, biologically active fragments, or variants thereof. In fact, there is virtually no limit to other components that may also be included, given that the additional agents do not cause a significant adverse effect upon contact with the target cells or host tissues. The rAAV particles may thus be delivered along with various other agents as required in the particular instance. Such compositions may be purified from host cells or other biological sources, or alternatively may be chemically synthesized. In some embodiments, the rAAV particles are delivered to the eye. In some embodiments, rAAV particles are delivered intraocularly, intravitreally, subretinally, parenterally, intravenously, intracerebro-ventricularly, or intrathecally.

The pharmaceutical forms of the rAAV particle compositions suitable for injectable use include sterile aqueous solutions or dispersions. In some embodiments, the form is sterile and fluid to the extent that easy syringability exists. In some embodiments, the form is stable under the conditions of manufacture and storage and is preserved against the contaminating action of microorganisms, such as bacteria and fungi. The carrier can be a solvent or dispersion medium containing, for example, water, saline, ethanol, polyol (e.g., glycerol, propylene glycol, and liquid polyethylene glycol, and the like), suitable mixtures thereof, and/or vegetable oils. Proper fluidity may be maintained, for example, by the use of a coating, such as lecithin, by the maintenance of the required particle size in the case of dispersion and by the use of surfactants. For administration of an injectable aqueous solution, for example, the solution may be suitably buffered, if necessary, and the liquid diluent first rendered isotonic with sufficient saline or glucose. These particular aqueous solutions are especially suitable for intravenous, intramuscular, intravitreal, subretinal, subcutaneous and intraperitoneal administration. In this connection, a sterile aqueous medium that can be employed will be known to those of skill in the art in light of the present disclosure. For example, one dosage may be dissolved in 1 ml of isotonic NaCl solution and either added to 1000 ml of hypodermoclysis fluid or injected at the proposed site of infusion, (see for example, "Remington's Pharmaceutical Sciences" 15th Edition, pages 1035-1038 and 1570-1580). Some variation in dosage will necessarily occur depending on the condition of the subject being treated. The person responsible for administration will, in any event, determine the appropriate dose for the individual subject. Moreover, for human administration, preparations should meet sterility, pyrogenicity, and the general safety and purity standards as required by, e.g., FDA Office of Biologies standards.

Sterile injectable solutions are prepared by incorporating the rAAV particles in the required amount in the appropriate solvent with several of the other ingredients enumerated above, as required, followed by filtered sterilization or another sterilization technique.

Generally, dispersions are prepared by incorporating the various sterilized active ingredients into a sterile vehicle which contains the basic dispersion medium and the required other ingredients from those enumerated above. In the case of sterile powders for the preparation of sterile injectable solutions, the preferred methods of preparation are vacuum-drying and freeze-drying techniques which yield a powder of the active ingredient plus any additional desired ingredient from a previously sterile-filtered solution thereof.

The amount of rAAV particle or nucleic acid vector compositions and time of administration of such compositions will be within the purview of the skilled artisan having benefit of the present teachings. It is likely, however, that the administration of

therapeutically-effective amounts of the disclosed compositions may be achieved by a single administration, such as for example, a single injection of sufficient numbers of infectious particles to provide therapeutic benefit to the patient undergoing such treatment.

Alternatively, in some circumstances, it may be desirable to provide multiple, or successive administrations of the rAAV particle compositions, either over a relatively short, or a relatively prolonged period of time, as may be determined by the medical practitioner overseeing the administration of such compositions.

The composition may include rAAV particles, either alone, or in combination with one or more additional active ingredients, which may be obtained from natural or

recombinant sources or chemically synthesized.

Toxicity and efficacy of the compositions utilized in methods of the disclosure can be determined by standard pharmaceutical procedures, using either cells in culture or experimental animals to determine the LD50 (the dose lethal to 50% of the population). The dose ratio between toxicity and efficacy is the therapeutic index and it can be expressed as the ratio LD50/ED50. Those compositions that exhibit large therapeutic indices are preferred. While those that exhibit toxic side effects may be used, care should be taken to design a delivery system that minimizes the potential damage of such side effects. The dosage of compositions as described herein lies generally within a range that includes an ED50 with little or no toxicity. The dosage may vary within this range depending upon the dosage form employed and the route of administration utilized.

Subjects

Aspects of the disclosure relate to methods for use with a subject, such as human or non-human primate subjects. Non-limiting examples of non-human primate subjects include macaques (e.g., cynomolgus or rhesus macaques), marmosets, tamarins, spider monkeys, owl monkeys, vervet monkeys, squirrel monkeys, baboons, gorillas, chimpanzees, and

orangutans. In some embodiments, the subject is a human subject. Other exemplary subjects include domesticated animals (e.g., companion animals) such as dogs and cats; livestock such as horses, cattle, pigs, sheep, goats, and chickens; and other animals such as mice, rats, guinea pigs, and hamsters. Subjects having an eye disorder; e.g., cone-rod retinal dystrophy, can be identified by a skilled medical practitioner using methods known in the art, e.g., by measuring serum concentrations of associated markers, genetic analysis, CT, PET, or MRI scans, tissue biopsies, or any combination thereof.

Without further elaboration, it is believed that one skilled in the art can, based on the above description, utilize the present disclosure to its fullest extent. The following specific embodiments are, therefore, to be construed as merely illustrative, and not limitative of the remainder of the disclosure in any way whatsoever. All publications cited herein are incorporated by reference for the purposes or subject matter referenced herein.

EXAMPLES

Example 1. AAV-CRISPR/Cas9- based therapies for cone rod dystrophy

Clinical trials for RPE65-Leber congenital amaurosis (LCA2) have demonstrated the ability to deliver therapeutic transgene to the retinal pigment epithelium (RPE) with Adeno associated virus(AAV) thereby restoring retinal function and visually-evoked behavior to patients. This laid the groundwork for other AAV-mediated gene supplementation studies in patients with Choroideremia, Achromatopsia, Leber hereditary optic neuropathy, and X- linked Retinoschisis. Gene replacement is an effective approach for autosomal recessive disease wherein the aim is to supplement with a 'normal' gene encoding a protein missing from the patient's retina. It is ineffective, however, for addressing autosomal dominant conditions wherein gain-of-function mutations produce proteins with dominant negative effects or toxic gain of function properties. Mutations in GUCY2D, the gene encoding retinal guanylate cyclase- 1 (retGCl), are the leading cause of autosomal dominant, cone-rod dystrophy (adCORD). GUCY2D-adCORO or cone-rod dystrophy type 6 (CORD6) account for 35% of adCORD cases. Patients present with a loss of visual acuity, abnormal color vision, photophobia, visual field loss and macular atrophy within the first decade. In severe cases, rod degeneration and loss of peripheral visual field follow. Significant progress has been made towards clinical application of a gene replacement therapy for LCA due to recessive mutations in GUCY2D (LCA1). However, a different approach is needed to treat CORD6 where a gain of function mutation is responsible for dysfunction and dystrophy. CRISPR/Cas9 technology has received worldwide attention as a mechanism to permanently modify disease-causing genes. Efficient knock-out retGCl expression in mouse rods and cones, and induction a subsequent loss of retinal function using AAV-delivered

CRISPR/Cas9 targeted to Gucy2e (murine homologue of GUCY2D) has been shown. In macaque, subretinal delivery of AAV-CRISPR/Cas9 reagents targeting GUCY2D also resulted in specific editing of the locus, loss of retGCl expression and shortening of outer segments. These observations, in combination with the demonstrated success with GUCY2D gene replacement support the development of a 'knock-out + replacement' approach for treating CORD6. Notably, with rare exception, CORD6-causing mutations are confined to residue 838 of GUCY2D. Thus, CORD6 is also an ideal target for an allele- specific gene editing approach. Through directed evolution, a Cas9 has been developed with specificity for the R838S mutant allele sequence to evaluate an allele- specific AAV-CRISPR/Cas9 approach for treatment of CORD6. Through the development of clinically relevant treatments for CORD6, establish parameters for gene editing in primate retina that are applicable to other CRISPR/Cas9 therapies for treating inherited retinal disease. The preminilary data shows, the ability to efficiently edit a gene in post mitotic photoreceptors of primate with AAV- CRISPR/Cas9.

Gene replacement strategies are not suitable for treating dominantly inherited retinal dystrophies where gain of function mutations are responsible for dysfunction and dystrophy. To date, RNAi- mediated knockdown of transcripts arising from the dominant mutant gene has been successful in animal models of autosomal dominant retinitis pigmentosa. Strategies that simultaneously knock down both mutant and normal transcripts and supplement with a gene expressing a so-called 'hardened' RNA, resistant to RNAi mediated destruction are in clinical development. However, this approach relies on continuing expression of the RNAi and efficient destruction of mutant transcript. With CRISPR/Cas9 gene editing, there is now an opportunity to correct problems further upstream by 'knocking out' the underlying genetic defect. Therapeutic intervention for dominant disease can be achieved by editing both mutant and wild type alleles in conjunction with delivery of a normal, 'hardened' gene not recognized by the CRISPR/Cas9 reagents. Alternatively, if the mutational landscape is restricted to a small number, or even single nucleotide, allele specific approaches may be possible. It is hypothesized that both 'knock out + replacement' and allele-targeted AAV- CRISPR/Cas9-based approaches can be used for the treatment of cone rod dystrophy due to autosomal dominant mutations in GUCY2D. To date, no one has successfully used AAV- mediated CRISPR/Cas9 to specifically target a disease locus and restore function/preserve structure in an animal model of inherited retinal disease. Developing the tools with which to do so is a large unmet need.

Two different mouse models of CORD6 were utilized: the recently characterized transgenic human CORD6 mice and a novel mutant CORD6 mouse. Using a Cas9 created via directed evolution to recognize the specific PAM sequence overlapping with the R838S mutation, allele specific editing in the target cell (photoreceptors) was evaluated. Because sequence immediately upstream of R838 is highly conserved between mouse and human, the ability to test clinically relevant reagents (e.g., designed against human R838S GUCY2D) is afforded for their ability to edit the endogenous locus in the heterozygous CORD6 mutant mouse.

Development and validation of guide RNAs that efficiently direct SaCas9- mediated editing of Gucyle and GUCY2D in-vitro. Staphylococcus aureus (Sa)Cas9 guide RNAs targeting the mouse Gucy2e and cynomolgus macaque (Macaca fascicularis )fhuman GUCY2D loci were selected to target the early coding sequence of the genes. Using the Cas OFFinder software ¹ , gRNA target sites were screened for closely matched sites containing an NNGRRN PAM in the mouse (genome build mmlO) and macaque/human (genome build macFas5) genomes, respectively, and sites were prioritized based on orthogonality to the relevant genome. Guides were then screened for activity by plasmid transfection in cultured cells and indel rates determined by the T7E1 assay . The most active guides were selected for in vivo use. The chosen Gucy2e gRNAs ("guide 16") had an indel rate of 35% in mouse 3T3 cells. The chosen GUCY2D gRNAs ("guide 27") had an indel rate of 46% in HEK293 cells (FIG. 2). This was validated in M. fascicularis, non-human primate (NHP) T cells (data not shown). Based on mismatched nucleotides at the respective homologous locations, guide 27 was not predicted to target Gucy2e and, likewise, guide 16 was not predicted to target GUC2YD. This allowed the use of the species non-specific guides as negative controls in all downstream experiments. In later in vivo experiments, the species specificity of the guides was experimentally confirmed.

AAV5-hGRKlcapsid/promoter combination drives efficient SaCas9 expression in PRs. It was previously determined that AAV5 is capable of efficient rod and cone transduction following subretinal injection in mouse and primate . It was also determined that the human rhodopsin kinase (hGRKl) promoter has exclusive activity in NHP rods and cones ³ ' ⁴ . As such, the hGRKl promoter was evaluated for its ability to drive Cas9 expression in mouse PRs along with two commonly used, short, ubiquitous promoters- a shortened version of the Elongation Factor Alpha (EFs) and mini Cytomegalovirus Immediate Early (miCMV). Quantitative PCR (qPCR) analysis reveal that hGRKl was the most efficient at driving Cas9 expression in retina, and maintained specificity for PRs (data not shown).

Contemporaneously, Ruan et al. similarly found that AAV5-hGRKl drove efficient Cas9 expression in mouse retina ⁵ . Taken together, AAV5-hGRKl is a suitable benchmark capsid/promoter combination for use.

Human GUCY2D gene (SEQ ID NO: 10) and mouse Gucy2e gene (SEQ ID NO: 14) along with corresponding macaque, human, and mouse gene comparisons are shown in FIG. 13. Based on mismatched nucleotides at the respective homologous locations, 'guide 27' (SEQ ID NO: 9) was not predicted to target Gucy2e and, likewise, 'guide 16' (SEQ ID NO: 13) was not predicted to target GUC2YD. The nucleotide sequence encoding guide 27 and guide 16 are defined as SEQ ID Nos: 9 and 13, respectively. The corresponding transcribed RNA sequence contains uracil (U) in place of thymine (T). This allowed the use of the species non-specific guides as negative controls in all downstream experiments. In later, in vivo experiments, species specificity of the guides was experimentally confirmed. Sequences from the top to the bottom of the figure correspond to SEQ ID NOs: 9-16. As shown in FIG. 14, gRNA expression was directly correlated with success of subretinal injection, as evidenced by GFP expression in fundus images.

Efficient and selective editing of Gucyle in PRs of WT mice. Next, using AAV5 vectors incorporating the most efficient gRNA identified in vitro and AAV5-hGRKl-

(Sa)Cas9, gene editing experiments were carried out in vivo. Cohorts of 20, age-matched C57BL/6 mice of equal sexes were subretinally injected in their right eyes with the following two vectors- AAV5-U6-(M)G«c;y2e-gRNA16-hGRKl-GFP + AAV5-hGRKl-Cas9 (FIGs. 3A and 3C). A total of lul containing both vectors at a concentration of 3el2 vg/ml each (6e9 vg total) was delivered. Left eyes received AAV5-AAV5-U6-(P)G£/CF2£>-gRNA27- hGRKl-GFP + AAV5-hGRKl-Cas9 (FIGs. 3B and 3C). At 6 weeks post-injection, gRNA and Cas9 expression (qPCR) was evaluated, performed indel analysis, and determined whether delivery of editing reagents had an impact on retinal structure and/or function.

Taking advantage of the fact that the gRNA expression vectors also contained a GFP reporter (FIGs. 3A and 3B), fluorescence activated cell sorting (FACS) was used to isolate GFP positive (GFP+) PRs and GFP negative (GFP-) cells from retinas of a subset of mice. Both RNA and DNA was extracted from these populations. QPCR analysis revealed that both gRNAs and Cas9 were expressed only in GFP+ cells (FIG. 3D). Individual retinas from a separate subset of mice were probed for Cas9 expression with western blot. Cas9 protein was detectable in retinas injected with either AAV -GUCY2D gRNA27 + AAV-Cas9 or AAV- Gucy2e gRNA 16 + AAV-Cas9 (FIG. 3E). Different levels of Cas9 likely resulted from the variable success of subretinal injections, (see fluorescent fundus images at the bottom of each lane) (FIG. 3E). DNA extracted from both GFP+ PRs and GFP- cells was used for indel analysis to quantify and characterize gene editing. DNA from the GFP+ PRs of mice injected with AAV-Gucy2e gRNA 16 + AAV-Cas9 exhibited 44.8% editing at the predicted Gucy2e locus. Consistent with the qPCR expression data, DNA from the GFP- population contained no indels, confirming that editing was restricted to cells expressing the hGRKl driven reporter (e.g., PRs that received the AAW -Gucy2e gRNA16 vector). DNA from both the GFP+ and the GFP- cells in eyes injected with control AAY-GUCY2D gRNA27 + AAV- Cas9 contained no indels, confirming that GUCY2D gRNA27 does not recognize Gucy2e sequence. Despite the high rate of editing observed in AAY-Gucy2e gRNA + AAV-Cas9 injected mice, only modest declines in photopic b-wave responses were observed by ERG and no changes in retinal structure were observed by OCT (data not shown). This was expected given that C57BL/6 mice carry two copies of Gucy2e and also express Gucy2f (which encodes retGC2, a close relative of retGCl that provides cyclase activity in rod PRs) and the short length of time mice were kept in life post-delivery of AAV-CRISPR/Cas9 reagents ⁶ . Notably, retinas injected with AAV5-Cas9 alone had no detectable Cas9 protein, suggesting a destabilization of the endonuclease in the absence of gRNA (FIG. 3F). This was irrespective of the promoter used to drive Cas9 (hGRKl, CMV, or EFS).

FIGs. 15A-15C show that Gucy2e-gRNA and GUCY2D-gRNA were present in GFP+ PRs of left and right eyes, respectively 6 weeks post injection (FIG. 15A). GFP- cells did not express Cas9 or gRNA. Expression of both gRNAs was slightly lower than Cas9, a result likely attributable to the different promoters driving gRNA (U6) vs. Cas9 (hGRKl). Western blot revealed Cas9 expression in retinas from eyes injected with AAV-Cas9 plus AAV- G«c 2e-gRNA (n=4) and AAV-Cas9 + AAV-G£/CF2£>-gRNA (n=4) with expression levels varying according to the quality of subretinal injections (evidenced in fundus images of each eye taken prior to sacrifice) (FIG. 15B). This contrasts the result following injection of AAV-hGRKl-Cas9 alone and further supports that Cas9 is stabilized by the presence of gRNA. FIG. 15C shows scotopic A and B wave averages as well as photopic B wave averages in Gucy2e and GUCY2D targeted eyes. These results show that editing was only found in the cell-type targeted in the experiments. FIG. 16 shows editing rates by indel sequencing (SEQ ID NOs: 17-32). Deep sequencing confirmed efficient Gucy2e editing in WT mice co-injected with AAV-Cas9 and AAV-Gucy2e gRNA. In GFP+ PRs from left eyes, 28.7% non-homologous end joining (NHEJ) and 16.1% AAV vector insertions were observed at the cut site for a total editing rate of 44.8%. No editing was observed in GFP- cells from left eyes, indicating the requirement for gRNA in this process. Editing of Gucy2e did not occur in either GFP+ or GFP- cells from right eyes injected with AAV-GUCY2D-gRNA + AAV-Cas9, as expected.

Editing of Gucyle in PRs of GCl^GCl ^"7" mice leads to loss of retinal function and reduction of retGCl expression. In order to better assess whether a change in retinal phenotype could be affected by editing Gucy2e, mice carrying a single allele of Gucy2e (GCl ^+/~ ) were generated, on a Ga ^ knock-out background (GC2-/-J, i.e. "GC1 ^+/~ :GC2 ^_/ " mice. Age matched GC1 ^+/" :GC2 ^"A mice (n=10, equal sexes) were subretinally injected in their right eyes with the same AAV5- Gucy2e gRNA 16-hGRKl -GFP + AAV5-hGRKl-Cas9 vectors and dose as before. Left eyes were injected with AAW 5-GUCY2D gRNA27 + AAV5-hGRKl-Cas9. At 6 weeks post-injection, GFP expression was evaluated with fundoscopy (FIG. 4A), retinal function with ERG (FIGs. 4B and 4C), and retinal structure with OCT. Both rod and cone function were significantly decreased in eyes injected with AAV5-Gucy2e gRNA 16 + AAV-Cas9 relative to those receiving control AAV5-GUCY2D gRNA27 + AAV-Cas9 (FIGs. 4B and 4C). This effect was consistent, with 9/10 injected mice displaying reduced retinal function in the AA Y5-Gucy2e gRNA16 + AAV5-Cas9 treated eye. No significant difference in ONL thickness was observed between right and left eyes out to 3 months post-injection (data not shown). This was expected given that mice lacking both retGC 1 and retGC2 from conception (GCdKO mice) do not show appreciable ONL thinning until about 4-5 months of age . Notably, retGCl expression was profoundly reduced in PRs within the bleb of AAV5-Gucy2e gRNA16/Cas9- treated eyes (FIG. 5) whereas PRs in the control, AAV5-GUCY2D gRNA 27/Cas9- injected eye exhibited wild type-like retGCl expression in their outer segments (FIG. 5) . FIGs. 17A-17I show that by 20 weeks post-injection, photopic (cone-mediated) and scotopic (rod-mediated) function were significantly reduced in eyes injected with AAV-Cas9 + AAY-Gucy2e gRNA relative to those injected with AAV-Cas9 + AAV-orthologous gRNA control, or vehicle alone (FIGs. 17A, 17B). AAV-Cas9 + AAV-orthologous gRNA control- injected eyes did not differ from vehicle-injected controls (FIG. 17A). By 20 weeks post- injection, significant loss of retinal structure was observed in Gucy2e -edited eyes relative to controls (FIG. 17C). Cas9 expression was detectable in all vector-treated eyes (FIG. 17D). retGCl expression was reduced by -70% in Gucy2e -edited eyes relative to eyes injected with AAV-Cas9. + AAV-orthologous gRNA control (FIG. 17D, FIG. 17E). Transcript analysis revealed both Cas9 and gRNA expression in GFP+ sorted cells from treated eyes (FIG. 17F). FIG. 17G shows average GFP pixel intensity across fundus images of treated GC1 ^+/" :GC2 ^"A mice performed by loading images in sequence and using the average intensity Z-projection in ImageJ. A schematic showing where the 8 locations from which ONL thickness measurements were obtained is overlaid. In the superior temporal retinas, where vector is most often deposited during subretinal injection, GFP intensity was significantly lower in Gucy2e -edited eyes at 20 weeks post-injection. ONL width in superior temporal retinas is shown in FIG. 17H. AAV5-hGRKl- mediated Cas9 expression was restricted to

photoreceptors of subretinally injected GCl ^+/~ :GC2 ^_/~ mice and often colocalized with GFP expressed from the gRNA containing vector (FIG. 171).

FIGs. 18A-18H show that in AA V-Gucy2e gRNA/Cas9 injected eyes, ONL thinning was restricted to the region of the GFP+ injection bleb (FIG. 18A). Loss of retGCl in Gucy2e- targeted photoreceptors was also observed, particularly in cones, the cell type in which retGCl expression is highest in WT mice (FIGs. 18A-18G). Cones lacking Gucy2e- gRNA (outside the bleb) exhibited clear expression of retGCl in their outer segments (FIG. 18D, arrows) whereas cones within the bleb (those expressing Gucy2e-gKNA) lacked retGCl signal (FIG. 18G, white arrow). Taken together, these results show that targeting early coding sequence of Gucy2e in GCl ^+/~ :GC2 ^~/~ mice results in a loss of retinal

structure/function, and downregulation of retGCl. This phenotype is akin to animal models of recessive LCA1 carrying biallelic null mutations in Gucy2e. FIG. 18H shows GUCY2D targeted as a control. There were 31.5% indel reads and 4.5% AAV insertions yielding an overall editing percentage of 36%. Editing of GUCY2D in primate PRs leads to loss of retinal structure and function, and reduction of retGCl expression. Next, a pilot study in non-human primate (Macaco, fascicularis) was performed to ask whether editing of the GUCY2D locus was achievable and if downstream effects on retinal structure, function and expression of retGCl could be observed. Three macaques received subretinal injections of AAY5-V6-GUCY2D gRNA27-hGRKl-GFP + AAV5-hGRKl-Cas9 (right eyes) (FIGs. 3B and 3C) and AAV5- Gucy2e gRNA 16-hGRK 1 -GFP + AAV5-hGRKl-Cas9 (left eyes), except for one animal who received AAV5-hGRKl-GFP, alone in its left eye (FIG. 3A and 3C). Three subretinal blebs were created in each eye to allow for multiple downstream analyses (Table 1). It has been previously shown the ability to surgically create multiple, distinct blebs in NHP for a similar purpose ⁹ . Regular ophthalmological exams indicated vectors very well tolerated, with only one eye displaying mild inflammation which resolved following a short regimen of IM steroids. This eye received the Gucy2e gRNA vector and is attributed to the mild

inflammation to the multiple attempts required for successful formation of one of the subretinal blebs.

Higher power inserts of selected retinal regions in FIG. 6A show the loss in the right eye post-surgically of the ELM and photoreceptors in the injected region. At 2 months post- injection, fluorescent fundus images revealed GFP expression within all blebs of AAV- GUCY2D gRNA27/Cas9- and control treated (AAV-G«ry2e/Cas9 gRNA or AAV-GRK1- GFP)- treated eyes (FIG. 6A). OCT scans were acquired at baseline and at 2 months post- injection. Scans through macular blebs revealed shortening of PR outer segments and thinning of ONL in retinas treated with AAV-GUCY2D gRNA27/Cas9 (FIG. 6A, OD). Changes in the AAV- Gucy2e gRNA16/Cas9- treated retinas were consistent with what has been observed following subretinal injection of AAV vectors, namely disorganization of the ONL (FIG. 6A, OS). Unlike AAY-GUCY2D gRNA27/Cas9 treated eyes, PR outer segments remained relatively intact and no obvious loss of ONL was observed, with the exception being the aforementioned problematic subretinal bleb. Multifocal ERG analysis revealed a substantial decrease in central retinal function in AAY-GUCY2D gRNA27/Cas9-treated eyes 5 (FIG. 6B). Eyes injected with AAY-Gucy2e gRNA16/Cas9 exhibit some loss of function, albeit less than that observed in AAY-GUCY2D gRNA27/Cas9-treated eyes. Inferior temporal retinal blocks from the right and left eyes of each subject were dissociated and FACS performed to separate GFP+ and GFP- populations as previously described ⁹ . Indel analysis was conducted on both populations and revealed that editing was restricted to the l o GFP+ cells from AA -GUCY2D gRNA27/Cas9- treated retinas. The editing efficiency was similar (-10%) in all three macaques (FIG. 7). IHC analysis of retina spanning the transition region of GFP expression {e.g., the edge of the macular bleb) in the AA -GUCY2D gRNA27/Cas9- injected retina clearly shows that cells expressing GFP, and by association the GUCY2D gRNA27, exhibit reduced retGCl (FIG. 8). Conversely, PRs along the edge of

15 and beyond the GFP positive area exhibit retGCl expression in PR outer segments. PR outer segments are clearly reduced in length in the area absent retGCl expression, confirming OCT observations. No change in retGCl expression or OS length was observed between the treated and untreated areas of the retina receiving AAY-Gucy2e gRNA16/Cas9.

Table 1. Design of pilot study in non-human primate. Details from one representative subject

(out of 3) are shown. OD- right eye, OS- left eye

Diversification and selection for SaCas9 variants that recognize PAM sequence conforming to R838S but not wildtype allele. Allele specificity of CRISPR/Cas9 editing 25 has been explored using the prevalent single nucleotide polymorphisms that either cause or destroy PAM motifs required for selective editing ' . With CORD6, most mutations occur in residue 838, with the R838S mutation being both common and highly pathogenic.

Serendipitously, a consensus PAM sequence for SaCas9, NNGRR(N), is located immediately upstream of the 2512 C→ A transversion coding for the R838S substitution (FIG. 9). As a 5 result a Cas9 recognizing NNGRRA versus NNGRR would lead to allele specific editing.

Using a Cas9 Scanning Mutagenesis At Random Targets (SMART) library, both positive (selection for cutting) and negative (selection against cutting) was performed using a phage based system (FIG. 10). Selection resulted in identification of three Cas9 variants that exhibit allele specificity for R838S target sequence (variant 1, 3 and 4), and another variant o that exhibits higher efficiency of cleavage for the R838S target, but still leads to partial

cleavage of wildtype.

Taken together, the preliminary data provide strong support for both a 'knock out + replacement' and an allele targeted approach to treat autosomal dominant GUCY2D CORD6. 5 Example 2: AAV-CRISPR/Cas9 gene editing in human GUCY2DCR838S) transgenic mouse models of CORD6.

Aspects of the disclosure include determining whether ablation of human mutant R838S GUCY2D expression via CRISPR/Cas9 ameliorates loss of retinal structure and function in a transgenic model of CORD6. Utilization of a gRNA already pre-validated in o human cells and in macaque to target human GUCY2D should result in editing of the

transgenic human GUCY2D R838S contained within the R838S CORD6 tg mice. R838S CORD6 transgenic mice were generated by injecting mouse eggs with a construct containing human GUCY2D cDNA containing the 2512C→ A transversion that codes for the R838S substitution under the control of the rod opsin promoter which restricts expression of the 5 R838S GUCY2D mutant to rods, leaving cones as an internal control. Founders were bred to C67B6J mice for at least 4 consecutive generations to establish two separate R838S+ expressing lines. The "379" line exhibits a more gradual deterioration (arbitrarily dubbed "slower" line) and line "362", a more severe phenotype ("faster" line). By 1 month, scotopic a- and b-waves are reduced to 1/2 and 1/3 of normal, respectively in "379" mice. Responses to half maximal stimuli are unchanged, however, indicating that reduced function is a result of rod loss and not decreased sensitivity. By 6 months, scotopic a- and b-waves are reduced 4- and 2- fold relative to normal. Cone function remains normal in "379" mice out to 6

5 months (the latest time point evaluated). Loss of ONL becomes evident by 6 weeks of age, and by 3-4 months (mos), ONL thickness is reduced to half of normal. By 6 mos, only 1/3 of ONL nuclei remain. Notably, the amount of mutant R838S cyclase expressed in "379" mice is less than half that of endogenous wild type retGCl yet this is sufficient to induce early- onset loss of retinal structure and function. Line 362 expresses at least twice the amount of o mutant R838S cyclase relative to that seen in line 379, and thus exhibits more rapid

deterioration. By 3.5 months, scotopic a- waves are negligible and b- waves rudimentary. Cone function is maintained at normal levels. By 3.5 mos, less than 20% of ONL remained in "362" mice, and by 5 months, this is reduced to a single layer of nuclei. The effects of gene editing in both the slow and fast transgenic lines are evaluated. Sufficient editing result5 in preservation of retinal structure, improvements in retinal function and a shift in Ca2+

sensitivity of the cyclase towards that of wt retGCl. In the fast- line, continued maintenance of ONL beyond the age at which all rods are lost (~5 months) would suggest that PRs, once corrected, are able to persist indefinitely, as has been recently shown in the context of recessive retinal disease.

o The extent to which AAV-CRISPR/Cas9- mediated editing of GUCY2D(R838S) are determined can improve retinal function and promote preservation of PRs in human R838S CORD6 transgenic mouse models. In Experiment 1, the performance of subretinally delivered CRISPR/Cas9 reagents packaged in AAV5 is evaluated, the benchmark capsid35, and two rationally designed AAV capsids, AAV8(dbY-F+T-V) and AAV2(4pMut)AHS. 5 AAV8(dbY-F+T-V) contains two tyrosine to phenylalanine (Y-F) mutations, Y447F and

Y733F and an additional threonine to valine mutation (T-V), T494V that allows the capsid to evade intracellular proteosomal mediated degradation, thereby enhancing transduction efficiency. AAV8- based capsids promote early onset of expression in retina and are particularly well suited for addressing early onset retinal degenerative models.

AAV2(4pMut)AHS is a rationally-designed AAV2- based capsid combining two classes of mutations. The first set, three Y-F and one T-V mutations, aid in avoiding the proteosome (i.e., 4pMut). The second set ablate binding of the AAV2 capsid to heparan sulfate proteoglycan (i.e., AHS). This variant displays improved diffusion/enhanced lateral spread in the subretinal space and a concomitant increase in the area of retina transduced. A 1 μΐ subretinal injection of 5e9 vg of AAV2(4pMut)AHS results in the transduction of 75% of PRs as opposed to AAV5 which transduces -30% of PRs at the same concentration. The same CRISPR/Cas9 reagents that efficiently edit GUCY2D, but not Gucy2e, are tested in both the slow and fast CORD6 tg lines. Cohorts of mice (n=30) for each line receive subretinal injections of lul of a mixture of AAV-GUCY2D gRNA27-hGRKl-GFP + AAV-hGRKl- Cas9 packaged in either AAV5, AAV8(dbY-F+T-V) or AAV2(4pMut)AHS in their right eyes. The concentration of each virus is the same as that used in the preliminary experiments (3el2vg/ml). Left eyes receive AAV-hGRKl-GFP packaged in the matched capsid at a concentration of 3el2vg/ml. The fast "362" tg line is treated at post-natal day 14 (P14) to correspond with natural eye opening and the slow "372" line are treated at P21. Injection success are determined by measuring GFP expression as assessed by fluorescent fundoscopy 1 month post injection. Retinal function and structure are evaluated by ERG and OCT, respectively at 1, 2, 4, 6 and 12 months post- injection. Retinas from a subset of mice are harvested, dissociated, sorted via FACS and DNA extracted for determination of editing efficiencies using the same methodology described in the preliminary data. The nature of sequence insertions at cut sights were investigated as previously observed a high frequency of vector sequence integration that incorporates one of the ITRs (FIG. 7). At 3-6 months post- treatment (may vary depending on mouse line), subsets of mice are sent to Salus University for biochemical analysis of guanylate cyclase function (e.g., retGC activity assay).

Additional mice are sacrificed at interim time points for immunohistochemistry (IHC) and western blot (WB) to evaluate the localization and relative expression of retGCl, GCAP1, and other PR proteins of interest. The amount of GFP positive PRs remaining in GUCY2D- gRNA27 versus contralateral GFP only treated eyes is quantified. It is expected that the majority of PRs remaining in GUCY2D-gKN A27- treated eyes are GFP positive. In

Experiment 2 gene editing in the same two mouse lines are evaluated following intravitreal delivery of the CRISPR/Cas9 reagents packaged in a novel AAV capsid, "M3-B(Y-F+T-V)" 5 that was mined via directed evolution in NHP and displays highly efficient PR transduction following Ivt delivery relative to benchmark vectors. The same series of outcome measures outlined in Experiment 1 are performed on these mice, including quantification of gene editing and transduction efficiency, evaluation of retinal structure and function, biochemical analysis of guanylate cyclase activity, and IHC/WB for localization and characterization of o proteins of interest.

FIGs. 19A-19D show 10 week post-injection results for GUCY2D editing in R838S transgenic mice. AAV-CRISPR/Cas9-based editing of GUCY2D is therapeutic in a transgenic mouse model of R838S CORD6. By 10 weeks post-injection, scotopic (rod- mediated) function was significantly improved in eyes injected with AAV-Cas9 + AAV- 5 GUCY2D gRNA relative to those injected with AAV-Cas9 + AAV-orthologous gRNA

control (FIGs. 19A, 19B). Significant preservation of retinal structure was also observed in G£/CF2Z)-edited eyes relative to controls (FIG. 19C). FIG. 19D shows fundus images of R838S CORD6 mice 6 weeks post-injection with either AAV-Cas9 + AAY-GUCY2D gRNA vectors, or AAY-GUCY2D gRNA alone. Exposure and gain settings were consistent o throughout.

Example 3: Clinically applicable CRISPR/Cas9 gene editing approaches for the treatment of CORD6

'Knock-out and replacement' of GUCY2D or allele- specific editing of R838S

5 GUCY2D in conjunction with the development of a self-inactivating Cas9. While evaluating the impact of knocking out G£/CF2£>(R838S) expression using CRISPR/Cas9 in the R838S CORD6 tg mice address the question of whether remaining PR cells persist once the underlying gain of function mutation is nullified, the approach is not immediately translatable. Here, two independent approaches were developed for the treatment of CORD6 that rely on editing of GUCY2D and are clinically translatable. The first hurdle to translation was to address the issue of persistent Cas9 expression. While no data showing Cas9- mediated toxicity in retina is known, it is preferable to limit Cas9 expression to the time 5 frame required for efficiently editing the target locus. Control of Cas9 expression through a doxycycline regulated promoter has been successfully used 42. The disadvantage of this approach, however, is that it doesn't allow for the use of tissue- specific promoters that limit expression (and by inference editing) to the target cell. The hGRKl promoter efficiently limits Cas9 expression and gene editing to PRs. Here, a system wherein a

o doxycycline/tetracycline inducible, pol III/RNA promoter drives expression of a gRNA

targeted to dual recognition sequences flanking the Cas9 cDNA on its expression cassette was developed.

The second hurdle to translation is the need to provide a replacement gene when the gRNA used for editing recognizes exonic sequence, as is the case with the GUCY2D-5 gRNA27 (FIG. 9). Alternatively, CRISPR/Cas9 reagents that selectively distinguish mutant from normal alleles may be utilized.

Two different approaches for limiting the duration of Cas9 expression were designed. The first is a Tet-inducible self-inactivating Cas9 system (FIG. 11A). The AAV-Cas9 construct contains targeting sites for a unique gRNA engineered to not recognize mouse, o macaque or human genome targets and whose expression is under the control of a Tet- inducible pol III promoter. AAV-Cas9 also expresses the Tet-ON transactivator protein (rtTA) by way of a P2A ribosomal skipping-self-cleavage signal between Cas9 and rtTA. The version selected, rtTA3, is engineered to be completely inactive in the un-induced state, yet more sensitive and active in the presence of inducer (doxycycline), and is highly efficient 5 in-vivo42-44. In a preferred embodiment, inclusion of all elements in a single vector ensures deactivation is not dependent on two different AAV vectors transducing the same cell.

However, a single vector system results in a slightly over-sized AAV vector genome (5.1 KB). Therefore a second dual vector Tet-inducible self-inactivating system (FIG. 11B) was constructed. In this version, Cas9 vector contains flanking target sites for the inactivating gRNA. The second vector contains the Tet-inducible inactivating gRNA as well as GRK1 driving GFP-P2A-rtTA3 cDNA that is flanked by target sites for the inactivating gRNA. In the dual vector system, shut-down of GFP expression via editing by the Tet- 5 induced gRNA will serve as a marker for Cas9 inactivation. Importantly, both systems, when induced, should result in ablation of both Cas9 and rtTA expression. The latter, also an exogenous protein derived from bacteria, has hampered broad application of Tet controllable systems due to delayed immune response to TetR or rtTA in some tissues. The feasibility and efficiency of self-inactivating Cas9 constructs are assessed. In Experiment 1, constructs are o created containing Cas9 cDNA flanked by synthetic gRNA target sequence that contains consensus SaCas9 PAM sequence not predicted to occur in any human or mouse gene.

Within the same construct a Tet-inducible U6 (or HI) promoter containing dual Tetracycline operator sequences (Tet O) is included located upstream and downstream (US/DS) of TATA box (FIG. 11). This arrangement has been shown to display tight suppression in the non-5 induced state and high responsiveness/strong expression of shRNAs following doxycycline induction in a number of mammalian cell lines. The design utilizes the same sequences published by Henriksen et al. This approach for regulating expression of an shRNA has been successfully used in vivo to create an inducible mouse model of Fiedreich's Ataxia

(FRDAkd), which importantly displays an inducible and reversible PR phenotype, indicating o that the Tet-inducible Pol III promoter is functioning well at the level of the photoreceptor

(PR). Tet-inducible, self-inactivating Cas9 constructs first are tested by transfection of HEK293T and 661W cone PR cells under induced and non-induced conditions to confirm expression of Cas9 (WB) and cleavage upon induction (PCR). A self-inactivating Cas9 construct with a standard (non-inducible) U6 promoter driving the targeting gRNA (with the 5 same arrangement of target sites) are also be created for comparison. It is worth noting that this non-regulated system was successful for expression of Cas9 sufficient to achieve gene editing at the target locus and self-cleavage of the Cas9 gene, in vitro.

The self-inactivating Cas9 constructs were packaged in AAV5 and co-injected with AAV5-G«c 2e-gRNA16-hGRKl-GFP into C57B16 mice. In some embodiments, Cas9 can be deactivated by Dox induction. Four weeks post injection, a subset of mice received doxycycline using the same dosing regimen used in FRDAkd mouse study. Following a 2- week induction period, all mice were humanely sacrificed and retinas collected for analysis of 5 Cas9 expression by qPCR and WB, expression of the induced gRNA by qPCR, and indel analysis for editing of Gucy2e, as done in the past.

Example 4: The Knock-Out And Replace Strategy Is Effective In Mice.

Given this ability to efficiently edit Gucy2e and substantially reduce retGCl o expression, a "knock out + complementation in trans" approach was tested in which Gucy2e was knocked out and and complemented with a "hardened" Gucy2e gene delivered together with the CRISPR/Cas9 reagents. The advantage of this approach is it could be used to treat all allelic forms of CORD6. "Hardened" Gucy2e, in which the sequence recognized by Gucy2e-gRNAl6 and adjacent PAM site was modified using alternative codons, was cloned5 into the U6-Gac 2e-gRNA16-hGRKl-GFP construct to replace GFP. First, it was confirmed that hdGucy2e was functional in subretinally injected GCdko mice (i.e. lacking any functional guanylate cyclase activity) (data not shown).

Next, the right eyes of GC1 ^+/" :GC2 ^_/" mice were injected with AAV8(733)-hGRKl- hdGucy2e + AAV5-hGRKl-Cas9 + AAV5-U6-G«c;y2e-gRNA16-GRKl-GFP vectors at a o total concentration of 3el2 vg/ml. Left eyes received AAV5-hGRKl-Cas9 + AAV5-U6-

Gac 2e-gRNA16-hGRKl-GFP. Fundoscopy was performed to confirm GFP expression (data not shown) and ERG was performed to evaluate retinal function at 4 and 6 weeks post- injection. As expected, left eyes (Gucy2e edited only) exhibited significant declines in retinal function by 4 weeks p.i. ERG amplitudes were higher in the right eyes which also received 5 AAY-hdGucy2e (FIG. 4). Responses in right eyes (knock out + complementation in trans) were not significantly different from control eyes injected with BSS or hdGucy2e alone (FIG. 24). In Experiment 2, experiments are carried out to test a 'knock out and replacement' approach in which to knock-out all retGCl alleles and replace them with a 'hardened' GUCY2D gene delivered along with the CRISPR/Cas9 reagents. The advantage of this is that all allelic forms of CORD6 would be treatable via this approach. As a first step, a 'hardened' version of GUCY2D, in which the stretch of sequence recognized by GUCY2D-gKN A27 has been modified by the use of alternative codons, are cloned into the U6-Gac 2e-gRNA16- hGRKl-GFP construct to replace GFP (FIG. 12). The MGUCY2D contain either HA or GFP tag on the C-terminus. It has been observed that C-terminus tag placement does not impair retGCl function, and that GFP fluorescence is visible in OS of PRs. The GFP tag allows for identification of PRs expressing the exogenously delivered retGC 1. Prior to use in gene editing experiments, vectors are first tested individually in GC1/GC2 double knock-out (e.g., lacking any functional guanylate cyclase activity) mice to confirm that dGUCY2D- GFP or hdG£/CF2Z)-HA adequately rescue retGCl function in rods and cones. Into the optimal capsid identified in Example 2, the U6-G«c 2e-gRNA16-hGRKl-hdG£/CF2£>-GFP and hGRKl-Cas9 constructs are packaged. Both AAV vectors are then tested in GC1 ^+/" :GC2 ^{" /_} and GC2 ^_/" mice along with mice injected with AAV- Gucy2 e -gRN A 16-hGRK 1 - GFP + AAV-hGRKl-Cas9, the latter (lacking the hdGUCY2D replacement gene) establish the baseline for comparing phenotypic and structural improvements due to the replacement effect of hdGUCY2D. Separately GCl ^+/" :Nrr ^A and Nrl ^_/" mice are also injected with the vectors. This specifically assesses the ability of these reagents to knockout and replace retGCl in a cone only retina, and adds to the understanding of whether there is a bias in editing efficiency between rods and cones. As in Example 2, success of injection is assessed by fundoscopy (GFP expression) and mice are carried out to 12 months post injection with the same in-life analysis and WB quantifying the level of remaining (endogenous, unedited) retGCl vs.

retGC 1_GFP mediated by the replacement vector, respectively. Indel analysis was also performed. While homology directed repair (HDR) is not anticipated with dGUCY2D serving as donor strand (sequence is divergent in this region, hence non-recognition of GUCY2D by gRNA Gucy2e), events were detected by way of the human versus mouse sequence and engineered sequence at the gRNA27 target location. If this approach is successful, the Gucy2e-gKNAl6 are replaced by GUCY2D-gKNA21 for testing in primates (see Example 2, Experiment 3).

In Experiment 3, a heterozygous CORD6 mutant mouse that is currently under construction at Jackson labs was used. This mouse harbors the same C-^A nucleotide inversion leading to the R838S CORD6 mutation and is being made using CRISPR/Cas9 to swap in a 100 bp region of exon 13 containing the aforementioned nucleotide change along with several other silent changes that aids in genotyping and indel analysis (e.g., to differentiate it from the wt allele after NHEJ repair and to identify instances of HDR).

Specificity for the R838S allele is accomplished via the engineered Cas9 that specifically recognizes PAM sequence, NNGRRA, where 'A' conforms to the mutated nucleotide in the R838S GUCY2D. As can been visualized in FIG. 9, the protospacer sequence for gRNA directing the modified Cas9 (G£/CF2Z)-gRNA838) is identical in mouse and

human/macaque. In addition, the PAM sequence, while different, is still a consensus match to what is recognized by the engineered, allele specific Cas9. Therefore, allele specific editing of GUCY2D R838S was performed using heterozygous R838S CORD6 mutant mice. Expression of mutant R838S GUCY2D in line "379" is half of endogenous wtretGCl levels. A robust degenerative phenotype in the heterozygous CORD6 mutant mice in which both cones and rods are dysfunctional and undergo degeneration (as opposed to the transgenic mice, in which rods are sole source of intrinsic dysfunction) is expected. Het CORD6 mutant mice are treated with allele specific gRNA-Cas9 reagents (AAV-G£/CF2£>-gRNA838- hGRKl-GFP + AAV-hGRKl-Cas9) in one eye only. The age of injection and AAV capsid used is determined based on the results of Example 2. Natural history is performed in the untreated eyes of these mice along with a group of naive, untreated mice. As in Example 2, mice undergo ERG, OCT, IHC and WB to longitudinally characterize retinal function and structure. Retinas are collected, GFP+ cells sorted by FACS from which RNA and DNA are extracted for transcript and indel analysis to determine the percentage of editing in mutant versus wt alleles. As before, HDR is assessed by way of the silent mutations in the mutant allele.

Example 5: CRISPR/Cas9 delivery to primate photoreceptors

In Example 5, parameters for efficient and safe gene editing of GUCY2D using subretinal or intravitreal delivery of AAV-CRISPR/Cas9 and an evaluation of clinically relevant vectors for 'Knock out + replacement' and 'allele specific' editing approaches in macaque were investigated.

Differences in retinal anatomy and biochemistry dictate that gene therapies showing proof of concept in rodent and canine models undergo careful consideration prior to clinical application. If necessary, they are modified based on results of testing in primate retina.

Macaque species have a foveated retina with PR distribution, and barriers to transduction by AAV {e.g. , inner limiting membrane) very similar to humans. Therefore in the experiments below, information gleaned in the pilot study were built upon by continuing to evaluate AAV-CRISPR/Cas9 reagents for editing of GUCY2D with the goal of establishing a dose range wherein effective editing takes place in the absence of pathological changes un-related to the targeted gene alteration. Existing reagents that promoted editing and expected phenotypic changes in the pilot study were used and adjusted from there. Additional AAV capsids of interest that have the potential for higher transduction efficiency (and hence better editing) and improved lateral spread thereby promoting transduction of a larger area of retina following SR injection are investigated. Gene editing following Ivt delivery of reagents using a novel capsid variant identified through directed evolution/screening performed in macaque is assessed. Lastly, reagents developed in Example 3 ('knock out and replacement' editing vectors and 'allele specific editing' vectors) are utilized, and their performance in primate retina is evaluated.

In the pilot primate study, 3el2 vg/ml each of G£/CF2£>gRNA27+hGRKl-GFP and hGRKl-Cas9 vectors were delivered (6el2 vg/ml combined concentration). Due to the limited number of animals central retinal samples for IHC were prioritized, where a striking reduction in retGCl expression and shortening of outer segments concomitant with GFP expression (e.g., GUCY2D-gRNA vector transduction) is observed. Samples used to quantify GUCY2D editing in PRs were harvested from inferior temporal retina and indicated efficiencies of -10%. This leads to the question, "what is the efficiency of editing in central versus mid-peripheral retina?" CORD6 is a disease which manifests in the macula and spreads outward. Hence, in young patients the macula would be included as a target of therapy. However, in patients with advanced disease, mid to peripheral retina is targeted as the macula has already suffered significant degeneration. Focus is therefore on both retinal areas in the context of GUCY2D editing.

In Example 3 the same GUCY2D gene editing reagents, packaged in AAV5, and delivered in two locations, a lOOul macular bleb and a lOOul mid-peripheral (inferior or superior) bleb were tested. Using a total of 3 animals, 3 doses, 3el2 vg/ml (same as pilot study), lel2 vg/ml, and 3el 1 vg/ml, were evaluated with a total of 2 eyes injected at each dose. For reference, pharmacology studies in macaque with AAV5-GRK1-GFP at the mid dose concentration (lel2 vg/ml) result in 75% of photoreceptor transduction. OCT and mfERG are performed pre-injection and again at two time points post injection (4 and 10 weeks) to evaluate retinal structure and function, respectively. General ophthalmological exams are performed prior to injection and again weekly to assess tolerability to vectors. In life GFP fluorescence (mediated by the gRNA vector) is captured using SLO. Serum and peripheral blood mononuclear cells (PBMCs) are collected for testing of neutralizing antibodies to the AAV5 capsid and cell-mediated immune reactivity to Cas9, respectively. Animals are humanely euthanized 10-12 weeks post injection. Macular (4mm punch) and mid peripheral blebs (consisting of as much of the GFP positive bleb as possible) are processed separately to isolate PRs by FACS from which RNA and DNA are isolated for transcript and indel analysis. The most likely, off-target editing sites prioritized in coding sequence or in non-coding regions of tumor suppressors, oncogenes or inherited retinal disease-related genes also assessed for indels. Results of this experiment refine the dose of AAV required for efficient editing of GUCY2D in central and mid-peripheral retina, and provide a comparison of regional editing efficiencies. Utilizing a dose selected based on Experiment 1, in Experiment 2 gene editing is evaluated using two additional AAV capsids- AAV8(dbY-F+T-V) and AAV2(4pMut)AHS relative to AAV5 (rationale for their use is described above). Using three animals, the same approach is utilized as above (central and mid-peripheral blebs). Each capsid is injected into 2 eyes. Digital video recording (4K resolution) is used to capture images of blebs

immediately after injection. This, in conjunction with SLO images of GFP expression and landmark blood vessels visible in both image modalities are used to evaluate lateral spread of transduction outside of the bleb area. It is found that AAV5-mediated transgene expression remains close to the margins of the bleb. All other procedures are the same as above (e.g. , OCT, mfERG, quantification of transcripts, and PR editing efficiencies from central and peripheral retina and safety end points). In Experiment 3, the same GUCY2D editing reagents packaged in novel AAV capsid variants mined from capsid library screening in primate via Ivt injection are tested. Using three animals, the three best capsids (each capsid mutant is injected into 2 eyes each) are tested. The delivered dose is determined by ongoing experiments). GFP transgene expression is documented by SLO and the same procedures performed as above. A 4mm macular punch is used for isolating PRs and performing transcript and indel analysis to quantify editing efficiencies. Based on experience, transduction by Ivt- delivered AAV vectors is greater in the central retina. However, if peripheral transduction is sufficient (based on SLO imaging), peripheral retina is collected for quantification of editing.

In Experiment 4, "knock-down + replacement" reagents developed in Example 3 is packaged in the best performing capsid identified in Experiments 1 through 3. It is likely that the injection route is subretinal using one of the capsids in Experiment 2, however, the possibility of using Ivt mediated delivery of one of the capsids tested in Experiment 3 is not excluded. Here 4 animals are used, with 2 receiving AAV-U6-G£/CF2£>-gRNA27-hGRKl- (Hd)G£/CF2 J>_GFP(or HA) bilaterally, 2 receiving AAV-U6-G£/CF2 J>-gRNA27-hGRKl- (Hd)G£/CF2£>_GFP(or HA) in their left eyes and A A V-hGRK 1 - GFP control vector in their right eyes. Dose is determined by experiment 1 (or 3), with left eyes receiving control vector (AAV-hGRKl-GFP) at the same total dose. A lOOul macular injection a lOOul inferior or superior mid-peripheral injection is placed in each eye. In life analysis is performed as above. SLO is used to evaluate expression of GFP-tagged GUCY2D (retGCl_GFP) and GFP in control eyes. Two macular blebs and two peripheral blebs are harvested for quantification 5 of gene editing. As in the mouse experiments HDR is assessed by the silent mutation

engineered into the Hd GUCY2D. Two macular blebs and two mid-peripheral blebs, along with areas of untreated retina, are evaluated by WB to quantify retGCl and retGCl_GFP to ascertain the level of both GUCY2D knockout and replacement with GUCY2D_GFP. The remaining two macular blebs and mid-peripheral blebs undergo careful IHC/microscopy to l o look for retGC 1_GFP in OS of photoreceptors.

In Experiment 5, allele specific reagents developed in Example 3 (AAY-GUCY2D- gRNA838-hGRKl-GFP + AAV-hGRKl-Cas9) are tested to confirm their lack of editing at the wt GUCY2D locus and general tolerability. A total of 2 animals are used and vector dose based on results of experiments above. Animals receive macular and mid-peripheral blebs.

15 The same in life analyses and end-point analyses are performed. Macular and mid-peripheral blebs are collected, undergo FACS to isolate PRs and RNA/DNA isolated for transcript/indel analysis to determine if editing occurred at the GUCY2D locus. Indels are evaluated at predicted, off-target editing sites with prioritization of coding sequence or non-coding regions of tumor suppressors, oncogenes or inherited retinal disease-related genes.

Example 6: AAV-CRISPR/Cas9- based editing of GUCY2D alters retinal structure and function and reduces retGCl expression in macaque photoreceptors.

Retinal cross sections from macular blocks of GR114QB's right and left eyes were stained, with focus placed on the edge of the bleb, where both GFP+ and GFP- PRs (those with and without gRNA) could be found. In AAV-G£/CF2£>-gRNA/Cas9- injected retina, retGCl expression was reduced or absent from GFP+ PRs (FIGs. 21A, 21B). Outer segments within the GFP+ bleb were also noticeably shortened, as indicated by rhodopsin staining in FIG 21C, and FIG. 21D. Outside the bleb, where presumably no GUCY2D- gRNA was expressed (or expressed at levels below detection), retGCl was present in the PR OS, which appeared morphologically normal (FIGs. 21A and 21C). Despite a reduction in PR OS length in the macular block of this eye, ONL thickness was normal and unchanged relative to the control eye. Sections from the inferior nasal bleb of GR114QB OD were also evaluated. retGCl expression was absent from PRs within this peripheral bleb and a pronounced loss of ONL was also observed. A single row of PR cell bodies remained, all of which were cones, as evidenced by their labeling with cone arrestin antibody. These cones lacked IS and OS. In the control eye (AAV-Gac}>2e-gRNA/Cas9-injected), retGCl was visible in PR outer segments (OS) throughout the retinal section regardless of whether that PR expressed GFP (i.e., Gucy2e gRNA) (FIGs. 21E and 21F). No changes in PR OS or ONL thickness were observed retinas injected with AAY-Gucy2e gRNA/Cas9 (FIGs. 21G and 21H).

Western blots of protein from macaque retinas treated with AAV-Cas9 plus either AAV-GUCY2D- gRNA27 or control AA V-Gucy2e-gRNA 16 were probed for the presence of retGCl and its biochemical partner, GCAP1. Both were normalized to primate cone arrestin to control for input. Clear reductions in both retGCl and GCAP1 were observed in retinas treated with AAV-GUCY2D- gRNA27/Cas9 (FIG. 20). Confirming the IHC results, this shows that editing of GUCY2D leads to loss of retGCl expression in macaque photoreceptors.

As shown in FIG. 22 (bottom), transcript analysis of WT mice 6 weeks post-injection with AAY-Gucy2e gRNA-hGRKl-GFP vector alone reveals Gucy2e gRNA expression is correlated with the level of GFP expression in associated fundus images.

FIG. 23A is a representative ELISPOT plate image. PBMCs isolated from JR40D at specified timepoints were plated at 160,000 to 370,000 cells per well and mixed with individual SaCas9 peptide pool containing -36 peptides of either 9-mers overlapping by 4 amino acids, or 15-mers overlapping by 10 aa. The total peptides from 6 pools tile the entire SaCas9 protein sequences. The control NHP from CepheusBio was immunized with viral antigens in Pepmix and Tetanus. No T cell antigens were added to the wells with cells alone. INFy-positive spots normalized to 1E6 PBMC are presented in FIG. 23B for CD8 T cell responses to SaCas9 9-mer antigens, and FIG. 23C for CD4 T cell responses to SaCas9 15- mer antigens.

As shown in FIG. 24, ERG analysis performed at 4 and 6 weeks post-injection of GC1 ^+/" :GC2 ^_/" mice injected with AAV8(733)-hGRKl-WG«c;y2e + AAV5-hGRKl-Cas9 + AAV5-U6-Gac 2e-gRNA16-GRKl-GFP vectors demonstrated that responses in right eyes (knock out + complementation in trans) were not significantly different from control eyes injected with BSS or hdGucy2e alone.

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Materials and Methods

Guide RNA Design.

gRNAs were designed to target early coding sequence in either Gucy2e or GUCY2D, with the goal of preventing expression of retGCl protein. Guide design for S. aureus gRNAs was carried out using Godot, a custom guide RNA design software based on the public tool

Cas-OFFinder 33. Godot scores guides after calculating their genome-wide off-target propensity. Genome builds used were MacFas5 for cynomolgus macaque gRNAs and mmlO for mouse guide RNAs. NHP GUCY2D guides were selected to also target the human GUCY2D gene. Guides were prioritized based on orthogonality in the target species genome, with strong preference given for gRNAs starting with a 5'G and a PAM sequence of

NNGRRT.

Guide RNA Efficacy Testing

Activity of guide RNAs was tested by transfecting a plasmid encoding Sa Cas9, driven by the CMV promoter, and linear DNA expressing guide RNAs, driven by U6 promoter, into cells. NIH 3T3 cells (ATCC) were used to test mouse gRNAs and HEK293 cells (ATCC) were used to test NHP gRNAs (because all NHP gRNAs cross-react with human gene sequence). NIH 3T3 cells and HEK293 cells were maintained in Gibco

DMEM+Glutamax supplemented with 1% PenStrep and 10% fetal bovine serum. HEK293 cells were transfected with 750ng Cas9 plasmid and 250ng linear gRNA-expressing DNA using TransIT-293 Transfection Reagent (Mirus Bio). NIH 3T3 cells were transfected by Lonza nucleofection with 750ng Cas9 plasmid and 250ng linear gRNA-expressing DNA in SG nucleofection solution, using pulse code EN-158. Cells were harvested 3 days post- transfection and genomic DNA was isolated using the Agencourt DNAdvance kit (Beckman Coulter) according to manufacturer's instructions. Editing rates were determined by PCR amplifying the region surrounding the gRNA target sites and performing a standard T7 Endonuclease I assay (New England Biolabs), which was analyzed on a QIAxcel analyzer

(Qiagen).

Experimental animals

To avoid confusion about nomenclature across species, genes and their encoded proteins are described herein. Retinal guanylate cyclase- 1 (retGCl) and retinal guanylate cyclase-2 (retGC2) are encoded in mice by Gucy2e and Gucy2f, respectively. In macaque, retGCl is encoded by GUCY2D. C57B1/6J (WT), and Gucy2e knockout (GO ^7" ) mice were obtained from Jackson Laboratories (Bar Harbor, ME) ³⁴ . Gucy2e/Gucy2f double knockout (GCdko) mice were generously provided by Dr. Wolfgang Baehr (University of Utah) ⁵ . R838S CORD6 transgenic mice (line '379') were generously provided by Dr. Alex Dizhoor (Salus University) ¹⁰ . To generate a line containing a single allele of Gucy2e and a full knockout of Gucy2f(GCl ^+/~ :GC ' ^~ ), GCdko mice were first crossed with wild type C57/B16 (GCl ^+/+ :GC2 ^+/(+) ) mice to create experimental GC1 ^+/" :GC2 ^" males, and GC1 ^+/" :GC2 ^+/" double- heterozygote females. To generate experimental females (GC1 ^+/" :GC2 ^"/ ), experimental males were back-crossed with GCdko females. Experimental females and males were crossed to produce GCl ^+/+ :GC2 ^{"/( )} breeders. These breeders were used to produce 100% experimental offspring when bred with GCdko. Genotyping primers to identify presence/absence of Gucy2e (retGCl) included 'GC1F4' (forward primer in WT intron 4), 5'-

TCCTATCCACGACAGGACCAAGACTGT (SEQ ID NO: 33), 'GC1R4' (reverse primer in WT intron 5), 5 '-GAGAGCAGAAGGGTAGC ATTAGCTC AG (SEQ ID NO: 34), and 'NeoF4' (forward primer in neo cassette), 5 '- ACCGCTATCAGGAC ATAGCGTTGGCTA (SEQ ID NO: 35). For Gucy2f (retGC2), 'Pla2' (forward primer in neo cassette), 5'- GTTCTTCGGACGCCTCGTCAACAC (SEQ ID NO: 36), 'GC2mt-R2' (reverse primer), 5'- GTGCCTACAGGACTCTTGATGTCATTC (SEQ ID NO: 37), 'GCtowtl' (WT) 5'- CAAGACATTTGACAGGAGTTACTC (SEQ ID NO: 38), and 'GCtoda6' (WT) 5'- GTTCTGAGCTACAGATCCTACAGTG (SEQ ID NO: 39) were used. R838S CORD6 mice were genotyped using a forward primer located in exon 4 and reverse primer bridging exons 7 and 8 of human RetGCl. Respective sequences are 5'- CGATCC AAACAAC ATCTGCGGT-3 ' (SEQ ID NO: 40) and 5'- CAGCCAAACCCTGTCTCCCTCAT-3' (SEQ ID NO: 41). Primer annealing was independent of R838S mutation.

All mice were bred and maintained at the University of Florida Health Science Center Animal Care Services Facility under a 12-hour/ 12-hour light/dark cycle. Food and water were available ad libitum. All experiments were approved by the University of Florida's Institutional Animal Care and Use Committee and were conducted in accordance with the ARVO Statement for the Use of Animals in Ophthalmic and Vision Research and with National Institutes of Health regulations.

Three adult, male macaques (Macaco, fascicularis) were used in this study (SA65E - 7 yr, 10 months; GR114QB- 6 yr, 1 month; JR40D- 6 yr, 9 months). All procedures performed on macaques were approved by Institutional Animal Care and Use Committees at the University of Alabama at Birmingham (UAB) and performed in accordance with the

Association for Research in Vision and Ophthalmology Statement for the use of animals in ophthalmic and vision research.

Construction of AAV vectors

Vector plasmids pMC12 (pTR-U6-mG«c;y2e-16-GRKl-GFP), pKJS 115 (pTR-U6- nhpG£/CF2£>-27-GRKl-GFP) and pAF251 (pTR-GRKl-Cas9) were manufactured to large scale and purified by solid phase, anion exchange chromatography using a commercially available kit (Qiagen). Subsequently, vector plasmids along with AAV5 helper plasmid (pXYZ5), containing AAV2 rep, AAV5 cap and required Adenovirus helper genes were co- transfected into HEK293 cells according to previously published methods 35. Cells were harvested 72hrs post transfection. Virus was purified by iodixanol discontinuous density gradient ultracentrifugation followed by ion exchange chromatography and buffer exchanged into a Balanced Salt Solution (BSS) supplemented with 0.014% Tween 20. Virus was titered for vector genomes (vg) by Dot-blot and evaluated by SDS-PAGE to confirm high level purity of capsid proteins VP1, VP2, and VP3 (data not shown). Each undiluted vector preparation was tested for the presence of endotoxin with all registering at <5 Eu/ml.

Additionally, AA V5 - Gucy2e-gRNA 16-hGRK 1 -GFP and AAV5-G£/CF2 J>-gRNA27- hGRKl-GFP vector particles were also visualized by electron microscopy to confirm the presence of mostly 'full' particles. Individual vector titers were as follows: AAY5-Gucy2e- gRNA16-hGRKl-GFP: 8.64xl0 ¹³ vg/ml, AAV5-G£/CF2 J>-gRNA27-hGRKl-GFP:

1.56xl0 ¹⁴ vg/ml and AAV5-hGRKl-Cas9: 6.95xl0 ¹³ vg/ml. Vectors were diluted with BSS- Tween to the desired concentration for experiments. Subretinal Injections

One microliter (μΐ) of vector(s) was delivered to the subretinal space of C57B1/6J (WT), GCl ^+/~ :GC2 ^_/~ , or R838S CORD6 mice under a Lecia M80 Stereomicro scope according to previously published methods ³⁶ . To compare promoters driving Cas9, single vectors were injected into WT mice at either high (3x10 12 vg/ml) or low (3 x 1011

5 vg/ml) concentrations. To evaluate gene editing in all mouse strains, two vectors were co-delivered, each at 3xl0 ¹² vg/ml, for a total concentration of 6xl0 ¹² vg/ml. A subset of GCl ^+/~ :GC2 ^_/~ mice received higher doses with vectors co-delivered at 3x10 13 vg/ml, for a total

concentration of 6x10 13 vg/ml. Injection blebs were imaged immediately following injection o and further analysis was carried out only on animals that received comparable, successful injections (>60% retinal detachment and minimal complications). It is well established that the area of vector transduction corresponds to at least the area of retinal detachment ³⁶ ' ³⁷ . Subretinal injections in macaque eyes were performed according to the previously published methods with minor modifications . Three macaques received subretinal injections of

5 AAV5-U6-G£/CF2 gRNA27-hGRKl-GFP + AAV5-hGRKl-Cas9 (right eyes) and AAV5- G«c 2e-gRNA 16-hGRK 1 -GFP + AAV5-hGRKl-Cas9 (left eyes), except for one animal whose left eye was used for other purposes. Three distinct subretinal blebs were created in each eye to accommodate multiple outcome measures including cryo-immunohistochemistry, western blot, and transcript/indel analysis. Blebs were directed to the macula (M), inferior o nasal (IN), and inferior temporal (IT) retina in each eye. The ability to surgically create

multiple, distinct blebs in NHP for a similar purpose 38 was previously demonstrated.

Subjects received Dexamethasone (0.25mg/kg IM) the day before and the day of surgery. An Accurus 800CS surgical system with Xenon light source, Total Plus 23 gauge Vitrectomy Pak (Alcon, Inc., Fort Worth, TX) and Zeiss VISU 200 ophthalmic surgical microscope

5 equipped with digital video (Endure Medical, Cumming, GA) were used for the surgery. A standard 23-gauge three-port pars plana vitrectomy was performed with an inferior infusion cannula maintaining a pressure of 20-30 mm/Hg with BSS Plus (Alcon, Inc., Fort Worth, TX). Subsequently, the superior-temporal sclerotomy was enlarged with a 20-gauge MVR blade for the injection cannula. A 39-gauge injection cannula with 20-gauge shaft

(Synergetics, O'Fallon, MO) was used to deliver vector into the subretinal space of subjects SA65E and GRl 14QB. A 39-gauge injection cannula (Katalyst) attached to a 1ml disposable barrel injector (Katalyst Injector System, DV1600) was used to deliver vector into the subretinal space of subject JR40D. All blebs in subject SA65E were created without incident. In subject GRl 14QB, a small air bubble was inadvertently delivered to the ΓΤ bleb of the OD eye but no subsequent damage was observed. All other blebs in this subject were created without incident. Slight retinal damage occurred in the IN and IT blebs of subject JR40D's OS eye. All other blebs in this subject were created without incident. Following subretinal injections, sclerotomy sites and conjunctiva were sutured closed using 9.0 vicryl, and subconjunctival cefazolin and dexamethasone were administered. To prevent corneal drying during surgical recovery, triple antibiotic ophthalmic ointment was applied to both eyes. Upon recovery, the subject received subcutaneous sustained release buprenorphine (0.2 mg/kg) and Meloxicam (0.6 mg/kg) and cefazolin (25 mg/kg IM). In all but one eye, recovery was uneventful; the corneas of the treated eyes remained clear with only mild conjunctival redness, which resolved within a day after surgery. The OS eye of subject JR40D showed slight vitreal haziness four days post-operatively. The animal was treated with Dexamethasone (0.25 mg/kg IM) for 1 day followed by a 4 day taper and, upon exam, the eye appeared normal 8 days post-operatively.

In-life imaging

Mice were sedated and expression of GFP was documented using a Micron III fundoscope (Phoenix Research Laboratories, Pleasanton, CA) with a green fluorescent filter. GFP expression was similarly documented at either 4, 6, 10 or 20 weeks post subretinal injection in all strains that received AAV5-G£/CF2£>-gRNA27-hGRKl-GFP or AAV5- Gac 2e-gRNA16-hGRKl-GFP vectors. Exposure settings were identical for all mice.

Averaging of GFP pixel intensity was performed across select cohorts by loading images in sequence and using the average intensity Z-projection in ImageJ. Outer nuclear layer (ONL) thickness in WT and GC1 ^" GC2 ^{" "} mice was quantified by optical coherence tomography (OCT) (Bioptigen Inc, Durham, NC) between 4 to 20 weeks p.i. according to previously published methods . Briefly, after sedation and dilation, three lateral images (nasal to temporal) were collected, starting 3 mm above the meridian crossing 5 through the center of the optic nerve head (ONH), at the ONH meridian and 3 mm below ONH meridian. A corresponding box centered on the ONH with eight measurement points separated by 3 mm from each other was created. ONL thickness in mice injected with AAV- Cas9 plus either AAV-Gwcy2e-gRNA or control AAV-G£/CF2£>-gRNA were compared. Statistical significance was determined by a paired i-test with P values of <0.05 considered o significant.

All NHP subjects were sedated, situated and imaged using a Spectralis™ HRA+OCT (Heidelberg Engineering, Inc., Germany) scanning laser ophthalmoscope as previously described. Images were obtained with either the 30 or 55 degree objective using infrared (820 nm) and autofluorescence (488nm) modes without optical coherence tomography

5 (OCT), and the 30 degree objective for OCT scans. Volume OCT scans were obtained in the macular region of all treated eyes. Fundus images were obtained using a Topcon TRC-50EX Retinal Camera with user- selectable excitation/emission filters, and a Fundus Photo Digital Imaging System (St. Louis Ophthalmic Equipment Co.). o Electroretinographic Analyses

Full field electroretinograms (ERGs) of treated mice were recorded using a UTAS Visual Diagnostic System equipped with Big Shot Ganzfeld (LKC Technologies,

Gaithersburg, MD) or a Diagnosys Celeris unit (Lowell, MA) according to methods previously described with minor modifications ⁴⁰ . Recordings were initially conducted at 6 5 weeks p.i. (p.i.), with certain cohorts subjected to repeated, longer-term measurements.

Following overnight dark adaptation, scotopic ERGs were elicited at intensities ranging from -20 db to 0 db with interstimulus intervals of 30 sec, averaged from five measurements at each intensity. Mice were then light-adapted to a 30 cds/m white background for 7 min. Photopic responses were elicited, with intensities ranging from -3 dB to 10 dB. Fifty responses with interstimulus intervals of 0.4 sec were recorded in the presence of a 20 cds/m white background and averaged at each intensity. The b-wave amplitudes were defined as the difference between the a-wave troughs to the positive peaks of each waveform. At each time point, maximum scotopic and photopic b-wave amplitudes (those generated at 0 dB and 10 dB, respectively) from all treated, untreated, and control mice within each cohort were averaged as mean +standard error. Values were imported into SigmaPlot for final graphical presentation.

Tissue Preparation

At approximately 6 or 20 weeks p.L, mouse eyes were enucleated and fixed in 4% paraformaldehyde for -12 hours. Eyecups were dissected and prepared for sectioning according to previously described methods ⁴¹ .

At 8 weeks p.L, NHPs were perfused, euthanized, and their eyes enucleated/processed according to previously published methods with some modification 29 ' 42. The resulting eyecups were immersed in oxygenated Ames media. Retina from the OD and OS eyes were then dissected into multiple quadrants. For subject SA65E, IN retina from the OD eye was flash frozen. The IT and macular retina were dissociated and GFP positive cells from these samples were sorted with FACS as before 38. For subject GR114QB, the IT retinas from both OD and OS eyes were dissociated and GFP positive cells sorted with FACS. The remaining retinas from both eyes were fixed in 4% PFA for 1 hour at room temperature and then transferred to 0.1M PBS with sodium azide and stored at 4°C. For subject JR40D, the IT retinas from both OD and OS eyes were flash frozen. The IN and macular retinas were dissociated and GFP positive cells sorted with FACS. Fixed retina from subject GR114QB was blocked (5 mm in superior/inferior axis, 8 mm in nasal temporal axis), to isolate macular and IN blebs. Embedding of retina blocks consisted of immersion/equilibration in five different, and successive, solutions: 10% sucrose/PB; 20% sucrose/PB; 30% sucrose/PB; 4 parts 30% sucrose/PB to 1 part HistoPrep (Fisher Scientific, Pittsburgh, PA); and 2 parts 30% sucrose/PB to 1 part HistoPrep. All incubations took place at room temperature for 30 minutes except the 30% sucrose/PB, which took place overnight at 4C. Once the final incubation was complete, the tissue was placed in 2 parts 30% sucrose to 1 part Histoprep, oriented, and frozen immediately by partial submersion in liquid nitrogen. Tissue was cut on a cryostat (Leica CM3050 S, Wetzlar, Germany) with the cabinet and object temperatures set at - 25°C and - 15°C, respectively. All sections were 10 μιη thick. Detailed notes were kept during cryosectioning, keeping track of every section pulled and whether or not that section was mounted or discarded, while periodically monitoring the freshly cut sections with the light microscope. Sectioning in this manner allowed for reasonable orientation within the block, keeping in mind that normal variations occur with cutting at 10 μιη, including expansion and contraction of embedding medium. Sections were mounted on Superfrost Plus (Fisher Scientific) slides.

Immunohistochemistry and Microscopy

Retinal cryosections from mice treated with editing reagents were immunostained with antibodies raised against retGCl (1:5000 generously provided by Dr. Alex Dizhoor, Salus University) or cone arrestin (1: 100, generously provided by Dr. Clay Smith, University of Florida). Following an overnight incubation in primary antibodies at 37° C, IgG secondary antibodies Alexafluor-488, Alexafluor-594 or Alexafluor- 647 were applied for 1 hr at room temperature. Sections were counterstained with 4', 6'-diaminio-2-phenylindole (DAPI) for 5 min at room temperature.

Macular cryosections from both the OD and OS eyes and IN cryosections from the OD eye of GR114QB were stained. The IN retina from the OS eye was damaged/lost during the initial eye dissection and thus not processed for IHC. All sections were washed three times with IX PBS (15 minutes each). Samples were then incubated in 0.5% TritonX -100 for 1 hour in the dark at room temperature and blocked in a mixture of 10% goat serum in IX PBS for 1 hour at room temperature. Slides containing serial retina samples were then incubated with retGCl, cone arrestin, or rhodopsin (1:50, generously provided by Dr. Clay Smith, University of Florida) antibodies described above in a solution containing 1% NHP serum in IX PBS for approximately 12 hours at 4C. Samples were then washed three times with IX PBS (10 minutes each) and incubated for 1 hour at room temperature, with IgG secondary antibodies (Molecular Probes, Eugene, OR) tagged with Alexa-594 (to label retGCl) or Alexa-Cy5 (to label cone arrestin) fluorophores diluted 1:500 in a mixture of IX PBS containing 3% NHP serum. Autofluorescence eliminator reagent (Cat. #2160; EMD Millipore, Billerica, MA) was also applied. Samples were counterstained with DAPI for 5 minutes at room temperature. After a final rinse with IX PBS, samples were mounted in an aqueous-based media (DAKO) and coverslipped. Confocal images of retinal sections were obtained with a laser scanning Lecia TCS SP8 confocal microscope. Exposure/gain settings remained constant within each experiment.

FACS

Mice were euthanized, retinas were dissociated and GFP+ photoreceptors were collected as previously described ⁴³ . Briefly, immediately following sacrifice, retinas were placed in papain for dissociation (Worthington Papain Dissociation System cat# LK003150). After dissociation, cells were placed in 5% FBS and FACs sorted on a BD FACSAria II. A common template gate was used for all eyes to collect GFP positive photoreceptors. Once collected, cells were pelleted and frozen for further RNA and DNA analysis.

Retinal samples from NHPs were dissociated with papain (Worthington Biochemical

Corporation, NJ, Cat #3150) according to the manufacture's protocol and sorted according to the previously published methods with minor modification 38. In brief, papain was pre- incubated in 5 ml of Earle's Balanced Salt Solution (EBSS) for 10 min at 37°C. After preincubation, 250 μΐ of DNase (dissolved in either 500 μΐ or 250 μΐ of EBSS) was added to a final concentration of -20 or 40 units/ml papain and 0.005% DNase. Dissected retina samples were placed in 15 ml falcon tubes containing 700 μΐ of papain/DNase and equilibrated with 95% 0 ₂ :5% C0 _2. Retina blocks were dissociated by incubation with activated papain at 37°C for 45 min with constant agitation followed by trituration. Dissociated cells were spun down for 5 min at 2000 rpm and resuspended in 500 μΐ of resuspension media (430 μΐ EBSS, 50 μΐ albumin-ovomucoid inhibitor, 25 μΐ DNase). To prepare the density gradient, 600 μΐ of albumin-ovomucoid inhibitor was added to a 15 ml Falcon tube, and the cell suspension layered on top. Following centrifugation for 6 min at 1000 rpm, the cells were gently rinsed with lx PBS, then resuspended with lx PBS/5% FBS. Sorting of GFP-positive (GFP+) and unlabeled cells was performed on a BD FACS ARIA SORP equipped with BD FACS Diva software 8.0.1 and a 100 micron nozzle. The filters used to detect the GFP positive fraction were 505LP and 530/30BP (range 515-545 nm) off the Blue 488 nm laser. Sorted cells were then placed into 15mL tubes and centrifuged at 2500 rpm for 15 minutes. Supernatant was removed and cells were resuspended in 600 uL of RNA later. Samples were then split in half by placing 300 uL of each sample into 1.5 mL tubes.

Nucleic Acid Isolation from Mouse and NHP Retinal Tissue

Genomic DNA was isolated using the DNEasy Blood and Tissue Kit (Qiagen) according to manufacturer's instructions and quantified using Qubit fluorometric quantitation (Thermo Fisher). Total RNA was isolated using the mz ^' rVana miRNA Isolation Kit, with phenol (Thermo Fisher) following the total RNA extraction protocol, according to manufacturer's instructions and DNAse treated with Turbo ΌΝΑ-free DNA removal kit (Thermo Fisher). qRT-PCR

RNA was reverse transcribed using the Superscript III First-Strand Synthesis SuperMix for qRT-PCR Kit (Thermo) according to manufacturer's instructions except that 1 μL· of a 52.5 μΜ stock of a gene-specific primer for reverse transcribing the gRNA is included (5 '-TCTCGCCAACAAGTTGACGAG-3', SEQ ID NO: 42). The Cas9 mRNA and total genomic RNA are reverse transcribed using the random hexamers present in the master mix reagent. qPCR was performed in triplicate on a CFX384 Real Time PCR Detection System (BioRad) using Taqman Universal PCR Mastermix (Thermo Fisher). Housekeeping gene control was quantified using Thermo Fisher Mouse GAPDH Endogenous Control #4352932E. SaCas9 mRNA and gRNA were quantified. Sequencing to Determine Editing Efficiency

To determine targeted gene editing efficiency, the region surrounding the gRNA cut site was PCR-amplified from genomic DNA isolated from retinal tissue or sorted PRs. PCR products were cloned into a plasmid backbone using the Zero-Blunt TOPO kit (Thermo Fisher). The TOPO ligation reaction was transformed into chemically competent Top 10 cells and individual colonies were isolated and sequenced by GENEWIZ, Inc. Sanger sequencing reads were aligned to reference sequence to quantify rates of targeted gene editing. Non- limiting examples of sequencing results are shown in FIGs. 25 and 26.

Western blot

Flash frozen mouse retinas and designated retinal blocks from macaque were processed according to previously described methods ⁴⁴ . The tissue was lysed by sonication (4x5 sec) in 150 microliters of RIPA buffer with Halt Protease Inhibitor (Thermo Scientific Cat#1860932). Cell debris was removed by centrifugation at 14,000 rpm for 10 min at room temperature. The protein concentration of the supernatant was determined with bicinchoninic acid (BCA) (Thermo Fisher Scientific), and equal amounts of protein were separated on 4- 20% polyacrylamide gels (BioRad, Hercules, CA) and subsequently transferred onto polyvinylidene difluoride (PVDF) membranes (Millipore, Billerica, MA). Blots were labeled with antibodies specific for saCas9, β-actin (1:5000; Abeam, Cambridge, MA), retGCl (1:20,000, generously provided by Dr. Alex Dizhoor, Salus University), GCAP1 ("UW101", 1:20,000, generously provided by Dr. Wolfgang Baehr, University of Utah) and/or cone arrestin (1:00) generously provided by Dr. Clay Smith, University of Florida). Both retGCl and GCAP1 expression in macaque retinas were normalized to cone arrestin. Neutralizing antibody assays

NHP serum was screened for the presence of neutralizing antibodies against AAV5 prior to purchase according to previously published methods . ARPE-19 cells (ATCC, Manassas, VA) were maintained in a culture medium consisting of Dulbecco's modified Eagle's medium (DMEM)— Nutrient Mixture F-12, 1: 1 mixture with Hepes buffer containing 10% fetal bovine serum (FBS), 0.384% (w/v) additional sodium bicarbonate, 1% 200 Mm L- glutamine, and 50 mg/ml Gentamicin. Cells were incubated at 37C in 7% C02. Serum samples from subjects SA65E, GR114QB, and JR40D and naive serum from a mouse (Sigma) were heat-inactivated at 56°C for 35 minutes. Self-complimentary AAV5-smCBA- mCherry vector (10 ⁴ genomic copies per cell) was diluted in serum-free DMEM/F-12 1: 1 modified medium and incubated with a series of dilutions (1: 10, 1:40, 1: 160) of heat- inactivated serum samples in DMEM/F-12 1: 1 modified medium for 1 hour at 37°C. The serum-vector mixture was then used to infect ARPE-19 cells seeded in 96-well plates containing 3 x 10 ⁴ cells/well for 1 hour. After 1 hour incubation, an equal volume of 20% FBS DMEM/F-12 1: 1 modified medium was added to each well and incubated for 72 hours at 37°C in 7% C0 ₂ . Three days post-infection, cells were observed under a fluorescent microscope to confirm reporter gene expression (EVOS XL Core). Cells were then dissociated with Accutase solution (MP Biomedicals, Solon, OH), and 10,000 cells per sample were counted and analyzed using a BD LSR II flow cytometer equipped with BD FACSDIVA 6.2 software (BD Biosciences, San Jose, CA). mCherry fluorescence was quantified with a PE-Texas-Red-A filter with an excitation wavelength of 532 nm and an emission band pass of 600-620 nm. The transduction efficiency was calculated by multiplying the percentage of cells positive for mCherry by the mean fluorescence intensity ⁴⁵ ' ⁴⁶ . The neutralizing antibody (nAb) titer was reported as the highest serum dilution that inhibited self-complementary AAV5-smCBA-mCherry transduction (mCherry expression) by > 50%, compared with naive serum control. Serum samples were collected pre-treatment and post-treatment. A sample taken from an animal not utilized in this study that was shown previously to be strongly neutralized by AAV5 was used as a positive control.

Guanylate cyclase activity assays

GCl ^+/" :GC2 ^"/_ (n=4) mice were dark-adapted overnight, sacrificed under infrared illumination, and their retinas extracted and assayed for guanylate cyclase activity in the dark

32 47 48

using [a- P]GTP as a substrate according to a previously described protocol . The assay mixture (25 μ¾ contained 30 mM MOPS-KOH (pH 7.2), 60 mM KC1, 4 mM NaCl, 1 mM DTT, 2 mM Ca ²⁺ /EGTA buffer, 1 mM free Mg ²⁺ , 0.3 mM ATP, 4 mM cGMP, 1 mM GTP, 1 μα of [a- ³² P]GTP, 0.1 μα of [8- ³ H]cGMP (Perkin Elmer, Waltham, MA), phosphodiesterase inhibitors zaprinast and dipyridamole, 10 mM creatine phosphate, and 0.5

32

unit of creatine phosphokinase. The resultant [ P]cGMP product, together with the internal standard of [8- H]cGMP, was purified using fluorescently backed polyethyleneimine cellulose thin-layer chromatography plate (Merck, Whitehouse Station, NJ) as described previously ⁴⁹ , and the radioactivity of both tracers was counted after elution in 1 M LiCl using ScintiSafe scintillation cocktail (Fisher/Thermo Scientific, Waltham, MA) containing 20% ethanol. Ca ²⁺ /EGTA buffers containing calibrated free Ca ²⁺ and Mg ²⁺ concentrations were prepared using published methods ⁵⁰ and verified by fluorescent Ca ²⁺ indicator dyes as previously described ⁵¹ . REFERENCES CITED:

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OTHER EMBODIMENTS

All of the features disclosed in this specification may be combined in any

combination. Each feature disclosed in this specification may be replaced by an alternative feature serving the same, equivalent, or similar purpose. Thus, unless expressly stated otherwise, each feature disclosed is only an example of a generic series of equivalent or similar features.

From the above description, one skilled in the art can easily ascertain the essential characteristics of the present disclosure, and without departing from the spirit and scope thereof, can make various changes and modifications of the disclosure to adapt it to various usages and conditions. Thus, other embodiments are also within the claims.

EQUIVALENTS While several inventive embodiments have been described and illustrated herein, those of ordinary skill in the art will readily envision a variety of other means and/or structures for performing the function and/or obtaining the results and/or one or more of the advantages described herein, and each of such variations and/or modifications is deemed to 5 be within the scope of the inventive embodiments described herein. More generally, those skilled in the art will readily appreciate that all parameters, dimensions, materials, and configurations described herein are meant to be exemplary and that the actual parameters, dimensions, materials, and/or configurations will depend upon the specific application or applications for which the inventive teachings is/are used. Those skilled in the art will o recognize, or be able to ascertain using no more than routine experimentation, many

equivalents to the specific inventive embodiments described herein. It is, therefore, to be understood that the foregoing embodiments are presented by way of example only and that, within the scope of the appended claims and equivalents thereto, inventive embodiments may be practiced otherwise than as specifically described and claimed. Inventive embodiments of5 the present disclosure are directed to each individual feature, system, article, material, kit, and/or method described herein. In addition, any combination of two or more such features, systems, articles, materials, kits, and/or methods, if such features, systems, articles, materials, kits, and/or methods are not mutually inconsistent, is included within the inventive scope of the present disclosure.

o All definitions, as defined and used herein, should be understood to control over

dictionary definitions, definitions in documents incorporated by reference, and/or ordinary meanings of the defined terms.

All references, patents and patent applications disclosed herein are incorporated by reference with respect to the subject matter for which each is cited, which in some cases may 5 encompass the entirety of the document.

The indefinite articles "a" and "an," as used herein in the specification and in the claims, unless clearly indicated to the contrary, should be understood to mean "at least one." The phrase "and/or," as used herein in the specification and in the claims, should be understood to mean "either or both" of the elements so conjoined, i.e., elements that are conjunctively present in some cases and disjunctively present in other cases. Multiple elements listed with "and/or" should be construed in the same fashion, i.e., "one or more" of the elements so conjoined. Other elements may optionally be present other than the elements specifically identified by the "and/or" clause, whether related or unrelated to those elements specifically identified. Thus, as a non-limiting example, a reference to "A and/or B", when used in conjunction with open-ended language such as "comprising" can refer, in one embodiment, to A only (optionally including elements other than B); in another embodiment, to B only (optionally including elements other than A); in yet another embodiment, to both A and B (optionally including other elements); etc.

As used herein in the specification and in the claims, "or" should be understood to have the same meaning as "and/or" as defined above. For example, when separating items in a list, "or" or "and/or" shall be interpreted as being inclusive, i.e., the inclusion of at least one, but also including more than one, of a number or list of elements, and, optionally, additional unlisted items. Only terms clearly indicated to the contrary, such as "only one of or "exactly one of," or, when used in the claims, "consisting of," will refer to the inclusion of exactly one element of a number or list of elements. In general, the term "or" as used herein shall only be interpreted as indicating exclusive alternatives (i.e. "one or the other but not both") when preceded by terms of exclusivity, such as "either," "one of," "only one of," or "exactly one of." "Consisting essentially of," when used in the claims, shall have its ordinary meaning as used in the field of patent law.

As used herein in the specification and in the claims, the phrase "at least one," in reference to a list of one or more elements, should be understood to mean at least one element selected from any one or more of the elements in the list of elements, but not necessarily including at least one of each and every element specifically listed within the list of elements and not excluding any combinations of elements in the list of elements. This definition also allows that elements may optionally be present other than the elements specifically identified within the list of elements to which the phrase "at least one" refers, whether related or unrelated to those elements specifically identified. Thus, as a non-limiting example, "at least one of A and B" (or, equivalently, "at least one of A or B," or, equivalently "at least one of A and/or B") can refer, in one embodiment, to at least one, optionally including more than one, A, with no B present (and optionally including elements other than B); in another

embodiment, to at least one, optionally including more than one, B, with no A present (and optionally including elements other than A); in yet another embodiment, to at least one, optionally including more than one, A, and at least one, optionally including more than one, B (and optionally including other elements); etc.

It should also be understood that, unless clearly indicated to the contrary, in any methods claimed herein that include more than one step or act, the order of the steps or acts of the method is not necessarily limited to the order in which the steps or acts of the method are recited.

In the claims, as well as in the specification above, all transitional phrases such as "comprising," "including," "carrying," "having," "containing," "involving," "holding," "composed of," and the like are to be understood to be open-ended, i.e., to mean including but not limited to. Only the transitional phrases "consisting of and "consisting essentially of shall be closed or semi-closed transitional phrases, respectively, as set forth in the United States Patent Office Manual of Patent Examining Procedures, Section 2111.03. It should be appreciated that embodiments described in this document using an open-ended transitional phrase (e.g. , "comprising") are also contemplated, in alternative embodiments, as "consisting of and "consisting essentially of the feature described by the open-ended transitional phrase. For example, if the disclosure describes "a composition comprising A and B", the disclosure also contemplates the alternative embodiments "a composition consisting of A and B" and "a composition consisting essentially of A and B".