Vitamin A Palmitate Supplementation in Patients With Reticular Pseudodrusen (RPD) and Delayed Dark Adaptation

An Investigation of Vitamin A Palmitate Supplementation in Patients With Reticular Pseudodrusen (RPD) and Delayed Dark Adaptation

Background:

Age-related macular degeneration (AMD) is an eye disease. It is the leading cause of vision loss in people over 55 in the U.S. Changes in the eye can make it difficult for they eye to adjust to low light. This is known as dark adaptation. This is particularly significant in people with reticular pseudodrusen (RPD). Identifying and watching the early to middle stages of AMD and changes in dark adaptation might help researchers learn to stop the disease before it becomes severe. Taking vitamin A might help improve vision in people with RPD.

Objectives:

To see if taking 16,000 IU of vitamin A per day improves vision in people with RPD. Also to improve understanding of RPD and associated dark adaptation.

Eligibility:

Adults ages 50 and older with RPD and normal liver function

Design:

Participants will be screened with:

Medical and eye disease history

Eye exam: The pupil will be dilated with eye drops. Pictures will be taken of the retina and the inside of the eye.

Including the screening visit, participants will have at least 5 visits. They will be about once a month over 6 months and last 4-6 hours. Visits include:

Questions about eye problems in certain light

Eye exam

Blood and urine tests

Dark adaptation protocol: Participants will sit at a machine in a dark room. They will look into the machine and push a button when they see a light. This lasts 20-40 minutes.

Participants will take a vitamin A supplement by mouth once a day for 2 months. They will record when they take the pills in a diary.

Study Overview

• Status: Completed
• Conditions: Age-Related Macular Degeneration; Reticular Pseudodrusen (RPD)
• Intervention / Treatment: Drug: Vitamin A Palmitate

Detailed Description

Objective: The objective of this study is to investigate the potential efficacy and safety of vitamin A palmitate dosing in improving dark adaptation in participants with reticular pseudodrusen (RPD) and abnormal dark adaptation.

Study Population: The first cohort consists of seven participants with RPD who meet the eligibility criteria. The second cohort will consist of five participants with RPD who meet the eligibility criteria. Up to five additional participants may be accrued in the second cohort to account for participants who withdraw from the study prior to receiving two months of study supplementation for a reason unrelated to an adverse reaction. Up to 18 participants may be enrolled in this study.

Design: This is a pilot, uncontrolled, prospective, single center study to investigate the potential efficacy and safety of vitamin A palmitate dosing in improving dark adaptation in participants with RPD and abnormal dark adaptation. Participants in the first cohort were instructed to take 16,000 IU of vitamin A palmitate daily for two months. Participants in the second cohort will be instructed to take 48,000 IU of vitamin A palmitate daily for one month. Enrollment for Cohort 1 ended on January 10, 2019. Participants in both cohorts will continue in the study for one month after ending Vitamin A supplementation. Participants in Cohort 1 may enroll into Cohort 2 as long as their last intake of vitamin A palmitate was greater than two months prior to their enrollment into Cohort 2.

Outcome Measures: For each cohort, the primary outcome is the measurement of dark adaptation parameters (thresholds and kinetics) by the following: dark adaptation times as measured by the AdaptDx comparing before and after vitamin A palmitate and dark adaptation parameters as measured by the Medmont comparing before and after vitamin A palmitate supplementation. The primary outcome will be assessed at Month 2 in the first cohort and Month 1 in the second cohort. For both cohorts, the secondary outcomes include changes in low luminance visual acuity (LLVA) and changes in patient reported outcomes as measured by the low luminance questionnaire (LLQ). The secondary outcomes also include measurement of dark adaptation parameters (thresholds and kinetics) comparing baseline and one month after completing supplementation (Month 3 in Cohort 1 and Month 2 in Cohort 2).

• Study Type: Interventional
• Enrollment (Actual): 9
• Phase: Early Phase 1

Contacts and Locations

Study Locations

• United States
  • Maryland
    • Bethesda, Maryland, United States, 20892
      • National Institutes of Health Clinical Center

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 50 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No

Description

• INCLUSION CRITERIA:

To be eligible, the following inclusion criteria must be met, where applicable.

1. Participant must be 50 years of age or older.
2. Participant must understand and sign the protocol s informed consent document.
3. Any participant of childbearing potential must be willing to undergo urine pregnancy tests throughout the study.

4. Any participant of childbearing potential and any participant able to father children must have (or have a partner who has) had a hysterectomy or vasectomy, be completely abstinent from intercourse, or must agree to practice at least one acceptable method of contraception throughout the course of the study and for one week after study supplement discontinuation. Acceptable methods of contraception include:

   • Hormonal contraception (i.e. birth control pills, injected hormones, dermal patch or vaginal ring),
   • Intrauterine device,
   • Barrier methods (diaphragm, condom) with spermicide, or
   • Surgical sterilization (tubal ligation).
5. Participants must agree to notify the study investigator or coordinator if any of their doctors initiate a new prescription medication during the course of this study.
6. Participant must agree to not take vitamin A palmitate greater than or equal to 8,000 IU outside the study supplementation.
7. For supplementation eligibility, participant must have normal liver function as demonstrated by the Chemistry 20 panel, or have mild abnormalities not above grade 1 as defined by the Common Terminology Criteria for Adverse Events v4.0 (CTCAE).
8. Participant must not be pregnant or breast-feeding and must have a negative urine pregnancy test within 24 hours prior to initiation of study medication.

EXCLUSION CRITERIA:

A participant is not eligible if any of the following exclusion criteria are present.

1. Participant is in another investigational study and actively receiving study therapy.
2. Participant is unable to comply with study procedures or follow-up visits.
3. Participant is already taking vitamin A palmitate supplements greater than or equal to 8,000 IU.
4. Participant has a history of vitamin A deficiency.
5. Participant has a condition that, in the opinion of the investigator, would preclude participation in the study (e.g., unstable medical status including blood pressure and glycemic control).
6. Participant has a history of hepatitis or liver failure.
7. Participant has chronic gastrointestinal disease.
8. Participant will be excluded if the participant has serologic evidence of an active hepatitis infection.
9. Participant was in Cohort 1 and took his/her last dose of vitamin A palmitate less than two months prior to enrolling in Cohort 2.

STUDY EYE INCLUSION CRITERIA:

1. The eye must have a best-corrected ETDRS visual acuity score better than or equal to 20/80 (i.e., equal to or better than 54 letters).
2. Participant must have presence of reticular pseudodrusen on multi-modal imaging.
3. Abnormal dark adaptation, which is defined as having an AdaptDx test with a RIT of 16 minutes or more at the screening visit. This is at least one standard deviation greater than the average normal RIT and includes room to account for variability in testing. If at any point during current testing or under a previous NEI protocol, a participant has exceeded the 40 minute test ceiling, they will have satisfied the inclusion criteria.

STUDY EYE EXCLUSION CRITERIA:

1. Presence of advanced macular degeneration with central geographic atrophy or choroidal neovascularization.
2. An ocular condition is present (other than AMD) that, in the opinion of the investigator, might alter visual acuity during the course of the study (e.g., vein occlusion, uveitis or other ocular inflammatory disease, neovascular glaucoma, Irvine-Gass Syndrome, etc.).
3. Substantial cataract that, in the opinion of the investigator, is likely to be decreasing visual acuity by three lines or more (i.e., cataract would be reducing acuity to 20/40 or worse if eye was otherwise normal).
4. History of major ocular surgery (e.g., cataract extraction, scleral buckle, any intraocular surgery, etc.) within three months prior to study entry.
5. History of YAG (Yttrium-Aluminum Garnet) capsulotomy performed within two months prior to study entry.

CHOICE OF STUDY EYE IN CASES OF BILATERAL DISEASE:

If both eyes meet the study eye eligibility criteria described above, the following criteria will be used to select the study eye for the purposes of this investigation:

1. The eye with the better visual acuity will be chosen.
2. If both eyes are equal acuity, the right eye will be arbitrarily chosen as the study eye

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: N/A
• Interventional Model: Single Group Assignment
• Masking: None (Open Label)

Number of Arms

1

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Participants; Participants with reticular pseudodrusen	Drug: Vitamin A Palmitate; Provide vitamin A to participants with pre/post assessments of vision.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Change in Dark Adaptation Rod Intercept Time (RIT) From Baseline in the Study Eye at the Treatment Completion Visit (Month 2 for Cohort 1 and Month 1 for Cohort 2)	The mean change in rod intercept time (RIT) in the study eye at the treatment completion visit from baseline was descriptively summarized and assessed using a Student's paired t-test at a two-sided Type I error rate of 5%.	Baseline to Month 2 for Cohort 1 and Baseline to Month 1 for Cohort 2

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Change in Low Luminance Visual Acuity (LLVA) From Baseline in the Study Eye at the Treatment Completion and Post-Treatment Follow-Up Visits	The mean change in low luminance visual acuity (LLVA) in the study eye from baseline at the treatment completion and post-treatment follow-up visits were descriptively summarized.	Treatment Completion Visit: Month 2 for Cohort 1 and Month 1 for Cohort 2; Post-Treatment Follow-Up Visit: Month 3 for Cohort 1 and Month 2 for Cohort 2
Change in Dark Adaptation Rod Intercept Time (RIT) From Baseline in the Study Eye at the Post-Treatment Follow-Up Visit (Month 3 for Cohort 1 and Month 2 for Cohort 2)	The mean change in rod intercept time (RIT) in the study eye at the post-treatment follow-up visit from baseline was descriptively summarized and assessed using a Student's paired t-test at a two-sided Type I error rate of 5%.	Baseline to Month 3 for Cohort 1 and Baseline to Month 2 for Cohort 2
Change in Low Luminance Questionnaire (LLQ) Composite Score From Baseline at the Treatment Completion and Post-Treatment Follow-Up Visits	Low Luminance Questionnaire (LLQ) is a 32-item questionnaire relating to difficulty with visual function in low luminance settings. Individual questions are assigned to one of six distinct subscales and are scored in 25-point increments (range=0 to 100, higher values=better outcome). Applicable questions are averaged to produce (weighted) subscale scores (range=0 to 100, higher values=better outcome). (Weighted) Subscale scores are averaged to produce a composite score (range=0 to 100, higher values=better outcome). The mean change in LLQ composite score from baseline at the treatment completion and post-treatment completion visits are descriptively summarized. A positive score change represents improvement in functioning from baseline (i.e., higher values=better outcome), whereas a negative score change represents a decline in functioning from baseline (i.e., lower values=worse outcome).	Treatment Completion Visit: Month 2 for Cohort 1 and Month 1 for Cohort 2; Post-Treatment Follow-Up Visit: Month 3 for Cohort 1 and Month 2 for Cohort 2
Change in Low Luminance Questionnaire (LLQ) Driving Subscale Score From Baseline at the Treatment Completion and Post-Treatment Follow-Up Visits	Low Luminance Questionnaire (LLQ) is a 32-item questionnaire relating to difficulty with visual function in low luminance settings. Individual questions are assigned to one of six distinct subscales and are scored in 25-point increments (range=0 to 100, higher values=better outcome). Applicable questions are averaged to produce (weighted) subscale scores (range=0 to 100, higher values=better outcome). The mean change in LLQ driving subscale score from baseline at the treatment completion and post-treatment completion visits are descriptively summarized. A positive score change represents improvement in functioning from baseline (i.e., higher values=better outcome), whereas a negative score change represents a decline in functioning from baseline (i.e., lower values=worse outcome).	Treatment Completion Visit: Month 2 for Cohort 1 and Month 1 for Cohort 2; Post-Treatment Follow-Up Visit: Month 3 for Cohort 1 and Month 2 for Cohort 2
Change in Low Luminance Questionnaire (LLQ) Extreme Lighting Subscale Score From Baseline at the Treatment Completion and Post-Treatment Follow-Up Visits	Low Luminance Questionnaire (LLQ) is a 32-item questionnaire relating to difficulty with visual function in low luminance settings. Individual questions are assigned to one of six distinct subscales and are scored in 25-point increments (range=0 to 100, higher values=better outcome). Applicable questions are averaged to produce (weighted) subscale scores (range=0 to 100, higher values=better outcome). The mean change in LLQ extreme lighting subscale score from baseline at the treatment completion and post-treatment completion visits are descriptively summarized. A positive score change represents improvement in functioning from baseline (i.e., higher values=better outcome), whereas a negative score change represents a decline in functioning from baseline (i.e., lower values=worse outcome).	Treatment Completion Visit: Month 2 for Cohort 1 and Month 1 for Cohort 2; Post-Treatment Follow-Up Visit: Month 3 for Cohort 1 and Month 2 for Cohort 2
Change in Low Luminance Questionnaire (LLQ) Mobility Subscale Score From Baseline at the Treatment Completion and Post-Treatment Follow-Up Visits	Low Luminance Questionnaire (LLQ) is a 32-item questionnaire relating to difficulty with visual function in low luminance settings. Individual questions are assigned to one of six distinct subscales and are scored in 25-point increments (range=0 to 100, higher values=better outcome). Applicable questions are averaged to produce (weighted) subscale scores (range=0 to 100, higher values=better outcome). The mean change in LLQ mobility subscale score from baseline at the treatment completion and post-treatment completion visits are descriptively summarized. A positive score change represents improvement in functioning from baseline (i.e., higher values=better outcome), whereas a negative score change represents a decline in functioning from baseline (i.e., lower values=worse outcome).	Treatment Completion Visit: Month 2 for Cohort 1 and Month 1 for Cohort 2; Post-Treatment Follow-Up Visit: Month 3 for Cohort 1 and Month 2 for Cohort 2
Change in Low Luminance Questionnaire (LLQ) Emotional Distress Subscale Score From Baseline at the Treatment Completion and Post-Treatment Follow-Up Visits	Low Luminance Questionnaire (LLQ) is a 32-item questionnaire relating to difficulty with visual function in low luminance settings. Individual questions are assigned to one of six distinct subscales and are scored in 25-point increments (range=0 to 100, higher values=better outcome). Applicable questions are averaged to produce (weighted) subscale scores (range=0 to 100, higher values=better outcome). The mean change in LLQ emotional distress subscale score from baseline at the treatment completion and post-treatment completion visits are descriptively summarized. A positive score change represents improvement in functioning from baseline (i.e., higher values=better outcome), whereas a negative score change represents a decline in functioning from baseline (i.e., lower values=worse outcome).	Treatment Completion Visit: Month 2 for Cohort 1 and Month 1 for Cohort 2; Post-Treatment Follow-Up Visit: Month 3 for Cohort 1 and Month 2 for Cohort 2
Change in Low Luminance Questionnaire (LLQ) General Dim Lighting Subscale Score From Baseline at the Treatment Completion and Post-Treatment Follow-Up Visits	Low Luminance Questionnaire (LLQ) is a 32-item questionnaire relating to difficulty with visual function in low luminance settings. Individual questions are assigned to one of six distinct subscales and are scored in 25-point increments (range=0 to 100, higher values=better outcome). Applicable questions are averaged to produce (weighted) subscale scores (range=0 to 100, higher values=better outcome). The mean change in LLQ general dim lighting subscale score from baseline at the treatment completion and post-treatment completion visits are descriptively summarized. A positive score change represents improvement in functioning from baseline (i.e., higher values=better outcome), whereas a negative score change represents a decline in functioning from baseline (i.e., lower values=worse outcome).	Treatment Completion Visit: Month 2 for Cohort 1 and Month 1 for Cohort 2; Post-Treatment Follow-Up Visit: Month 3 for Cohort 1 and Month 2 for Cohort 2
Change in Low Luminance Questionnaire (LLQ) Peripheral Vision Subscale Score From Baseline at the Treatment Completion and Post-Treatment Follow-Up Visits	Low Luminance Questionnaire (LLQ) is a 32-item questionnaire relating to difficulty with visual function in low luminance settings. Individual questions are assigned to one of six distinct subscales and are scored in 25-point increments (range=0 to 100, higher values=better outcome). Applicable questions are averaged to produce (weighted) subscale scores (range=0 to 100, higher values=better outcome). The mean change in LLQ peripheral vision subscale score from baseline at the treatment completion and post-treatment completion visits are descriptively summarized. A positive score change represents improvement in functioning from baseline (i.e., higher values=better outcome), whereas a negative score change represents a decline in functioning from baseline (i.e., lower values=worse outcome).	Treatment Completion Visit: Month 2 for Cohort 1 and Month 1 for Cohort 2; Post-Treatment Follow-Up Visit: Month 3 for Cohort 1 and Month 2 for Cohort 2

Collaborators and Investigators

• Sponsor: National Eye Institute (NEI)
• Investigators: Principal Investigator: Emily Y Chew, M.D., National Eye Institute (NEI)

Publications and helpful links

General Publications

• Pfau K, Jeffrey BG, Cukras CA. LOW-DOSE SUPPLEMENTATION WITH RETINOL IMPROVES RETINAL FUNCTION IN EYES WITH AGE-RELATED MACULAR DEGENERATION BUT WITHOUT RETICULAR PSEUDODRUSEN. Retina. 2023 Sep 1;43(9):1462-1471. doi: 10.1097/IAE.0000000000003840.

Helpful Links

• NIH Clinical Center Detailed Web Page

Study record dates

Study Major Dates

• Study Start (Actual): May 14, 2018
• Primary Completion (Actual): June 17, 2022
• Study Completion (Actual): June 17, 2022

Study Registration Dates

• First Submitted: March 21, 2018
• First Submitted That Met QC Criteria: March 24, 2018
• First Posted (Actual): March 27, 2018

Study Record Updates

• Last Update Posted (Actual): April 16, 2025
• Last Update Submitted That Met QC Criteria: March 27, 2025
• Last Verified: December 1, 2023

More Information

Terms related to this study

• Keywords: Age-Related Macular Degeneration (AMD); Eye Examinations; Retinal Pigment Epithelium
• Additional Relevant MeSH Terms: Eye Diseases; Retinal Diseases; Retinal Degeneration; Macular Degeneration; Retinal Drusen; Antineoplastic Agents; Physiological Effects of Drugs; Molecular Mechanisms of Pharmacological Action; Micronutrients; Antioxidants; Protective Agents; Vitamins; Anticarcinogenic Agents; Vitamin A; Retinol palmitate
• Other Study ID Numbers: 180068; 18-EI-0068

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: UNDECIDED

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: Yes
• Studies a U.S. FDA-regulated device product: No