Revakinagene taroretcel-lwey for MacTel: Charles Wykoff, MD, PhD, on a year of real-world experience

After performing the first commercial revakinagene taroretcel-lwey (Encelto; Neurotech Pharmaceuticals) implantation outside of a clinical trial, Charles Wykoff, MD, PhD, director of research at Retina Consultants of Texas, offered a detailed account of how the first year of real-world use has shaped his clinical approach to macular telangiectasia type 2 (MacTel).

MacTel remains underdiagnosed and historically undertreated, and Wykoff emphasized that FDA approval has meaningfully accelerated education efforts among referring physicians and general ophthalmologists. The approval of revakinagene taroretcel-lwey as the first and only FDA-approved treatment for MacTel has been described as a significant milestone for patients with this progressive retinal disease, with the implantable device using encapsulated cell therapy (ECT) technology to continuously deliver therapeutic doses of ciliary neurotrophic factor (CNTF) to the retina.

Patient selection and procedure

On patient selection, Wykoff stressed that eligibility requires two core conditions: the patient must be symptomatic, and they must be experiencing documented progression. Confirmed MacTel diagnosis with EZ loss on imaging and absence of active neovascularization are also required. He actively avoids implanting patients on anti-VEGF therapy for neovascular complications and uses tools including the Amsler grid and microperimetry to confirm progression in patients who appear clinically stable. He was direct with patients that revakinagene taroretcel-lwey is not intended to improve vision—only to slow the rate of photoreceptor loss.

Wykoff described the implantation procedure as well within the retina surgeon's existing technical repertoire, typically not requiring a vitrectomy machine. The key steps include a 7 × 7 mm conjunctival peritomy placed inferotemporally, a 3-mm sclerotomy approximately 3.75 mm posterior to the surgical limbus, and fixation of the titanium loop with a double-armed 9-0 polypropylene suture, with wound closure using buried 9-0 nylon sutures. The primary technical challenge, he noted, is managing the fine 9-0 polypropylene suture, which is prone to kinking. In patients with bilateral disease interested in receiving bilateral implantation, Wykoff typically implants the worse-seeing eye first.

Looking ahead

Wykoff expressed enthusiasm for ECT as a broader drug delivery platform, noting its potential for delivering other therapeutic proteins. "It's fascinating and remarkably well tolerated in this population of patients," he said in the video interview. Known adverse events to counsel patients on include miosis, delayed dark adaptation, and the rare risk of device extrusion or intraocular tissue damage.