LIGHT IN THE DARKNESS: From an LCA Diagnosis to Advocacy in Turkey

Toprak Kulekci is a vivacious, seven-year-old budding ballerina who lives with her parents in Ankara, Turkey. When she was born in 2017, her father, Haydar, a software engineer, and mother, Gizem, an agricultural engineer, had no forewarning that their daughter could inherit a blinding retinal disease. However, with early concerns about her eyesight, they later discovered that Toprak had only five percent vision as a result of GUCY2D-associated Leber congenital amaurosis (LCA1). Thanks to her parents’ teamwork and tenacity, Toprak is thriving in school, taking ballet lessons and performing on stage with her class.

The Beginning

Haydar credits Gizem with having unique insights about their daughter. One morning, close to the end of her pregnancy, Gizem woke up feeling ill. “She said that something was wrong. The baby usually moved after she ate sweet things, but that morning, nothing happened after breakfast,” Haydar explained. A trip to the hospital resulted in an emergency cesarean section. “The umbilical cord was wrapped around Toprak’s neck eight times. If my wife hadn’t been paying attention to all of their little habits, we would have lost our daughter.”

Then, about a month after her birth, Gizem noticed that Toprak wasn’t making eye contact or closing her eyes when breastfeeding. “We waited about 40 days,” Haydar said, “and then we took her to the doctor. He said not to worry. Her eyes will get better.” A follow-up exam five months later showed no improvement.

Seeking A Diagnosis

The doctor’s evaluation ignited the couple’s problem-solving instincts. Determined to find an answer, they took Toprak to five or six doctors over the next year and a half. “Finally, one doctor said it could be LCA, and this was our first real answer,” Haydar said. “That day, we went to a research center for genetic testing, and several months later, it was confirmed that she had LCA1.”

With little to no information about LCA available in Turkey, the Kulekcis turned to the internet for answers. Haydar was elated when he discovered Shannon Boye, PhD, professor and chief – Division of Cellular and Molecular Therapy, Department of Pediatrics at the University of Florida. Dr. Boye and her team were researching an adeno-associated viral vector (AAV) delivered gene therapy treatment for LCA1. Not only was there someone who had deep knowledge about LCA1, but her lab was also working on a possible treatment. “That night, I emailed Dr. Boye,” Haydar said. “A couple of hours later, I received a response. In that moment, I cried, filled with hope again. It was so important to hear from a doctor on the other side of the world who knew about this disease and might be able to help fix it.” Haydar, who is fluent in English, asked Dr. Boye for her research papers so he could learn more about Toprak’s condition. He also contacted Penn Medicine, regularly sending them Toprak’s exam reports. Meanwhile, Toprak was receiving help at a local rehabilitation center. At the rehabilitation center and home, the focus was on helping her use and “love the light and contrasts” she could detect.

The Inclusive And Accessible Life Association

Through his research, Haydar realized that some organizations in other countries are focused on helping the blind and visually impaired. Others, including Hope in Focus (HIF), were dedicated to providing information and support for specific conditions such as LCA. Excited by the content on the HIF website, Haydar translated some of its articles into Turkish, putting them out to the media and on his blog while asking friends to share them.

Family photo with Gizem, Toprak, and Haydar on a mountain with the ocean and city behind them — Gizem, Toprak, and Haydar

“I realized what other organizations are doing to help the visually impaired, and I thought we needed to do this in Turkey,” he said. “Hope in Focus and Dr. Boye were role models for me, and in 2021, I created the Inclusive and Accessible Life Association. People with limited vision, blindness, or LCA all face similar issues, so our goal is to provide information and resources to anyone who is visually impaired in Turkey.”

Kindergarten Companion

Determined to continually improve Toprak’s quality of life, the Kulekcis’ information needs accelerated as she got older. “About two years before she went to school, I started researching what was available for education and how we could help her,” Haydar explained. “Many blind or visually impaired children in Turkey don’t go to kindergarten because families are not educated about it.”

Toprak’s kindergarten experience provided Haydar with firsthand information he could share with other parents. “When she started school, they told us that they didn’t know what they could do to help her. I took a two-month vacation from my job and sat with her every day in class, helping the teacher understand how to help my daughter,” Haydar said as he described perching on a tiny chair next to Toprak.

“I told the teacher that Toprak could handle everything and that she could help the teacher help her. I didn’t solve my daughter’s problems for her. I taught her how to solve them on her own,” he said. At the end of two months, Toprak told her father that she was fine and he should go home.

Haydar encourages other parents of visually impaired children to send their children to school and not be fearful about what might happen. He emphasizes the importance of parents allowing their children to solve some of their problems. “Many children who are visually impaired are less fearful than their parents. And most of them can manage and do much more than their parents expect.”

Let’s Dance!

Living across the street from a ballet school gave Toprak an unexpected opportunity. Her parents’ discussions about the school’s problematic traffic jams sparked her curiosity. “What is ballet?” she asked.

Toprak in her blue ballet leotard with the number 2 tag on her chest — Toprak ready for Ballet

After doing their best to describe ballet, Haydar found a high-contrast video of a performance to show Toprak. The video resulted in a torrent of questions about how to do ballet, whether there were special clothes for ballerinas, and whether she could take ballet lessons.

“We realized this could be an opportunity for her,” said Haydar. “But we didn’t have any experience with ballet. The school said we could do it but that they didn’t know how to teach her. So, I said, I am here for this problem!” Haydar began attending the classes, helping Toprak stretch and move her body correctly. “We’d get additional help from the teacher to explain how and where to put her foot or leg using words and moving her body into the correct position.” Haydar noted that ballet has additional benefits because visually impaired children often have difficulty understanding where their body is in space. “Ballet is not just visual but also a feeling and understanding of how the body works,” he said.

Toprak’s ballet experience has thus far culminated in two performances with her classmates, each before a thousand people at a performing arts center. “We tested her in the classes, and she hit the mirror a couple of times, but the teacher said not to worry. She can handle it,” Haydar said. Anxious about her first performance, the Kuleckis sat close to the stage in case she fell off. However, Toprak’s classmates successfully guided her when needed.

“When she was on the stage, she was like an angel walking and running around with her friends helping her,” Haydar said, his voice vibrant with joy. “Toprak solved some of her problems, and when she couldn’t see where to sit or stand, she gave a friend her arm. She didn’t give up! Isn’t this the solution for all of us—learning to ask for help and helping each other?”

HIF Family Conference

In 2023, the Kuleckis attended the HIF Family Conference in Indianapolis. Haydar said it was a significant event for them to attend. “We met many people there with LCA and some with the same gene as Toprak. We also met Dr. Boye there, and it was like a dream for us,” he said. “To think that we sent an email in 2019 to someone in the US who gave us answers and information about our daughter’s LCA, and now we see that person is real.”

Life Continues

In Turkey, schools often lack the knowledge or resources to meet the needs of visually impaired students, and Haydar often relies on his engineering background to find solutions. For example, Toprak finished first grade in June of this year. But she at first struggled to see the blackboard. Her father put a camera in front of the board, sending pictures to Toprak’s tablet so she could zoom in on the content. She also reads books using a digital magnifier, and the rehabilitation center teaches her Braille. The Kuleckis are grateful that Toprak’s last eye exam indicated stable vision, at least for now.

Gizem and Haydar work together to forge the best quality of life for Toprak that they can while sharing information and offering support to others through the Inclusive and Accessible Life Association. “We are a great family team! Gizem identifies a problem, I am the problem solver, and Toprak is a hardworking teammate who keeps us learning new things,” Haydar said.

From Uncertainty to Understanding for Family of 4-year-old Living with LCA1 GUCY2D

Desirae Potts breaks into tears when she recalls the first time a doctor said her infant son James had a disease she’d never heard of – Leber congenital amaurosis, known as LCA.

“I had no earthly idea what she was talking about. I left that appointment, I remember feeling so confused and so sad,” the 33-year-old mom said.

The doctor didn’t or couldn’t give Desirae and her husband, Robert, any information about LCA because the doc didn’t know a thing about the rare inherited retinal disease.

James holding a red solo cup and smiling. — A smiling James Potts

“I had to grieve the life that my son would have had,” she said. “But I also wish that I knew then what I know now, that is: Whether he could see or not, I have a bright light!

“He’s so amazing, I couldn’t imagine him any other way and I wouldn’t change it if I could.”

She thought about the best way to bring up her son.

“I quickly learned the best way to raise him would be to raise him like my sighted children. He is the most resilient and bright young man. I know he is so smart. He amazes me every day.”

Mom becomes nurse to better help her son

James was 10 months old when his parents learned their younger son’s genetic diagnosis: LCA1* caused by a mutation in his GUCY2D gene.

About the same time, Desirae kept listening to doctors talking over her head and decided to become a nurse.

“I wanted to help him with my knowledge. It definitely helps because I have more medical knowledge than I did before. I understand what the doctor is saying. The doctors used all these words I didn’t know, and I was scared that I didn’t know.”

She began nursing school in James’ first year and earned her nursing degree about a year and a half ago. James is now 4.

“I’m not as worried now, and I know what to do in certain situations.”

James goes to school for the full day in an integrated classroom at the same school as his older brother, 9-year-old Robert. His older sister, Ariona, is in high school.

Their mom is the school nurse at the four middle schools in the district of their South Texas coastal city.

Keeps informed of LCA1 GUCY2D research

Desirae knew something wasn’t right with her baby’s vision at 2 months when he didn’t track objects or light. At 4 months, an ophthalmologist prescribed glasses, but they didn’t help.

James with his hands in his mouth, sits in his high chair wearing a graphic tee. — James wearing his “Mr. Amazing” shirt

After the initial retinal disease diagnosis, James received his confirmed genetic diagnosis 6 months later at Baylor College of Medicine by Richard A. Lewis, MD, MS, Professor of Molecular and Human Genetics at the Houston medical school.

Annually, James visits John T. Stout, MD, PhD, who keeps the family informed of research in the LCA1 GUCY2D space. Dr. Stout specializes in retina/macular and retinal vascular diseases at Texas Children’s Hospital. His current research projects include human gene and stem cell therapy for proliferative and inherited ocular disease, retinal disease genotype-phenotype correlation, and intraocular angiogenesis, the formation of new blood vessels from the existing vascular tree.

LCA accounts for 5 percent of all retinal dystrophies and 20 percent of blindness in school-age children.

LCA1* is one of the most common of the more than 27 identified forms of the rare inherited retinal disease, affecting about 20 percent of people who live with the disease.

Some favs: Bagels and Daniel the Tiger

James received early-intervention therapy, and orientation and mobility therapy during his first years. He also sees a speech therapist at school and a developmental specialist in town.

Right now, his favorite food is bagels and butter. And he absolutely loves music and Daniel the Tiger, a spinoff from Mr. Rogers Neighborhood, where he sings songs about learning, and growing, and what to do with feelings.

James does not yet have words to describe his sight, which makes it hard to explain what he can see, although his mom believes he has light perception.

James’ vision is a family affair

“It not only affected him, but it also affected all of us,” Desirae said. “We all had to adjust and learn how to make things in a way that he could do things on his own and foster his independence.”

The Potts Family: Robert wearing red shirt in front, with L-R: Mom Desirae, Ariona, James, and Dad Robert — The Potts Family

Ariona, James’ 17-year-old sister, nurtures her little brother, with mom adding, “She’s the closest thing to me he can get. She’s very, very helpful.”

Robert was 5 when James was born.

“He didn’t quite understand what’s going on and how to be accommodating to his brother. We definitely had to inform him.”

Desirae is concerned about James pressing or rubbing his eyes, a symptom of LCA called oculodigit a l reflex. While the doctor said the reflex is normal, she is worried the action may cause harm. She tries to keep him occupied.

“I try very hard, but James is maybe the most headstrong person I have ever met in my entire life. If you tell him to do something, he will do the complete opposite. So, I tell him, ‘Don’t let me see your eyes,’ even though I don’t want him to defy me.”

James loves to explore and see with his hands.

“We don’t use the word ‘blind.’ We prefer to say that he sees with his hands. We don’t say ‘blind’ or ‘visually impaired.’ We do not want him to think that that would define him.

“That was something I had to teach both of our children, my husband, and all of our family. Some relatives are still in denial. We don’t put him in a box. We let him explore and have the same toys as his brother and sister,” she said.

“We try to have everyone stay on the same page to help build his confidence. Like it’s normal for him that he sees with his hands.”

*Next month, our Hope in Focus LCA Family Conference includes a presentation from an LCA1 GUCY2D researcher. The June 23-24 conference is in Indianapolis.

Let’s Chat About … Atsena Therapeutics’ LCA Research with Kara Fick and Shannon Boye

Atsena Therapeutics, a clinical-stage gene therapy company focused on reversing and preventing blindness, has an ongoing Phase 1/2 clinical trial evaluating a potential therapy for Leber congenital amaurosis 1 (LCA1) caused by mutations in the GUCY2D gene.

Kara Fick (L) and Shannon Boye (R) on Hope in Focus Let’s Chat About … series

We learned about this research from Kara Fick, head of Patient Advocacy and Medical Affairs at Atsena Therapeutics, and Atsena Founder and Director Shannon E. Boye, PhD, during our Oct. 27, 2022, webinar episode titled “Let’s Chat About…Atsena Therapeutics’ work in LCA.” Courtney Coates, Hope in Focus Director of Outreach and Development, moderated the session, which can be viewed here.

“Let’s Chat About…” is our free webinar series bringing together researchers, advocates, industry leaders, and people living with Leber congenital amaurosis (LCA) or other rare inherited retinal diseases (IRDs) for conversations important to the rare retinal disease community.

How did Atsena Therapeutics come to be?

Shannon and her husband, Sanford, met in grad school.

“It was a nerd romance,” she said.

Boye’s thesis involved developing viral vectors for retinal disease treatment, specifically for LCA1 (GUCY2D), and she became known for generating gene technology. She has authored more than 60 peer-reviewed manuscripts and multiple textbook chapters. She also has been actively involved in grant and manuscript review, and she has received several major awards.

Over several years, the couple worked with large, medium, and small pharmaceutical companies, but they grew frustrated at how long it took to bring developing therapies to patients.

“It was going very slowly and that was frustrating,” Boye said. “We saw business decisions overriding sound scientific decisions.”

Eventually, she sent a big long vent to Foundation for Fighting Blindness CEO Ben Yerxa, and he helped push her and her husband into starting their own company, Atsena Therapeutics. The couple co-founded the business, with Sanford Boye serving as Chief Technology Officer.

Kara Fick, who has been working as a patient advocate for rare diseases in the biotech world for nearly a decade, is passionate about bringing the patient voice, perspective, and expertise to the table.

“It’s pretty apparent, and you know from Atsena’s founding, that really keeping patients at the center and trying to move research forward so that it can get to patients is super important,” Fick said.

At Atsena, she strives to bridge the gap between the science of innovative therapies and the daily needs of individuals living with rare diseases. She also works to understand more clearly the barriers to diagnosis, treatment, and management of rare diseases and how to better address those hurdles with patients and clinicians.

What is gene therapy?

All of us have genes. They give us blue eyes or brown eyes, for instance. But our genes also make proteins. Proteins are the building blocks of life. They can act alone or in combination with other proteins to perform essential functions in our cells.

A good example of proteins important for vision are the proteins in our photoreceptors and retinas. Those proteins all work together to convert light into an electrochemical signal that is sent to the brain and processed as vision.

Genes make proteins, and proteins perform essential functions. But sometimes, we can have a misspelling in our genes — in other words, a mutation. Because of that misspelling or mutation, in some cases, the protein that gene was supposed to make did not form. In other cases, perhaps, the protein forms, but it’s misshapen and can’t interact properly with the other proteins. When that happens, the normal biological function of the protein is disrupted, for example, in your photoreceptors. As a result, your photoreceptors are unable to transmit light into a signal processed as vision.

The concept of gene therapy involves taking a healthy copy of a gene that lacks that misspelling and delivering that healthy version of the gene to the photoreceptor cells.

How is the LCA gene therapy trial going?

Drug development and gene therapy development take a long time, and there are a lot of processes that companies have to go through to ensure that anything given to patients is safe and effective.

Work to develop this gene therapy began in earnest in 2004 in Boye’s lab at the University of Florida. After pre-clinical studies in chickens and mice, they were ready for clinical trials in humans.

Atsena is working on a combination Phase 1/2 clinical trial for LCA1 (GUCY2D). In this phase of the trial, researchers test different gene therapy doses, find the best dose, and closely monitor the safety of the therapy.

“Because we’re doing a combo Phase 1/2, we’re looking primarily at safety, but we’re also incorporating some tests into the clinical trial that can help to tell us a little bit about the efficacy of the gene therapy,” Boye said.

‘Researchers began with adults aged 18 and up but recently opened it up to ages 6 and up. Fifteen people, all with GUCY2D mutations, are taking part in the trial, ranging in age from 12 to 76 years old.

So far, the trial is going well, with no participants reporting serious side effects related to the gene therapy. They did see two cases of inflammation, but both were mild and resolved after treatment.

Besides safety monitoring, Atsena has conducted several tests, including the Full-field Stimulus Test (FST). The test quantifies visual perception through flashes of varying luminance. Researchers saw significant improvements in the results of that test from individuals who received the highest dose of the gene therapy.

Participants receiving the gene therapy also showed clear improvement in a multi-luminance mobility test (MLMT), in which they navigated a course with obstacles of varying height and under different levels of illumination.

Participants also underwent a third test, called the BCVA or Best Corrected Visual Acuity, which measures everyday vision. (Think of the poster with different letters you’re asked to read at the eye doctor’s.) That test had more mixed results, with some patients seeing improvement and others not seeing much, if any, improvement.

What happens next?

This is still just the preliminary data. Atsena needs all 15 participants in its trial to get through their first full year after being treated with gene therapy. Then, they’ll collect all of the data, analyze it, and summarize it vigorously and thoroughly before moving on to the next phase.

At that point, they’ll need to meet with the Food and Drug Administration (FDA) and other regulatory agencies to get their agreement and permission to move forward with a Phase 3 trial. That trial will focus on efficacy and seeing how well the gene therapy works. It’ll still pay attention to safety, but the primary goal of Phase 3 is to focus on efficacy and use that as supportive data that could be submitted to the FDA and other agencies to get full approval of the gene therapy.

Why genetic testing is essential for clinical trials?

As more trials are starting and more gene-specific research is being done, it’s going to become more important to know precisely which genetic mutation may be causing your LCA.

“Getting genetic testing is essential for figuring out the specific genetic mutation that may be causing your LCA,” says Boye.

If you have not been genetically tested, talk to Hope in Focus. There’s no cost to patients and family members to receive genetic testing.

Living with Leber Congenital Amaurosis: Dami’s Story

I was born in 1976 in Spokane, Washington. By the time I was born, my parents’ relationship was basically over, so I was raised by a single mom. It was clear from a very young age that I had significant vision loss. I started wearing glasses at 18 months. I went through lots of grueling tests as a toddler to figure out the cause of my vision loss with no real answers. Despite this, I lived a very full life. I was a Girl Scout. I did gymnastics. Basically, I did everything my friends did.

When I was 10, my mother took me to a research hospital in Portland, Oregon. After two days of testing, they told my mother I had Leber congenital amaurosis type 1. They told her I would likely be totally blind by the time I was 17.

So, I lived my days after that doing and seeing what I could because my vision had an expiration date. I didn’t just do the same stuff as my friends. I did more. I also got involved in the blindness community. I did public speaking in high school. I worked with blind kids, noticing that parents were not doing their children any favors by treating their children like fragile flowers. I worked with children with so few social skills because their parents didn’t expect them to act like the other kids. All that did was hurt them. But, I digress from my story.

So, I turned 17, and I could still see. Now, instead of vision having an expiration date, every day with vision was a gift. I went to college and met an amazing boy. We were married and pregnant with our first child within a year of meeting because I couldn’t stand the thought of not seeing my baby’s face.

I could go on forever about my life, but most of it is only interesting to me, so I’ll fast forward. I am 43, still married to that amazing boy, and we have two amazing boys of our own. I earned a Master’s degree in communications, and I work for a state agency that does vocational rehabilitation for people with visual impairments. I also still have a decent amount of vision, from my perspective.

A few weeks ago, I read a Facebook post about genetic testing. Nobody had ever talked to me about this before. I have regular eye appointments, but they really just check my vision and cataracts. I want to know more. I have started thinking I may have been misdiagnosed years ago, but I don’t even know where to begin. I’ve signed up for the genetic databases, but now what? It is such a strange feeling to doubt the one thing that had seemed certain my whole life.

So, that’s me. I’m not inspiring or pitiful. I’m just me, trying to figure out where I go from here and so glad to know I’m not alone.