AU2013205649A1 - Improving trabeculectomy outcome - Google Patents

Abstract

The current invention relates to the improvement of trabeculectomy surgery. The improvement more specifically resides in an extended lifetime of the sclera-corneal drainage channel created by trabeculectomy surgery. The improvement is obtained by post-surgical administration of ananti-PIGF antibody or fragment thereof.

Description

-1 IMPROVING TRABECULECTOMY OUTCOME This is a divisional of Australian Patent Application No. 2013202945, the entire contents of which are incorporated herein by reference. 5 FIELD OF THE INVENTION The current invention relates to the improvement of trabeculectomy surgery. The improvement more specifically resides in an extended lifetime of the sclera-corneal drainage channel created by trabeculectomy surgery. The improvement is obtained by administration 0 of an antibody, or antigen-binding fragment thereof, binding to placental growth factor (PlGF) and inhibiting PIGF activity. BACKGROUND OF THE INVENTION Glaucoma is a multifactorial, neurodegenerative disease and the second most important cause .5 of irreversible blindness (Quigley, 1996, Br J Ophthalmol 80,389-393). This disease is characterized by progressive retinal ganglion cell apoptosis, resulting in visual field loss. Current treatment of this disease is directed towards the reduction of intraocular pressure (IOP), which is the main risk factor for glaucoma (Collaborative Normal-Tension Glaucoma Study Group, 1998, Am J Opthalmol 126, 487-497). !0 Of all currently used treatments to lower IOP, glaucoma filtration surgery (trabeculectomy), or shortly filtration surgery, was shown to be the most effective (Burr et al., 2005, Cochrane Database Syst Rev 18(2):CD004399; Hitchings, 1998, Arch Ophthalmol 116, 241-242). A trabeculectomy creates a "controlled" leak of fluid (aqueous humor) from the eye, which 25 percolates under the conjunctiva. During the operation a piece of trabecular meshwork in the drainage angle of the eye is removed, creating an opening. The opening is partially covered with a flap of tissue from the sclera and conjunctiva. A small conjunctival blebb" (bubble) appears at the junction of the cornea and the sclera (limbus) where this surgically produced valve is made. 30 In 30% of the cases, however, the constructed channel closes due to excessive scar tissue formation, resulting in surgical failure (Addicks et al., 1983, Arch Ophthalmol 101, 795-798). The 4 important processes contributing to post-operative conjunctival scarring are: clot -2 formation, inflammation, angiogenesis and fibrosis (Lee et al., 1995, J Ocul Pharmacol Ther 11, 227-232; Lama & Fechtner, 2003, Surv Ophthalmol 48, 314-346). Indeed, increased conjunctival infiltration of inflammatory cells and Tenon fibroblasts (Hitchings & Grierson, 1983, Trans Ophthalmol Soc UK 103, 84-88; Skuta & Parrish, 1987, Surv Ophthalmol 32, 5 149-170), and higher levels of bleb vascularisation (Jampel et al., 1988, Arch Ophthalmol 106, 89-94) are associated with surgical failure. These processes are mediated by various cytokines (e.g. IL-I and [NF-a2b) and growth factors (e.g. PDGF, FGF, TGF-p3 and VEGF (Lama & Fechtner, 2003; Gillies & Su, 1991, Aust NZ J Ophthalmol 19, 299-304)). Peroperative anti-mitotics, such as mitomycin-C and 5-Fluorouracyl can improve surgical o outcome (Quigley, 1996; Katz et al., 1995, Ophthalmol 102, 1263-1269). However, these antimetabolites carry a risk of vision-threatening complications such as scleral thinning and infections (Lama & Fechtner, 2003; Hitchings & Grierson, 1983; Skuta & Parrish, 1987; Jampel et al., 1988; Gillies & Su, 1991; Katz et al., 1995; Greenfield et al., 1998, Arch Ophthalmol 116, 443-447). Furthermore, blocking TGF-B seemed promising in animal .5 models (Cordeiro et al., 2003, Gene Ther 10, 59-71), but was not efficient in a clinical study (CAT-152 0102 Trabeculectomy Study Group, Kwah, Grehn, 2007, Ophthalmol 114, 1822 1830). The number of post-trabeculectomy interventions expressed as the incidence of post surgery "bleb manipulations" was reported to be as high as 78% (King et al., 2007, Br J Ophthalmol 91, 873-877).Therefore, there is still a need for alternative strategies to prevent !o filtration failure and, thus, to reduce the incidence of bleb manipulations. Microplasminis a recombinant protein that dissolves blood clotsby degrading fibrin. Recently, microplasmin has been shown to be efficient, well tolerated and safe for intra ocular use(WO 2004/052228) and was approved by FDA in October 2012 for treating 25 vitreomacular adhesion (JETREA @; non-proprietary name: ocriplasmin). Results of the phase III clinical trials leading to this approval were published by Stalmans et al. (2012, N Engl J Med 367, 606-615). Plasmin was previously shown to be able to induce PVD as well (e.g. US 5,304,118). The mechanism by which PVD is induced by plasmin or microplasmin is currently not fully understood. Unsupported by any or any conclusive experimental data, 30 WO 2009/073457 and WO 2009/067407 propose subconjunctival plasmin injection for rescuing filtering blebs and the use of matrix metalloproteinase activating proteases for reducing IOP, respectively. WO 2011/023805 provides the evidence that anterior chamber -3 injection of microplasmin was effective in prolonging bleb survival, i.e., the mode of administration of microplasmin in this indication is determining success. Pegaptanib is a pegylated anti-VEGF aptamer (VEGF = vascular endothelial growth factor), a 5 single strand of nucleic acid (50 kDa). It specifically binds the VEGFi 65 isoform, thereby preventing the binding to the heparin binding domain.Van Bergen et al. 2011 (Exp Eye Res 93, 689-699) showed that single or repeated injection of pegaptanib after glaucoma filtration surgery (in a rabbit model) had marginal effect on bleb area and bleb survival. Bevacizumab is an antibody inhibiting all forms of VEGF-A. Li et al. 2009 (Invest Ophthalmol Vis Sci 50, 0 5217-5225) disclosed the effect of bevacizumab on glaucoma filtration surgery (in a rabbit model) which was, judging from the reported effect on bleb area, limited. SUMMARY OF THE INVENTION .5 The invention relates to an anti-PlGF (placental growth factor) antibody or fragment thereof for improving or enhancing the success rate of trabeculectomy surgery (or glaucoma filtration surgery) of an eye, or for preventing, reducing or retarding the occurrence of filtration failure after trabeculectomy surgery of an eye. 10 Alternatively, the invention relates to the use of an anti-PlGF antibody or fragment thereof for the manufacture of a medicament for, or in a method of, improving or enhancing the success rate of trabeculectomy surgery (or glaucoma filtration surgery) of an eye, or for/of preventing, reducing or retarding the occurrence of filtration failure after trabeculectomy 25 surgery of an eye. The anti-PIGF antibody or fragment thereof as described above may be in a pharmaceutically acceptable formulation capable of being administered to an eye. In particular, said pharmaceutically acceptable formulation is compatible with administration into the anterior 30 chamber of an eye, with in-bleb administration, with administration into the vitreous of an eye, with administration into the subconjunctiva of an eye, or with administration as eye drops.

-4 Said treating of filtration failure after trabeculectomy surgery of an eye, or said preventing, reducing or retarding of the occurrence offiltration failure after trabeculectomy surgery of an eye with an anti-PIGF antibody or fragment thereof as described above in particular results from administering to said eye at least a single dose, or, alternatively, multiple doses, of an 5 effective amount of said anti-PIGF antibody or fragment thereof. When multiple doses are administered to an eye, these may be administered with at least 6-hour time intervals, and may individually be administered in the same or different location. Said eye may be contacted further with one or more agents chosen from an agent for controlling the intra ocular pressure, an anti-inflammatory agent, an antiviral agent, an antibacterial agent, an .0 antiviral agent, an anti-angiogenic agent, an anti-mitotic agent, an antihistamine, an anesthetic, an agent to induce mydriasis and an agent to induce cycloplegia. Said further contacting may be occurring prior to, concurrent with, or after administering the anti-PIGF antibody or fragment thereof. L5 The anti-PIGF antibody or fragment thereof as described above may be in a pharmaceutically acceptable formulation further comprising one or more of an agent for controlling the intra ocular pressure, an anti-inflammatory agent, an antiviral agent, an antibacterial agent, an antiviral agent, an anti-angiogenic agent, an anti-mitotic agent, an antihistamine, an anesthetic, an agent to induce mydriasis and an agent to induce cycloplegia. ?0 FIGURE LEGENDS FIGURE 1. Fig. IA shows result of measurement of the intra-ocular pressure (IOP) in two groups (group size n=10) that had undergone glaucoma filtration surgery (GFS). One group 25 was treated with 1C8, an irrelevant mouse IgG antibody (4.8 mg/ml) and the other group was treated with DC101, an anti-murine VEGF-R2 antibody (6.2 mg/ml). lOPs were measured with a Tonolab (Technop@). Results are represented as mean ±SEM. IOP was not found to be significantly different in the 2 groups (p>0.05). Fig.1B shows in a similar way the result of measurement of in two groups (group size n=10) that had undergone GFS. One group was 30 treated with IC8, an irrelevant mouse IgG antibody (4.8 mg/ml) and the other group was treated with 5D1 ID4, an anti-murine PlGF antibody (5.2 mg/ml). IOP was not found to be significantly different in the 2 groups (p>0.05).

-5 FIGURE 2. Fig. 2A shows measurements of bleb area in two groups (group size n=10) that had undergone (GFS). One group was treated with 1C8, an irrelevant mouse IgG antibody (4.8 mg/ml) and the other group was treated with DC 101, an anti-murine VEGF-R2 antibody (6.2 mg/ml). Results are represented as mean ±SEM. DC101 significantly 5 improved bleb area as compared to 1C8 (p=0.05). Fig. 2B is similar to Fig. 2A except that both groups were larger in size (n=20) and were followed during a longer time period. Fig. 2C shows similar results as Fig. 2A and 2B except that the antibodies were injected repeatedly at days 0, 4 and 10 after surgery. .0 FIGURE 3. Fig. 3A shows bleb survival in two groups (group size n=10) that had undergone GFS. One group was treated with 1C8, an irrelevant mouse IgG antibody (4.8 mg/ml) and the other group was treated with DC101, an anti-murine VEGF-R2 antibody (6.2 mg/ml). Bleb survival was not found to be significantly different in the 2 groups (p=0.

2 3 ). After longer follow-up of two larger groups (n=20; Fig. 3B), significantly increased bleb L5 survival was observed in the DC101-treated group vs the IC8-treated group (p=0.0 6 ). Repeated injection of DC101 (group size n=10) at days 0, 4 and 10 after surgery further increased the bleb survival compared to single injections (Fig. 3C). FIGURE 4. Fig.4A shows measurements of bleb area in two groups (group size n=10) that 0o had undergone GFS. One group was treated with 1C8, an irrelevant mouse IgG antibody (4.8 mg/ml) and the other group was treated with 5D1 I D4, an anti-murine PIGF antibody (5.2 mg/mi). Results are represented as mean ±SEM. 5D11D4 significantly improved bleb area as compared to 1C8 (p=0.01). This effect extended till the end of a longer follow-up period of larger groups (n=20; Fig. 4B) and was markedly enhanced by repeat injections of 5D1 1D4 on 25 days 0, 4 and 10 after surgery (group size n=10; Fig. 4C). The latter effect was significantly more pronounced compared to repeat injections of anti-murine VEGF-R2 antibody DC101 (Fig. 2C / Fig. 6 C) FIGURE 5. Fig.5A shows bleb survival in two groups (group size n=10) that had 30 undergone GFS. One group was treated with IC8, an irrelevant mouse IgG antibody (4.8 mg/ml) and the other group was treated with 5D IID4, an anti-murine PIGF antibody (5.2 mg/ml). Results are represented as mean ±SEM. 5DllD4 significantly improved bleb survival as compared to I C8 (p=0.0 4 ). This effect extended till the end of a longer follow-up -6 period of larger groups (n=20; Fig. 5B) which was significantly more pronounced compared to the anti-murine VEGF-R2 antibody DC101 (Fig. 313), and was markedly enhanced by repeat injections of 5D 11D4 on days 0, 4 and 10 after surgery (group size n=10; Fig. 5C). 5 FIGURE 6. Fig.6A shows measurements of bleb area in two groups (group size n=10) that had undergone GFS. One group was treated with DC 101, an anti-murine VEGF-R2 antibody (6.2 mg/ml) and the other group was treated with 5D1 ID4, an anti-murine PIGF antibody (5.2 mg/ml). Results are represented as mean ±SEM. 5DI ID4 significantly improved bleb area as compared to I C8 (Fig. I). A trend towards an increased bleb area after 5D I ID4 o administration was observed compared to DC 101 delivery (p=0.07). The latter was confirmed and strengthened when observing two groups (group size n=20) for a longer time period (Fig. 613). The stronger effect of 5D11D4 administration over DC101 administration was moreover clearly obviated when comparing the effect of multiple administrations (at days 0, 4 and 10 after surgery; group size n=10) of the antibodies as depicted in Fig. 6C. [5 FIGURE 7. This figure shows measurement of bleb areas in two groups of mice (group size n=10) that had undergone GFS. One group was treated with IC8 (filled triangles), an irrelevant mouse IgG antibody (4.8 mg/ml) and the other group was treated with 5D I1 D4 (filled circles), an anti-murine PIGF antibody (5.2 mg/ml). Results are represented as mean ! ±SEM. Figure 7A displays the results obtained with injection of the antibodies in the eye's anterior chamber; Figure 7B displays the results obtained with subconjunctival injection of the antibodies; Figure 7C displays the results obtained with intravitreal injection of the antibodies. 5D1 1D4 significantly improved bleb area as compared to 1C8 (p<0.001). 25 FIGURE 8. This figure shows measurement of bleb survival in two groups of mice (group size n=10) that had undergone GFS. One group was treated with 1C8 (filled triangles), an irrelevant mouse IgG antibody (4.8 mg/ml) and the other group was treated with 5D1 D4 (filled circles), an anti-murine P1GF antibody (5.2 mg/ml). Figure 8A displays the results obtained with injection of the antibodies in the eye's anterior chamber; Figure 8B displays the 30 results obtained with subconjunctival injection of the antibodies; Figure 8C displays the results obtained with intravitreal injection of the antibodies. 5D 1ID4 significantly improved bleb survival as compared to IC8 (p<0.05).

-7 FIGURE 9. This figure shows measurement of bleb areas in three groups of mice (group size n=10) that had undergone GFS and that were treated with 5D1 1D4, an anti-murine PlGF antibody (5.2 mg/ml). Results are represented as mean ±SEM. Displayed are the results obtained with injection of the antibodies in the eye's anterior chamber (filled squares), the 5 results obtained with subconjunctival injection of the antibodies (filled circles), and the results obtained with intravitreal injection of the antibodies (filled triangles).No significant difference was detected between the effects on bleb area exerted by the anti-PIGF antibodies administered via the three different routes. 0 DETAILED DESCRIPTION OF THE INVENTION As known from clinical practice, each subject or patient undergoing trabeculectomy surgery is at significant risk to develop filtration failure. The present invention is based on the effect .5 of administration of an anti-PlGF antibody (in particular an antibody inhibiting an or the activity of placental growth factor, PlGF) on the clinical outcome of trabeculectomy surgery, said effect being positive and resulting in the prevention, reduction or retardation of the occurrence of filtration failure. The effects obtained with an anti-PIGF antibody are moreover markedly and unexpectedly more pronounced than the effects obtained with an inhibitor of !o VEGF-R2 (vascular endothelial growth factor receptor 2, known to bind VEGF) or obtained with inhibitors of VEGFi 65 (pegaptanib; Van Bergen et al. 2011, Exp Eye Res 93, 689-699) or of VEGF (bevacizumab; Li et al. 2009, Invest Ophthalmol Vis Sci 50, 5217-5225). Therefore, the invention relates to an anti-PIGF antibody or fragment thereof for treating 25 filtration failure after trabeculectomy surgery of an eye, or for improving the success rate of trabeculectomy surgery, or for increasing or enhancing the success rate of trabeculectomy surgery, or for preventing, reducing or retarding the occurrence of filtration failure after trabeculectomy surgery of an eye; all evidently as compared to trabeculectomy surgery performed without using an anti-PIGF antibody or fragment thereof. Alternatively, the 30 invention relates to the use of anti-PIGF antibody or fragment thereof for the manufacture of a medicament for, or in a method of, treating filtration failure after trabeculectomy surgery of an eye, or for/of improving the success rate of trabeculectomy surgery, or for/of increasing or enhancing the success rate of trabeculectomy surgery, or for/of preventing, reducing or retarding the occurrence of filtration failure after trabeculectomy surgery of an eye; all evidently as compared to trabeculectomy surgery performed without using an anti-PIGF antibody or fragment thereof. The terms "glaucoma filtration surgery", "filtration surgery" and "trabeculectomy surgery" are used herein interchangeably. 5 The "trabecular meshwork (TM)" is a mesh-like structure inside the eye at the iris-scleral junction of the anterior chamber angle. The TM filters the aqueous fluid and controls its flow into the canal of Schlemm prior to its leaving the anterior chamber. Increased resistance in the TM leads to reduced aqueous fluid outflow and thus increased intra-ocular pressure 0 (lOP). When left untreated, this elevated IOP leads to glaucomatous damage to the optic nerve and retinal nerve fibers, and leads to loss of vision. This vision loss can be prevented or halted by administering medication, an "agent for controlling the intra-ocular pressure", which controls .5 the intra-ocular pressure. Such medicaments include adrenergic blocking agents (beta blockers or sympatholytic drugs such as betaxolol, carteolol, levobunolol, metipanolol and timolol), adrenergic stimulating agents (sympathomimetic drugs such as aproclonidine, epinephrine, hydroxyamphetamine, phenylephrine, naphazoline and tetrahydrozaline), carbonic anhydrase inhibitors (such as systemic acetozolamide, and topical brinzolamide and !0 dorzolamide), miotics (cholinergic stimulating agents, parasympathomimetic drugs such as carbachol and pilocarpine), osmotic agents (such as glycerin and mannitol), prostaglandin and prostaglandin analogues (prostamides, bimatoprost, unoprostone isopropyl, travoprost, latanoprost, natural prostaglandin, prostaglandin F2a, and FP prostanoid receptor agonists). When such medicaments are not efficient (or not anymore), then filtration surgery is a viable 25 treatment. "Trabeculectomy", "trabeculectomy surgery" or "filtration surgery", or "glaucoma filtration surgery", is defined as a surgical procedure on the eye wherein part of the trabecular meshwork is removed whereby a filtration site (a sclera-corneal drainage channel) is created 30 that increases the outflow of aqueous fluid from the eye; this type of filtering procedure is commonly used in the treatment of glaucoma, and more specifically to reduce the lOP in an eye subject to/suffering from glaucoma.

-9 "Filtration failure" is a condition reversing the clinically desired effect of trabeculectomy surgery, i.e., reversing the desired drop in IOP. The initial post-operative time is crucial in the sense that eye-healing activities are highest in this period. This period of high eye-healing capacity is dependent upon the species and spans about 2 weeks for rabbits and up to 1- to 2 5 months in humans. Upon contacting an anti-PlGF antibody or fragment thereof with an eye according to the current invention, the frequency of occurrence of filtration failure over a given period of time is lowered. The anti-PlGF antibody or fragment thereof used according to the current invention thus results in the prevention, reduction or retarding of the occurrence of filtration failure, or in an improvement, enhancement or increase of the success rate of .0 trabeculectomy surgery (compared to trabeculectomy surgery without administering or using an anti-PIGF antibody or fragment thereof). The anti-PIGF antibody or fragment thereof, or a medicament comprising it, may be in a pharmaceutically acceptable formulation (or composition or solution) capable of being L5 administered to an eye. In particular, said formulation (or composition or solution) is capable of being administered into the anterior chamber of the eye or compatible with administration into the anterior chamber of the eye. Alternatively, said formulation (or composition or solution) is capable of being administered into the vitreous (i.e. intravitreal administration) or compatible with administration into the vitreous. In another alternative, said formulation (or ?0 composition or solution) is capable of being administered into the subconjunctiva (i.e. subconjunctival administration) or compatible with administration into the subconjunctiva.Further alternatively, said formulation (or composition or solution) is capable of being administered intothe surgically created bleb (i.e., in-bleb administration) or compatible with administration into such bleb. The anti-PIGF antibody or fragment thereof, 25 or a medicament comprising it, may be in a pharmaceutically acceptable formulation (or composition or solution) capable of being administered to an eye in the form eye drops. Said administration may e.g. be by injection of the formulation (or composition or solution) or medicament comprising an anti-PIGF antibody or fragment thereof, such as in the case of administration into the anterior chamber, into the vitreous, into the subconjunctiva or into the 30 bleb. Alternatively, said administration may occur in the form of eye drops. Although not required, there may be an additional advantage in said formulation being a slow-release formulation such as a gel-like formulation.

-10 The improvement, enhancement or increase of the success rate of trabeculectomy surgery (or glaucoma filtration surgery) of an eye, or of the prevention, reduction or retardation of the occurrence of filtration failure after trabeculectomy surgery of an eye may result from introduction into the eye of an effective amount of at least a single dose of an anti-PIGF S antibody (or fragment thereof) or of a formulation (or composition or solution) or medicament comprising it. In particular, the location of said administration is into the anterior chamber of an eye, into the vitreous of an eye, into the subconjunctiva of an eye, or into the bleb created by glaucoma filtration surgery of an eye, or is a combination thereof. Alternatively, said administration is occurring in the form of (administering an effective dose 0 of) eye drops containing an anti-PIGF antibody or fragment thereof, possible combined with administration via another route (e.g. with one or more of administration in the anterior chamber, intravitreal administration, subconjunctival administration, in-bleb administration).Multiple doses of an effective amount of said anti-PlGF antibody or fragment thereof (or of a formulation (or composition or solution) or medicament comprising it) may L5 be administered, such as to increase efficacy. When multiple doses are administered to an eye, these may be administered with at least 6-hour time intervals, with about 12-hour time intervals, with about 18-hr time intervals, with about 1-day time intervals, with about 2-day time intervals, with about 3-day time intervals, with about 4-day time intervals, with about 7 day time intervals, with about 2-week time intervals with about 1-month time intervals, with ?0 about 2-month time intervals or with about 3-month time intervals. When multiple doses are administered to an eye with time intervals, the time interval between two subsequent doses may change during the treatment depending on the evolution of the clinical result. For example, time intervals between subsequent doses may be short immediately after the trabeculectomy surgery and may increase with increasing time after the trabeculectomy 25 surgery. In case of administration of multiple doses, each individual dose may be administered into the anterior chamber of said eye, may be administered into the vitreous of said eye, may be administered in the subconjunctiva of said eye, may be administered into the bleb created by the trabeculectomy surgery of said eye, or may be administered as eye drops to said eye. Said multiple doses, when separated in time, thus could all individually be 30 applied in the same location (e.g. anterior chamber or vitreous) or could all individually be applied in a different location, or could partially be applied in the same location and partially in (oner or more) different locations. Any order of administration in different locations is possible. If for example two administrations are envisaged, then a first administration could -11 be intravitreal (or another location) and the second in the anterior chamber (or another location different from the location of first administration), or vice versa. Alternatively, said multiple doses could all or in part be administered at once via different contacting routes such as for example combined concurrent administration in the anterior chamber and via eye 5 drops. In any of the above, said anti-PIGF antibody may be any type of antibody or any fragment of any thereof that is capable of binding to PIGF and of inhibiting an activity of PlGF. In particular, said anti-PlGF antibody or fragment thereof may be neutralizing an activity of 0 PIGF, thus may be a neutralizing anti-PIGF antibody or neutralizing anti-PIGF antibody fragment. Such antibodies include all types of antibodies known in the art, such as human or humanized antibodies, cameloid antibodies, nanobodies, domain antibodies, mono- or plural specific antibodies, etc., and any fragment of any thereof. Examples of anti-PIGF antibodies are described in WO 01/85796 and WO 2006/099698. In particular, an anti-PIGF antibody L5 for use as described herein is effective in inhibiting the activity of placental growth factor as present in the subject undergoing trabeculectomy. In particular, said subject is a mammal, more in particular a human. The invention further covers ananti-PlGF antibody (or any fragment thereof)as described 20 above for improving, enhancing or increasing the success rate of trabeculectomy surgery, or for treating filtration failure after trabeculectomy surgery of an eye, or for preventing, reducing or retarding the occurrence of filtration failure after trabeculectomy surgery of an eye, wherein the anti-PIGF antibody or fragment thereof is in a pharmaceutically acceptable formulation (or composition or solution) that may further comprise one or more of an agent 25 for controlling the intra-ocular pressure, an anti-inflammatory agent, an antiviral agent, an antibacterial agent, an antiviral agent, an anti-angiogenic agent, an anti-mitotic agent, an antihistamine, an anesthetic, an agent to induce mydriasis and an agent to induce cycloplegia. Alternatively, when said further agent is, or said further agents are, not included in the pharmaceutically acceptable formulation (or composition or solution) containing said anti 30 PIGF antibody (or any fragment thereof), said eye may be contacted further with one or more agents chosen from an agent for controlling the intra-ocular pressure, an anti-inflammatory agent, an antiviral agent, an antibacterial agent, an antiviral agent, an anti-angiogenic agent,an anti-mitotic agent, an antihistamine, an anesthetic, an agent to induce mydriasis and -12 an agent to induce cycloplegia. Such further contacting may be prior to, concurrent with, or after the administration of an anti-PIGF antibody or any fragment thereof (or of a formulation, composition, solution, or medicament comprising it). 5 The invention further covers the use of an anti-PIGF antibody (or any fragment thereof) as described above for the manufacture of a medicament for improving, enhancing or increasing the success rate of trabeculectomy surgery, or for treating filtration failure after trabeculectomy surgery of an eye, or for preventing, reducing or retarding the occurrence of filtration failure after trabeculectomy surgery of an eye, wherein the anti-PIGF antibody or 0 fragment thereof is in a pharmaceutically acceptable composition that may further comprise one or more of an agent for controlling the intra-ocular pressure, an anti-inflammatory agent, an antiviral agent, an antibacterial agent, an antiviral agent, an anti-angiogenic agent, an anti mitotic agent, an antihistamine, an anesthetic, an agent to induce mydriasis and an agent to induce cycloplegia. Alternatively, when said further agent is, or said further agents are, not .5 included in the pharmaceutically acceptable formulation (or composition or solution) or medicament containing said an anti-PIGF antibody (or any fragment thereof), said eye may be contacted further with one or more agents chosen from an agent for controlling the intra ocular pressure, an anti-inflammatory agent, an antiviral agent, an antibacterial agent, an antiviral agent, an anti-angiogenic agent, an anti-mitotic agent, an antihistamine, an !o anesthetic, an agent to induce mydriasis and an agent to induce cycloplegia. Such further contacting may be prior to, concurrent with, or after the administration of an anti-PIGF antibody or any fragment thereof (or of a formulation, composition, solution, or medicament comprising it). 25 Methods of improving, increasing or enhancing the success rate of trabeculectomy surgery of an eye, of treatment of filtration failure after trabeculectomy surgery of an eye, and methods of preventing, reducing or retarding the occurrence of filtration failure after trabeculectomy surgery of an eye are also envisaged. These methods comprise the step of contacting said eye after trabeculectomy surgery with an effective amount of ananti-PIGF antibody (or a 30 fragment thereof) wherein said contacting results in said improvement, increase or enhancement of the success rate of trabeculectomy surgery treatment of an eye, in said treatment of filtration failure after trabeculectomy surgery of an eye, or in said preventing, reducing or retarding of the occurrence of filtration failure after trabeculectomy surgery of an -:13 eye. In such methods, the eye may further be contacted with an agent for controlling the intra ocular pressure, an anti-inflammatory agent, an antiviral agent, an antibacterial agent, an antiviral agent, an anti-angiogenic agent, an anti-mitotic agent, an antihistamine, an anesthetic, an agent to induce mydriasis and an agent to induce cycloplegia. Such further 5 agent different from an anti-PlGF antibody (or fragment thereof) may be co-administered with the anti-PIGF antibody in the same formulation (or composition or solution) or medicament, or concurrently in a separate formulation (or composition or solution) or medicament. Such further agent different from an anti-PIGF antibody (or fragment thereof) may alternatively be administered prior to or after administration of the anti-PIGF antibody 0 (or fragment thereof). "Contacting" means any mode of administration that results in interaction between an agcnt or composition such as a medicament and an object (such as conjunctiva or subconjunctival tissue) with which said agent or composition is contacted. The interaction between the agent .5 or composition and the object can occur starting immediately or nearly immediately with the administration of the agent or composition, can occur over an extended time period (starting immediately or nearly immediately with the administration of the agent or composition), or can be delayed relative to the time of administration of the agent or composition. More specifically the "contacting" results in delivering an effective amount of the agent, !0 composition or medicament to the object. The term "effective amount" refers to the dosing regimen of the agent, composition or medicament according to the invention, in particular of the active ingredient of the medicament according to the invention, i.e., an anti-PlGF antibody or a fragment thereof. The 25 effective amount will generally depend on and will need adjustment to the mode of contacting or administration. The effective amount of the agent, composition or medicament, more particular its active ingredient, is the amount required to obtain the desired clinical outcome or therapeutic or prophylactic effect without causing significant or unnecessary toxic effects. To obtain or maintain the effective amount, the agent, composition or 30 medicament may be administered as a single dose or in multiple doses. The effective amount may further vary depending on the severity of the condition that needs to be treated or the expected severity of the condition that needs to be prevented or treated; this may depend on the overall health and physical condition of the patient and usually the treating doctor's or -14 physician's assessment will be required to establish what is the effective amount. The effective amount may further be obtained by a combination of different types of contacting or administration. In the context of the present invention the effective amount may more particularly be obtained by either one or more of administration of topical eye drops, 5 administration by injection into the anterior chamber of an eye or administration by subconjunctival injection. A typical dose of a single administration of the agent, composition or medicament of the invention may comprise 10 pg to 20 mg of the active compound, or alternatively may comprise 10 ptg/kg body weight to 20 mg/kg body weight of the active compound. Administration of the medicament of the invention by means of injection 0 typically is kept to a minimum, i.e., the frequency of repeat injections is kept to a minimum. As the first weeks or months post-trabeculectomy (species dependent as described higher)are crucial in the sense that eye-healing activities are highest in this period, the duration of treatment with an agent, composition or medicament according to the present invention should be adjusted to this period. .5 In general, the formulation (or composition or solution) or medicament of the invention comprising an anti-PlGF antibody or fragment thereof according to the invention may, depending on its ultimate use and mode of administration, comprise one or more further active ingredients such as an agent controlling the intra-ocular pressure (see higher), an !0 anticoagulant, a thrombolytic agent, an anti-inflammatory agent, an antiviral agent, an antibacterial agent, an antifungal agent, an anti-angiogenic agent, an anti-mitotic agent, an antihistamine or anesthetic. "Anticoagulants" include hirudins, heparins, coumarins, low-molecular weight heparin, 25 thrombin inhibitors, platelet inhibitors, platelet aggregation inhibitors, coagulation factor inhibitors, anti-fibrin antibodies and factor VIII-inhibitors (such as those described in WO 01/04269 and WO 2005/016455). "Thrombolytic agents" include urokinase, streptokinase, tissue-type plasminogen activator 30 (tPA), urokinase-type plasminogen activator (uPA) and staphylokinase or any variant or derivative of any thereof such as APSAC (anisoylated plasminogen streptokinase activator complex), alteplase, reteplase, tenecteplase, and scuPA (single chain uPA), plasmin or any truncated variant thereof such as midiplasmin, miniplasmin, deltaplasmin and microplasmin.

"Anti-inflammatory agents" include steroids (e.g. prednisolone, methylprednisolone, cortisone, hydrocortisone, prednisone, triamcinolone, dexamethasone) and non-steroidal anti inflammatory agents (NSAIDs; e.g. acetaminophren, ibuprofen, aspirin). 5 "Antiviral agents" include trifluridine, vidarabine, acyclovir, valacyclovir, famciclovir, and doxuridine. "Antibacterial agents" or antibiotics include ampicillin, penicillin, tetracycline, o oxytetracycline, framycetin, gatifloxacin, gentamicin, tobramycin, bacitracin, neomycin and polymyxin. "Anti-mycotic/fungistatic/antifungal agents" include fluconazole, amphotericin, clotrimazole, econazole, itraconazole, miconazole, 5-fluorocytosine, ketoconazole and natamycin. .5 "Anti-angiogenic agents" include antibodies (or fragments thereof) such as anti-VEGF (vascular endothelial growth factor) or anti-PIGF (placental growth factor) antibodies and agents such as macugen (pegaptanib sodium), trypthophanyl-tRNA synthetase (TrpRS), anecortave acetate, combrestatin A4 prodrug, AdPEDF (adenovector capable of expressing !0 pigment epithelium-derived factor), VEGF-trap, inhibitor of VEGF receptor-2, inhibitors of VEGF, PlGF or TGF-p, Sirolimus (rapamycin) and endostatin. "Anti-mitotic agents" include mitomycin C and 5-fluorouracyl. 25 "Antihistamine" includes ketitofen fumarate and pheniramine maleate. "Anesthetics" include benzocaine, butamben, dibucaine, lidocaine, oxybuprocaine, pramoxine, proparacaine, proxymetacaine, tetracaine and amethocaine. 30 Other adjunct agents or drugs that can be used in conjunction with the anti-PIGF antibody or fragment thereof according to the invention include scopoloamine, atropine or tropicamide, to induce mydriasis (pupillary dilation) and/orcycloplegia (paralysis of the eye focusing muscle).

-lb In addition to the anti-PIGF antibody or fragment thereof, each of the above listed agents as well as antihistamine and anesthetics is to be considered as an "active ingredient". 5 A "pharmaceutically acceptable formulation" is, in the context of the current invention more particular an "ophthalmologically acceptable formulation". A formulation in general is a composition comprising a carrier, diluent or adjuvant compatible with the one or more active ingredients to be formulated, the whole formulation being compatible with the intended use in the intended tissue or organ, etc. Examples of pharmaceutically acceptable formulations as 0 well as methods for making them can be found, e.g., in Remington's Pharmaceutical Sciences (e.g. 2 0 th Edition; Lippincott, Williams & Wilkins, 2000) or in any Pharmacopeia handbook (e.g. US-, European- or International Pharmacopeia). "Lubricants" include propylene glycerol, glycerin, carboxymethylcellulose, hydroxypropylmethylcellulose, soy lecithin, polyvinyl alcohol, white petrolatum, mineral oil, 5 povidone, carbopol 980, polysorbate 80, dextran 70. EXAMPLES The Examples included hereafter demonstrate the invention and are not construed to be limiting the scope of the invention in any way. EXAMPLE 1. Anterior chamber administration PURPOSE. Excessive postoperative wound healing with subsequent inflammation and scarring frequently leads to surgical failure of glaucoma filtration surgery (GFS). The hypothesis was checkedthat placental growth factor (PlGF) plays a role in scar formation 25 after GFS, and that it may be a target for improvement of the outcome of this surgery. METHODS. Aqueous humor and plasma samples of glaucoma and control patients (n=10) were collected and PIGF levels were determined by ELISA. The effect of the anti-murine PIGF-antibody (5D1 1D4) was investigated in a mouse model of GFS in C75B1/6 mice. In the 30 single-injection setting, 5D1lD4 (Ipl; 5.2mg/ml; antibody described in detail in WO 01/85796) or 1C8, an irrelevant mouse IgG antibody against human tissue plasminogen activator (1p1l; 4.8 mg/ml; antibody available at ThromboGenics), were injected in the anterior chamber (n=10 eyes or n=20 eyes for both groups) immediately after surgery ("day -l/ 0"). An anti-murine VEGF-R2 antibody (DClO) was used as a positive control (1l ; 6.2 mg/ml; n=10). Mice were killed on post-operative day 8.in the multiple- or repeated-injection setting, the antibodies were administered as above, albeit it on days 0, 4 and 10 after surgery; groups of n=10 eyes were assessed; and mice were killed on post-operative day 13. 5 Treatment outcome was studied by clinical investigation of intra-ocular pressure (IOP), bleb area and bleb survival every other day. RESULTS. PlGF levels in aqueous humor were found to be significantly upregulated in glaucoma compared to control patients (17 ± 2 pg/ml versus 12 ± 0.75 pg/ml, p=0.03). No o significant differences were found in plasma concentrations of PlGF. In the mouse model. of GFS, single administration of the anti-PIGF antibody (5DllD4) significantly improved surgical outcome by increasing bleb survival (p=0.0 4 ) and bleb area (p=0.01) with 29% compared to negative control (1C8). A single administration of anti-VEGF-R2 (DC 101) also significantly improved bleb area with 7% as compared to 1C8 (p=0.05), but had no effect on .5 bleb survival (p=0.

2 3 ). A trend towards an increased bleb area after 5D 1D4 administration was observed compared to DC101 delivery (p=0.07). lOP was not found to be significantly different in any of the groups (p>0.05). Results of single administration of the antibodies are depicted in Figure 1 (lOP); Figures 2A, 2B, 4A, 4B, 6A and 6B (all bleb area); and Figures 3A, 3B, 5A and 5B (bleb survival). Multiple- or repeated administrations of the antibodies (at days 0, 4 and 10 after surgery) led to a more pronounced improvement of surgical outcome with both 5D IID4 and DC 101 separately compared to 1C8, and with a more pronounced positive outcome with 5D 1D4 compared to DC101. Furthermore, the trend towards an increased bleb area after 5DI I D4 25 administration compared to DC 101 upon single administration (p=0.07) was converted into a significant difference. The latter further proves that an anti-PIGF antibody (5DI 1D4) is more efficient in improving surgical outcome of GFS than an anti-VEGF-R2 antibody (DCIOI) (p=0.005). Results of repeated administrations of the antibodies are depicted in Figures 2C, 4C and 6C (all bleb area); and Figures 3C and 5C (bleb survival). 30 CONCLUSIONS. Local production of PIGF in the eye may indicate an important role for this growth factor in wound healing after GFS. Indeed, targeting PlGF with an inhibitory monoclonal antibody is efficacious in improving GFS outcome, even more efficacious than inhibition of VEGF-R2 as described herein, and more efficacious than inhibition of VEGF 165 (Van Bergen et al. 2011, Exp Eye Res 93, 689-699)or VEGF-A (Li et al. 2009, Invest Ophthalmol Vis Sci 50, 5217-5225). This effect is seen with single administration of an anti PlGF antibody and is significantly enhanced upon multiple administrations of an anti-PIGF 5 antibody. These results render PIGF avalidated target for ocular wound healing and point to the therapeutic benefits of PIGF-inhibition in this setting. EXAMPLE 2. Comparison of anterior chamber administration, intravitreal administration and subconjunctival administration. o Mouse model of glaucoma filtration surgery C57BL/6J mice (8-10 weeks old, Charles River Laboratories) were used in accordance with the standards in the Association for Research in Vision and Ophthalmology Statement for the Use of Animals in Ophthalmic and Vision Research. The Institutional Animal Care and Research Advisory Committee of KU Leuven approved all experimental animal procedures. .5 Mice were anesthetized with an intaperitoneal injection of 10 times-diluted (60 mg/kg final dose) sodium pentobarbital (Nembutal, 60 mg/ml; CEVA, Sante Animale). Filtering surgery was performed on both eyes, using a technique that has been described previously and that results in a filtering bleb. In the first experiment (n=10 eyes for all groups), mice were divided in different groups to investigate different administration route of the PIGF-antibody. !0 Immediately after surgery, the PIGF inhibitor (5.2 pg) was intracamerally (anterior chamber) injected in the first group of mice, subconjunctivally in the second group and the third group received an intravitreal injection of 5D IlD4. The isotype matched control antibody (IC8) was used in every group as a negative control. The injections were performed by using an analytic science syringe (SGE Analytic Science) and glass capillaries with a diameter of 50 25 70 [im at the end, controlled by the UMP3I Microsyringe Injector and Micro4 Controller (all from World Precision Instruments, Inc). Mice were clinically examined on day I after surgery and then every 2 days until they were sacrificed. The bleb area (width and length) were analyzed under topical anesthesia. 30 Commercial software (KS300; Zeiss) was used to determine the bleb size on bleb images of mice. These pictures were taken using a digital camera (Canon PowerShot S50) using a 3x optical zoom lens at a magnification of 4X. Bleb survival was taken as the end-point of the -19 study, while bleb failure was defined as the appearance of a scarred and flat bleb at 2 consecutive measurements. Statistical analysis 5 Data at individual time points were analyzed using mixed model analysis for repeated measures (using GraphPad Prism 5). Kaplan-Meier survival analysis was performed for bleb failure using the logrank test. P <0.05 was considered to be statistically significant. Data are represented as mean ± SEM. o RESULTS Optimal route of administration of the anti-PIGF antibody Previous study showed intra-ocular safety of anti-PIGF injections in the eye, however, the most optimal route of administration of the PIGF-antibody is still uncertain. Therefore, surgical outcome after a single intracameral, subconjunctival and intravitreal injection of the [5 PIGF antibody (5D1 ID4, 5.2 tg) were compared. Bleb area and bleb survival were analyzed until 14 days after surgery and showed that the three administration routes of the PIGF antibody were able to significantly improve bleb area (n=10; P<0.001) and bleb survival (n=10; P<0.05) compared to their respective controls (1C8; 4.8 pg) (Figures7 and 8). A direct comparison between the three groups showed no significant difference neither in bleb area 0 (Figure 9), nor in bleb survival (n=10; P=NS), indicating that all routes of injection or all routes/locations of administration are equally able to improve surgical outcome.

Claims (26)

1. An anti-PlGF antibody or fragment thereof for enhancing the success rate of trabeculectomy surgery of an eye, for treating filtration failure after trabeculectomy 5 surgery of an eye, or for preventing, reducing or retarding the occurrence of filtration failure after trabeculectomy surgery of an eye.

2. The anti-PlGF antibody or fragment thereof according to claim I which is in a pharmaceutically acceptable formulation capable of being administered to an eye. 0

3. The anti-PIGF antibody or fragment thereof according to claim 2 which is in a pharmaceutically acceptable formulation capable of being administered into the anterior chamber of an eye. .5

4. The anti-PIGF antibody or fragment thereof according to claim 2 which is in a pharmaceutically acceptable formulation capable of being administered into the bleb created by the trabeculectomy surgery.

5. The anti-PIGF antibody or fragment thereof according to claim 1 wherein said treating ?0 of filtration failure after trabeculectomy surgery of an eye, or said preventing, reducing or retarding of the occurrence of filtration failure after trabeculectomy surgery of an eye results from administering to said eye at least a single dose of an effective amount of said anti-PIGF antibody or fragment thereof. 25

6. The anti-PIGF antibody or fragment thereof according to any one of claims 1 to 5 which is in a pharmaceutically acceptable formulation further comprising one or more of an agent for controlling the intra-ocular pressure, an anti-inflammatory agent, an antiviral agent, an antibacterial agent, an antiviral agent, an anti-angiogenic agent, an anti mitotic agent, an antihistamine, an anesthetic, an agent to induce mydriasis and an agent 30 to induce cycloplegia. -21

7. The anti-PIGF antibody or fragment thereof according to claim 5 wherein said eye is contacted further with one or more agents chosen from an agent for controlling the intraocular pressure, an anti-inflammatory agent, an antiviral agent, an antibacterial agent, an antiviral agent, an anti-angiogenic agent, an anti-mitotic agent, an 5 antihistamine, an anesthetic, an agent to induce mydriasis and an agent to induce cycloplegia.

8. The anti-PlGF antibody or fragment thereof according to claim 7 wherein said further contacting is occurring prior to, concurrent with, or after administering the anti-PIGF 0 antibody or fragment thereof.

9. The anti-PIGF antibody or fragment thereof according to claim 1 wherein said treating of filtration failure after trabeculectomy surgery of an eye, or said preventing, reducing or retarding of the occurrence of filtration failure after trabeculectomy .5 surgery of an eye results from administering into the anterior chamber of an eye multiple doses of an effective amount of said anti-PlGF antibody or fragment thereof.

10. The anti-PlGF antibody or fragment thereof according to claim 9 wherein said multiple doses are administered with at least 6-hour time intervals. ?0

11. A method of enhancing the success rate of trabeculectomy surgery of an eye, of treating filtration failure after trabeculectomy surgery of an eye, or of preventing, reducing or retarding the occurrence of filtration failure after trabeculectomy surgery of an eye, said method comprising the step of administering an anti-PlGF antibody or 25 fragment thereof to said eye, thereby enhancing the success rate of trabeculectomy surgery of an eye, treating filtration failure after trabeculectomy surgery of an eye, or preventing, reducing or retarding the occurrence of filtration failure after trabeculectomy surgery. 30

12. The method according to claim I1 wherein at least a single dose of an effective amount said anti-PlGF antibody or fragment thereof is administered to said eye. -22

13. The method according to claim I I further comprising administration of one or more of an agent for controlling the intra-ocular pressure, an anti-inflammatory agent, an antiviral agent, an antibacterial agent, an antiviral agent, an anti-angiogenic agent, an anti-mitotic agent, an antihistamine, an anesthetic, an agent to induce mydriasis and 5 an agent to induce cycloplegia.

14. The method according to claim 13 wherein said further contacting is occurring prior to, concurrent with, or after administering the anti-PIGF antibody or fragment thereof. 0

15. The method according to claim I1 wherein multiple doses of an effective amount of said anti-PlGF antibody or fragment thereof are administered to said eye.

16. The method according to claim 15 wherein said multiple doses are administered with .5 at least 6-hour time intervals.

17. The method according to claim I1 wherein said anti-PlGF antibody or fragment thereof is administered into the anterior chamber of said eye, is administered into the vitreous of said eye, is administered in the subconjunctiva of said eye, is administered !0 into the bleb created by the trabeculectomy surgery of said eye, or is administered as eye drops to said eye.

18. The method according to claim 15 wherein each of said multiple doses is administered into the anterior chamber of said eye, is administered into the vitreous 25 of said eye, is administered in the subconjunctiva of said eye, is administered into the bleb created by the trabeculectomy surgery of said eye, or is administered as eye drops to said eye.

19. The method according to claim 11 wherein said anti-PIGF antibody or fragment 30 thereof is in a pharmaceutically acceptable formulation capable of being administered to an eye. -23

20. The method according to claim 11 wherein said anti-PIGF antibody or fragment thereof is in a pharmaceutically acceptable formulation capable of being administered into the anterior chamber of an eye. 5

21. The method according to claim 11 wherein said anti-PlGF antibody or fragment thereof is in a pharmaceutically acceptable formulation capable of being administered into the vitreous of an eye.

22. The method according to claim 11 wherein said anti-PlGF antibody or fragment 0 thereof is in a pharmaceutically acceptable formulation capable of being administered into the subconjunctiva of an eye.

23. The method according to claim I1 wherein said anti-PLGF antibody or fragment thereof is in a pharmaceutically acceptable formulation capable of being administered 5 into the bleb created by trabeculectomy surgery.

24. The method according to claim I1 wherein said anti-PIGF antibody or fragment thereof is in a pharmaceutically acceptable eye drop formulation capable of being administered to an eye !0

25. The method according to claim 11 wherein said anti-PIGF antibody or fragment thereof is in a pharmaceutically acceptable formulation further comprisingone or more agents selected from the group consisting of an agent for controlling the intra ocular pressure, an anti-inflammatory agent, an antiviral agent, an antibacterial agent, 25 an antiviral agent, an anti-angiogenic agent, an anti-mitotic agent, an antihistamine, an anesthetic, an agent to induce mydriasis and an agent to induce cycloplegia.

26. The method according to claim I1 wherein said anti-PlGF antibody or fragment thereof is capable of inhibiting an activity of PIGF. 30