EA046057B1 - HIGH MOLECULAR HYALURONIC ACID FOR THE TREATMENT AND PREVENTION OF SEVERE DISEASE OF THE OCULAR SURFACE - Google Patents

Description

Cross reference to related application

This application claims the benefit of U.S. Provisional Application Serial No. 62/659215, filed April 18, 2018, which is hereby incorporated by reference in its entirety, including any figures, tables, nucleic acid sequences, amino acid sequences, or graphics. materials.

Field of invention

The present invention relates to a liquid for reducing or delaying the onset of severe ocular surface disease and/or, once onset, its mitigation and long-term relief.

Prior Art

According to the International Statistical Classification of Diseases and Related Health Problems, 10th Revision, the scope of ocular surface disease (OSD) covers a range of diseases. Some of them have connections or even causal connections with insufficiency of the lacrimal apparatus. However, as evidenced by the ICD catalog, OSD associated with keratitis sicca overall represents only a small portion of all known severe ocular surface diseases. However, the diagnostic assessment in relation to the severity of ocular surface damage in the area of sicca keratitis is very well established; therefore, some of these diagnostics can be used as an aid to identify severity levels of other OSDs. In particular, the ability to distinguish between severe sicca keratitis and more moderate degrees of intensity is very useful (Baudouin S. et al., Revisiting the Vicious Circle of Dry Eye Disease: a Focus on the Pathophysiology of Meibomian Gland Dysfunction, Br J Ophthalmol, 2016, 100 (3):300-306), and a pattern of surface changes (van Setten G, Sandbank Epitheliopathy of the Conjunctiva (SEC): A New Indicator in Dry Eye Diagnostics Useful For Optimized Ocular Surgery, J Eye Cataract Surg, 2017, 3:1 -4; and van Setten G, The Anatomical Dry Eye - A Different Form of Ocular Surface Disease Deserves Focus, Open Journal of Ophthalmology, 2017, 7, 184-190).

The goal of treatment for OSD is to reverse any pathology to restore a normal situation or as close to a normal situation as possible. In the optimal case of success, this would be a complete return to normal from the disease and restoration of the state exactly and as completely as it was before the onset of the disease, also called restitutio ad integrum (recovery to the original state). The disease is characterized by the loss of any physiological characteristics of the ocular surface, such as transparency, shape and outline, elasticity, resistance to shock, etc., and specific anatomical requirements for achieving and maintaining these characteristics, such as innervation, epithelial integrity, extracellular composition matrix (ECM), tissue hydration and dehydration, tissue structure, tissue surfaces, etc.

Severe ocular surface disease is a stage of disease at which the function of the ocular surface or significant parts thereof, such as transparency and tissue integrity, has become impaired. The temporary or permanent nature of a given disease dictates the extent to which the mechanisms associated with the pathology are reversible, if at all. The predominance of the disease at a stage of greater severity or associated pathology dictates whether complete reversal is possible or not. In cases of severe ocular surface disease, such as corneal scarring following trauma, the altered state of the tissue itself may preclude restitutio ad integrum, since the state of the tissue is permanently and irrevocably altered. If the severity of ocular surface disease is characterized simply by a functional change, such as loss of surface clarity and hydration, and/or repairable surface damage, then complete recovery may still be possible, i.e. complete recovery and cure. Thus, the degree of functional decline correlates with the severity of the disease or change in condition. For example, acute or chronic loss of corneal transparency due to severe corneal edema caused by intraocular pressure or simple exposure to hypotonic conditions represents a condition of severe ocular surface disease.

This invention is particularly directed to methods and compositions for use in the treatment of severe ocular surface disease, such as severe sicca keratitis. As those skilled in the art will appreciate, severe keratitis sicca differs from mild-moderate keratitis sicca in etiology, symptoms, and recommended treatments. The International Tear Film and Ocular Surface Society (TFOS) has established a panel of discipline experts, the Dry Eye Workshop (DEWS), which has formed subcommittees to address specific aspects of sicca keratitis. One of them is the Subcommittee for the Management and Therapy of Keratitis Sicca. The results of the deliberations of the various subcommittees were submitted for publication in two series of consensus documents that represented the state of the art at the time of their publication in 2007 and 2017. These consensus documents included: A) Management and Therapy of Dry Eye Disease: Report of the Management and Therapy Subcommittee of the International Dry Eye Work Shop (2007), The Ocular Surface, April 2007, 5(2): 65-204 (at it is referenced herein as DEWS Report I (2007); and B) TFOS DEWS II Management and Therapy Report, The Ocular Surface, 2017, 15:575-628 (referenced herein as DEWS Report II (2017) ).

DEWS I (2007) (on page 118) summarizes color grading systems

- 1 046057 ocular surface currently in use. The DEWS I report (2007) then defined in Table. 2 (page 173) four levels of severity of dry keratitis, with levels 1 and 2 representing mild to moderate dry keratitis, and levels 3 and 4 representing severe dry keratitis. In table Figure 4 on page 174 shows a staged or staged treatment approach in which recommended treatments are classified based on the level of severity of the disease. As shown in table. 4, there is a development of treatment corresponding to the severity of the disease; thus, the intensity of the intervention chosen is usually proportionate to the severity of the sicca keratitis. For example, artificial tear substitutes (which include hyaluronic acid eye drops) are considered appropriate for grade 1 disease, anti-inflammatories are administered for grade 2 disease, whereas grade 3 disease is likely to require autologous serum eye drops or other treatment appropriate for severe dry keratitis.

The DEWS II report (2017) reflects expert agreement that artificial tears replace or supplement the natural tear film but do not address the underlying pathophysiology (see page 576, right column, section 2.1). This consensus report states that there does not appear to be any significant difference in the effectiveness of artificial tear substitutes (see page 577, left column, section 2.1.1.1.1). Additionally, expert opinion was that high viscosity eye drops may increase retention time on the ocular surface, but may also cause temporary visual impairment and result in unwanted residue on the eyelids and eyelashes, resulting in decreased tolerance and compliance with treatment regimens. . Eye drops with very high viscosity are typically recommended for use during the night, with drops with low viscosity used during the day. DEWS II (2017) reported the benefits of autologous serum over artificial tears for the treatment of severe sicca keratitis (see page 580, section 2.1.2.1).

Autologous serum eye drops are produced for the most severe stages of keratitis sicca in patients when other eye drops have failed or need to be discontinued. The beneficial effects of the substances included in the serum-based drops made them a valuable alternative for these patients. However, according to the current state of the art, once such therapy has been introduced, it is virtually impossible to return to other lubricating eye drops. Additionally, there are disadvantages to using autologous serum eye drops for the treatment of severe sicca keratitis, such as stringent regulatory requirements, the cost and logistical burden of obtaining patient blood, and the use of a preservation method and storage system that prevents or minimizes the degradation of important biological molecules such as growth factors and cytokines, during storage and help avoid contamination that would lead to the risk of infection.

Therefore, there is a need for alternative methods of treating severe sicca keratitis that provide the desired effectiveness but do not have the disadvantages of methods available in the art.

Summary of the invention

The present invention provides a liquid composition for the treatment or prevention of severe ocular surface disease (severe OSD). By topical administration of a liquid composition containing a very high molecular weight form of hyaluronic acid (also referred to as hyaluronan or HA) to the ocular surface, the present invention can attenuate severe ocular surface disease, prevent severe ocular surface disease, delay the onset of severe ocular surface disease, or prevent or delay further damage. ocular surface through severe ocular surface disease.

Thus, in one preferred aspect of the present invention there is provided a liquid for use in the treatment of severe ocular surface disease, wherein the liquid contains high molecular weight hyaluronic acid having an intrinsic viscosity greater than 2.5 m ³ /kg and a concentration of less than 0.2% w/v ., wherein the severe ocular surface disease is severe sicca keratitis, and where the liquid is intended for topical administration to the ocular surface of the eye of a human subject or a non-human animal subject. It is particularly preferred that the hyaluronic acid has a molecular weight of at least 3 million Daltons, such as a molecular weight in the range of 3 million to 4 million Daltons. Moreover, it is preferable that the liquid contains high molecular weight hyaluronic acid having a concentration of 0.1 to 0.19% w/v. In addition, in a preferred embodiment, the liquid may have: a) a pH of 6.8-7.6; b) osmolarity 240-330 mOsmol/kg; c) NaCl concentration 7.6-10.5 g/l; and/or d) phosphate concentration 1.0-1.4 mmol/l. It is further preferred that the liquid is a clear and colorless solution free of visible impurities and that the liquid is sterile. An example of a liquid for use according to this invention is Comfort Shield® preservative-free sodium hyaluronate eye drops.

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Detailed Description of the Invention

Hyaluronic acid (HA) is a carbohydrate - a mucopolysaccharide, in particular, which can be found in living organisms. The biological functions of endogenous HA include maintaining the elastic viscosity of fluid connective tissues such as joint synovial fluid and vitreal fluid of the eye (Necas J et al., Hyaluronic acid (hyaluronan): a review, Veterinarni Medicina, 2008, 53(8):397-411; Stern R et al., Hyaluronan fragments: An information-rich system, European Journal of Cell Biology, 2006, 85:699-715). Although the specific mechanisms involved in the diverse signaling of NA are still poorly understood, it is known that NA can modulate a variety of biological effects that may vary depending on the size of the NA (Cyphert JM et al., Size Matters: Molecular Weight Specificity of Hyaluronan Effects in Cell Biology, International Journal of Cell Biology, 2015, Epub 2015 Sep 10, 563818).

Sodium hyaluronate and other viscoelastic agents have been used in intraocular surgery since the 1970s. and for the treatment of sicca keratitis since the 1980s. (Higashide T and K Sugiyama, Use of viscoelastic substance in ophthalmic surgery-focus on sodium hyaluronate, Clinical Ophthalmology, 2008, 2(1):21-30; Polack FM and MT McNiece, The treatment of dry eyes with Na hyaluronate (Healon ) - preliminary report, 1982, 1(2): 133-136); however, until now little attention has been paid to the biological function of hyaluronic acid in epithelia (Muller-Lierheim WGK, Tranenersatzlosungen, Neues uber Hyaluronsaure, Aktuelle Kontaktologie, April 2015, 17-19).

One aspect of the present invention includes a method of reducing, preventing or delaying the onset of severe ocular surface disease, or preventing or delaying the progression of OSD from mild or moderate intensity to high intensity, the method comprising topical administration of a liquid containing high molecular weight hyaluronic acid (HA) to the ocular the surface of the eye of a human or non-human subject. This hyaluronic acid is high molecular weight, having an intrinsic viscosity of more than 2.5 m ³ /kg and a concentration of less than 0.2% w/v. The intrinsic viscosity can be determined by the method of European Pharmacopoeia 9.0, Sodium Hyaluronate, page 3584 (which is incorporated herein by reference in its entirety). Briefly, intrinsic viscosity [η] is calculated by linear least squares regression analysis using Martin's equation: Logl ₀ (n _r -1/c)=logl ₀ [η]+k[η]s. In some embodiments, the hyaluronic acid has an intrinsic viscosity greater than 2.9 m ³ /kg.

In some embodiments, the hyaluronic acid has a concentration of 0.1 to 0.19% w/v.

In some embodiments, the liquid has: a) a pH of 6.8-7.6; b) osmolarity 240-330 mOsmol/kg; c) NaCl concentration 7.6-10.5 g/l and/or d) phosphate concentration 1.0-1.4 mmol/l.

In some embodiments, the liquid is a clear and colorless solution containing no visible impurities. It is assumed that the liquid is sterile.

In some embodiments, the liquid of the invention is Comfort Shield® preservative-free sodium hyaluronate eye drops.

In a preferred embodiment, the severe ocular surface disease is severe keratitis sicca.

Another aspect of the present invention includes a method of reducing the ease of transition, delaying or preventing the transition from a temporary to permanent severe ocular surface disease, comprising topically administering a liquid containing high molecular weight hyaluronic acid (HA) to the ocular surface of the eye of a human subject or a non-human animal subject.

In some embodiments, the HA has a molecular weight of at least 3 million Daltons as calculated by the Mark-Hoovink equation. In some embodiments, the HA has a molecular weight in the range of 3 million to 4 million Daltons as calculated by the Mark Hoovink equation.

In some embodiments, the high molecular weight HA is hyaluronan. In some embodiments, the high molecular weight HA is cross-linked, such as Hylan A and Hylan B. In some embodiments, the high molecular weight HA is not cross-linked. In some embodiments, the high molecular weight HA is linear. In some embodiments, high molecular weight HA is nonlinear. In some embodiments, the high molecular weight HA is a hyaluronan derivative, such as an ester derivative, an amide derivative, or a sulfated derivative, or a combination of two or more of the above.

In some embodiments, the ocular surface to which the fluid is administered is in homeostasis at the time the fluid is administered. In other embodiments, the ocular surface of the subject's eye is not in homeostasis.

The administered fluid may enhance or improve the visual performance of the eye into which it is administered, regardless of whether the ocular surface is in homeostasis at the time the fluid is administered to the eye. The injected liquid helps stabilize the liquid film

- 3 046057 eyes (for example, tear film on the ocular surface), optimize vision and visual performance, especially under extreme conditions.

An increase or improvement in visual performance can be defined as an increase or improvement in the speed and/or accuracy of processing visual information. For example, visual performance can be described by how quickly and accurately an individual can process visual stimuli, as measured by criteria such as light adaptation, target contrast, and target size. Methods for assessing visual performance and changes in visual performance are known in the art (see, for example, Toda I et al., Visual performance after reduced blinking in eyes with soft contact lenses or after LASIK, J Refract. Surg., 2009, Jan., 25(1):69-73; and Rea MS and MJ Quellette, Relative visual performance: A basis for application, Lighting Res. Technol., 1991, 23(3): 135-144, which are incorporated herein by reference in in their entirety).

The liquid may be administered to the ocular surface of one or both eyes of the subject through any method of topical administration. For example, the liquid may be administered as one or more drops from an eye drop dispenser such as an eye dropper. This fluid may be self-administered or administered by a third party. The dosage administered, whether in single or multiple doses, to the ocular surface will vary depending on a number of factors including the condition and characteristics of the patient, severity of symptoms, concomitant treatments, frequency of treatment, and desired effect. For example, one or more than one drop (eg, each approximately 30 microliters) may be administered. While administration of 1-3 drops one to three times daily will be sufficient for mild to moderate ocular surface disease, more frequent topical administration may be required for severe ocular surface disease, especially during the initial phase of treatment, e.g. 3 drops four, five, six, seven, eight, nine, ten or more than ten times a day.

Advantageously, in some embodiments, the frequency of administration and/or amounts per dose may be decreased over time as ocular surface homeostasis is maintained or restored and the cornea stabilizes. For example, in some cases, after four weeks, the amount administered may be reduced and/or the frequency of administrations every day may be reduced, or the frequency of administrations may be reduced to once every half day.

The fluid may be administered prophylactically before severe ocular surface disease exists to reduce the severity of severe ocular surface disease, prevent severe ocular surface disease and/or delay its onset; or the liquid may be administered therapeutically after severe ocular surface disease occurs to reduce the severity of the severe ocular surface disease. Optionally, the fluid is administered prophylactically before an event or stimulus occurs that causes a given severe ocular surface disease, such as ocular trauma (eg, non-surgical trauma), ocular surgery (eg, glaucoma surgery, strabismus surgery, etc.) .) or eye infection. In some embodiments, the onset of severe ocular surface disease is delayed indefinitely (ie, prevented). In some embodiments, one or more than one symptom of a severe ocular surface disease is alleviated or eliminated. In some embodiments, all symptoms of a given severe ocular surface disease are alleviated or eliminated.

The liquid may also be administered prophylactically to subjects who are particularly sensitive or prone to infection in order to prevent or delay the onset of severe ocular surface disease. For example, the subject may be immunocompromised. A subject's immunosuppressive condition may have one or more causes, such as a medical treatment (eg, radiation therapy, chemotherapy, or other immunosuppressive treatment), an environmental exposure (eg, radiation exposure), or a genetic defect, whether the defect is expressed as a phenotype or not (i.e. only as a genotype). Subjects who are known to be immunocompromised or have a genetic defect associated with immunocompromised health, even if not expressed as a phenotype, would benefit from prophylactic use of the present invention, especially if it is assumed that the subject is exposed to conditions at risk for ocular surfaces.

In cases in which a severe ocular surface disease exists at the time of fluid administration, and the fluid is administered therapeutically, the method may further include the step of identifying the subject as having the severe ocular surface disease before administering the fluid.

In some embodiments, a given severe ocular surface disease may have one or more of the following characteristics: leukocyte invasion of the ocular surface and tears, upregulation of CD44 on the ocular surface, and activation of an immune cascade that includes one or more of the following: IL- 1 (interleukin-1), IL-2, IL-5, IL-6, IL-8, CXCL8, IL-10, IL-12, IL-16, IL-33, MCP1, CCL2, MIP1d (also known as CCL15), ENA-78, CXCL5, sILR1, sIL-6R, sgp sEGFR, sTNFR, I-17A, IL-21, IL-22, CXCL9, MIG, CXCL11, I-TAC, CXCL10, IP-10, MP- 1p, CCL4, RANTES and CCL5.

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This severe disease of the ocular surface can be caused by various stimuli - external, internal, or both. In some embodiments, this severe ocular surface disease is caused by an external stimulus resulting in disruption of the smoothness and/or integrity of the ocular surface (eg, medical therapy, ocular surgery, non-surgical trauma, contact lens wear, microbial infection, allergen, hapten, toxic agent or irritant ).

This severe ocular surface disease can be caused by various medical therapies, such as small molecule pharmaceuticals and biological agents. For example, this severe ocular surface disease may be induced by a beta blocker, which refers to agents that inhibit or block the activity of one or more beta adrenergic receptors. Beta blockers may be used to treat hypertension, stable and unstable angina, arrhythmias, migraines, esophageal bleeding, heart failure, and coronary artery disease, among other indications. Some beta blockers antagonize one specific beta adrenergic receptor subtype (eg, a beta-1 selective beta blocker, which selectively antagonize the beta 1 adrenergic receptor), whereas other beta blockers are non-selective. Some beta blockers may inhibit the effect of ligands such as norepinephrine or norepinephrine at one or more beta adrenergic receptors. Accordingly, the term beta blocker refers to all types of beta adrenergic receptor antagonists or inhibitors, regardless of whether the beta blocker antagonizes one, two, or more than two beta adrenergic receptors, and regardless of whether influence on other processes. Examples of beta blockers include acebutolol, alprenolol, atenolol, betaxolol, bisoprolol, bopindolol, bucindolol, butaxamine, carteolol, carvedilol, celiprolol, esmolol, labetalol, levobunolol, medroxalol, metypranolol, metoprolol, nadolol, nebivolol, nadolol, oxprenolol, penbu tolol, pindolol , propafenone, propranolol, sotalol, timolol and Eucommia bark, but are not limited to.

In some embodiments, the severe ocular surface disease is an ocular allergy. In some embodiments, the severe ocular surface disease is non-infectious keratoconjunctivitis caused by external injury, allergic keratoconjunctivitis (such as seasonal allergic keratoconjunctivitis), or infectious keratoconjunctivitis such as viral keratoconjunctivitis, bacterial keratoconjunctivitis, fungal keratoconjunctivitis, and parasitic keratoconjunctivitis conjunctivitis. In some embodiments, the severe ocular surface disease is caused by an internal stimulus (eg, a hormonal disorder (such as menopause and andropause), a rheumatic disease, epithelial mesenchymal transition (EMT), or an autoimmune disease).

This severe disease of the ocular surface can be caused by an injury to the eye. In some embodiments, the wound is caused by physical trauma, chemical trauma, or radiation (radiation damage). In some embodiments, the injury is caused by eye surgery. Examples of ocular surgical procedures include natural or artificial cornea transplants, corneal implants (eg, intracorneal rings (ICR) and keratoprosthesis), glaucoma surgery, cataract surgery (eg, phacoemulsification, extracapsular cataract surgery, or intracapsular surgery), refractive surgery (eg, radial keratotomy or refractive corneal incision), retinal surgery, strabismus surgery, laser-related surgery (eg, laser-assisted in situ keratomileusis (LASIK) or photorefractive keratectomy (PRK)), and stapling surgery . Administration of the fluid of the invention before, during and/or after ophthalmic surgery, such as glaucoma surgery, may improve clinical outcome, for example, by accelerating recovery, including restoration of visual efficiency after surgery, reducing scar formation, and reducing itching, irritation, pain and other discomfort.

The fluid may be administered to reduce or prevent or delay the onset of ocular discomfort, such as itching or ocular pain, associated with severe ocular surface disease. Eye pain may be associated with acute or chronic inflammation, or an immune response. With a decrease in pain comes a decrease in secondary neuroinflammatory effects (Belmonte C. et al., TFOS DEWS II pain and sensation report, The Ocular Surface, 15:404-437). The cause of this pain may be known or unknown.

In some embodiments, the severe ocular surface disease is severe keratitis sicca. In other embodiments, the severe ocular surface disease is a severe ocular surface disease other than severe sicca keratitis.

In some embodiments, the severe ocular surface disease is one or more of those listed in Table. 1.

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Table 1

Examples of severe ocular surface disease

Corneal swelling Hayes, S. et al, “The structural response of the cornea to changes in stromal hydration,” J.R. Soc. Interface, 2017, 14:1-9. Congenital corneal opacities Mataftsi, A. et al., “Chromosome abnormalities and the genetics of congenital corneal opacity”, Molecular Vision, 2011, 17:1624-1640. Corneal scars Nischal, K.K., “Genetics of Congenital Corneal Opacification—Impacton Diagnosis and Treatment,” Cornea, 2015, 34 Suppl 10:S24-34. Rose J.S. et al., “Objective quantification of corneal haziness using anterior segment optical coherence tomography,” Journal of Current Ophthalmology, 2018, 30(1):54-57. Giant papillary conjunctivitis Torricelli, A.A.M. et al., “The corneal fibrosis response to epithelial-stromal injury,” Exp Eye Res., 2016, 142:110118. Dunn, Jr., J.P. etal., “Giant papillary conjunctivitis associated with elevated corneal deposits,” Cornea, 1990, (4):357-8. Cicatricial pemphigoid Corneal opacity with decreased visual performance after laser treatment Ebrahimiadib, N. et al., “Atopy in Patients With Ocular Cicatricial Pemphigoid,” Cornea, 2018, 37(4):436-441. Liu, Y.L. et al., “Visual performance after excimer laser photorefractive keratectomy for high myopia,” Taiwan J Ophthalmol, 2017, 7(2):82-88. Severe ocular surface disease after a chemical burn Javadi, M.A. etal., “Chronicand Delayed-Onset Mustard Gas Keratitis, Report of 48 Patients and Review of Literature,” Ophthalmology, 2005, 112:(4):1-11. Xerophthalmia Baradaran-Rafii, A., “Mustard Gas Induced Ocular Surface Disorders,” Journal of Ophthalmic and Vision Research, 2013, 8(4):383-390. Rosen, D.S. et al., “Vitamin A deficiency and xerophthalmia in western Yemen,” EurJ Clin Nutr., 1996, 50(1):54-7. Trachoma with corneal scarring and vascularization Whitcher, J.P., et al. , “Corneal blindness: a global perspective”, Bull World Health Organ, 2001, 79(3):21421. Corneal scars after viral infections (measles) Bowman, R.J. et al. “Non-trachomatous corneal opacity in the Gambia-aetiology and visual burden,” Eye (Lond), 2002, 16(1):27-32.

In some embodiments, the severe ocular surface disease is one or more diseases selected from the following, as identified by ICD (International Classification of Diseases) coding:

ICD-10-CM codes > H00-H59 diseases of the eye and related organs > H15-H22 disorders of the sclera, cornea, iris and ciliary body >

other corneal disorders H18- >

Codes

H00-H05 disorders of the eyelid, lacrimal system and orbit

H10-H11 conjunctival disorders

H17.9 scars and opacities of the cornea, unknown etiology

H17.1 other central corneal opacities

H17.8 scars and corneal opacities of established etiology

Corneal opacity with:

H15-H22 disorders of the sclera, cornea, iris and ciliary body

H53-H54 visual impairment and blindness

H55-H57 other disorders of the eye and related organs

H58-H59 Occurring during surgery and post-procedural complications and disorders, not elsewhere classified.

Optionally, the liquid further includes one or more bioactive agents (eg, a hydrophobic active ingredient). The term bioactive agent as used herein refers to any substance that has an effect on

- 6 046057 human subject or non-human animal subject, when administered in an effective amount to affect tissue. The bioactive agent may be any class of substance, such as a drug molecule or biological product (eg, polypeptide, carbohydrate, glycoprotein, immunoglobulin, nucleic acid), may be natural or artificially produced, and may act through any mechanism, such as pharmacological, immunological or metabolic. Examples of classes of bioactive agents include agents that modify ocular pressure (eg, enzyme inhibitors) and antiangiogenic agents. Some specific examples of bioactive agents include steroids (eg, corticosteroids), antibiotics, immunosuppressants, immunomodulatory agents, tacrolimus, plasmin activator, antiplasmin, and cyclosporin A. In some embodiments, the bioactive agent is a steroid or antibiotic for treating or preventing an eye infection; an anti-glaucoma drug such as a prostaglandin analogue, beta blocker, alpha agonist or carbonic anhydrase inhibitor; an ocular allergy relief agent such as a histamine antagonist or nonsteroidal anti-inflammatory drug; or mydriatic agent. Unfortunately, in some cases the bioactive agent or agents included in this liquid may be irritating or damaging to the eye (eg, cyclosporine A). Advantageously, through its rheological properties and other properties, the high molecular weight HA in a given fluid may relieve and/or protect the eye from the irritating and/or damaging effects of the bioactive agent or agents in the fluid (i.e., the bioactive agent would be more irritating or more damaging to eyes when administered without high molecular weight NA).

In some embodiments, the liquid does not contain a steroid, antibiotic, or immunomodulator. In some embodiments, the liquid does not contain another bioactive agent (eg, does not contain a hydrophobic active ingredient).

In some circumstances, it may be desirable to include one or more preservatives or detergents in a given liquid. Often such preservatives and detergents are irritating or damaging to the eye. Advantageously, through its rheological properties and other properties, the liquid can soften and/or protect the eye from the irritating and/or damaging effects of the preservative or detergent in the composition. Thus, in some embodiments, the liquid further contains a preservative or detergent that is irritating or damaging to the eye (ie, a preservative or detergent that would be more irritating or damaging to the eye if administered without the high molecular weight HA). In some embodiments, the liquid does not contain a preservative or detergent.

In some embodiments, the liquid includes cyclosporine A, cetalkonium chloride, tyloxapol, or a combination of two or more of the above.

In some embodiments, the liquid is administered to the subject before, during, and/or after the subject is administered another composition containing the bioactive agent. In some circumstances it may be desirable to include one or more preservatives or detergents in another composition. As stated above, often such preservatives and detergents are irritating or damaging to the eye, and some bioactive agents themselves may be irritating or damaging to the eye. Advantageously, through its rheological properties and other properties, the liquid can soften and/or protect the eye from the irritating and/or damaging effects of a bioactive agent, preservative and/or detergent in another composition. Thus, the bioactive agent, preservative and/or detergent in another composition would be more irritating or more damaging to the eye when administered without the liquid.

In some embodiments, the other composition includes one or more than one antibiotic, immunosuppressant, or immunomodulatory agent.

In some embodiments, the other composition includes cyclosporine A, cetalkonium chloride, tyloxapol, or a combination of two or more of the above.

The other composition administered to the subject may be in any form and administered by any route (eg, locally or systemically). In some embodiments, another composition is administered to the eye, for example, topically or by injection. In some embodiments, another composition is administered topically to the ocular surface.

In some embodiments, the preservative or detergent included in the liquid or other composition is a chemical preservative or an oxidative preservative.

In some embodiments, the preservative or detergent included in the liquid or other composition is a preservative or detergent that kills susceptible microbial cells by disrupting the lipid structure of the microbial cell membrane, thereby increasing the permeability of the microbial cell membrane.

In some embodiments, the preservative or detergent included in the liquid or other composition is a preservative or detergent that causes damage to corneal tissues such as corneal epithelium, endothelium, stroma, and contact surfaces such as membranes.

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In some embodiments, the preservative or detergent included in the liquid or other composition is selected from the group consisting of a quaternary ammonium preservative (e.g., benzalkonium chloride (BAC) or cetalkonium chloride), chlorobutanol, edetate disodium (EDTA), polyquaternary-1 (eg, Polyquad™ preservative), stabilized oxidizing agent (eg, stabilized oxychlor complex (eg, Purite™ preservative)), ionic buffered preservative (eg, sofZia™ preservative), tilopaxol and sorbate.

In some embodiments, the liquid is at least substantially free of mucin; or, in other words, has a mucin concentration of less than 0.3% w/v.

In some embodiments, the liquid includes a preservative. In other embodiments, the liquid does not include a preservative (ie, the liquid does not contain a preservative).

In some embodiments, the fluid further includes glycosaminoglycan (GAG), i.e. includes one or more GAGs other than high molecular weight HA; electrolyte (eg sodium chloride); buffer (eg phosphate buffer); or a combination of two or more of the above.

In some embodiments, the severe ocular surface disease is severe keratitis sicca. In other embodiments, the severe ocular surface disease is a severe ocular surface disease other than severe sicca keratitis.

The subject may or may not have keratitis sicca (tear deficiency type or quality sicca type) at the time the fluid is administered to the subject's eye. In some embodiments of therapeutic or prophylactic methods, the eye of the subject to which the fluid is administered does not have tear deficiency (ATD) at the time of fluid administration (ie, in the absence of ATD). In some embodiments of the therapeutic or prophylactic methods, the eye of the subject to which the fluid is administered does not have dry keratitis at the time of administration of the fluid (ie, no dry keratitis). In some embodiments of therapeutic or prophylactic methods, the eye of the subject to which the fluid is administered does not have dry keratitis at the time of fluid administration (ie, in the absence of tear fluid deficiency or high-grade dry keratitis).

In some embodiments of the therapeutic or prophylactic methods, the subject does not suffer from tear volume deficiency; however, the subject has an ocular surface abnormality (topographic abnormality) involving elevations on the cornea or anywhere on the surface of the eye that are not covered by normal tear film (tear film with normal surface tension and viscosity), resulting in areas of friction on the ocular surface (van Setten, Epitheliopathy of the bleb (EoB)-identifying attrition: A new model for failure of glaucoma surgery, New Frontiers in Ophthalmology, 2018: 4(3): 1-4).

This liquid can be used in combination with bandage contact lenses. Thus, the method may further include applying a bandage contact lens to the eye before, during, and/or after administration of the fluid. For example, the liquid may be administered before the bandage contact lenses are applied, after the bandage contact lenses, and/or the liquid is applied to the bandage contact lenses before the bandage contact lenses are applied to the eye. The use of this fluid allows bandage contact lenses to apply pressure to the ocular surface while minimizing friction on the ocular surface. Advantageously, the liquid and band contact lenses can be safely used shortly after eye surgery, such as glaucoma surgery.

Another aspect of the present invention relates to a kit that can be used to carry out the method of the invention described herein, i.e. reducing or delaying the onset of severe ocular surface disease. This kit contains the fluid described herein and one or more bandage contact lenses. The bandage contact lenses may be packaged with the liquid in the same container (with the bandage contact lenses in contact with the liquid), or the bandage contact lenses may be separate from the liquid, packaged in separate containers. Suitable containers include, for example, bottles, vials, syringes, blister packs, etc. These containers can be formed from a number of materials such as glass or plastic.

The kit may include a delivery vehicle (alone or in association with a liquid) that is brought into contact with the ocular surface or other part of the eye. For example, the kit may include particles (eg, microparticles or nanoparticles) that are coated with liquid and/or release liquid onto the ocular surface.

Optionally, the kit may include an eye drop dispensing device (e.g., an eye dropper), which may or may not serve as a container for the liquid in the kit before the kit's outer packaging is accessed (e.g., opened), i.e. e. The eye drop dispensing device may be operated to contain liquid provided in a kit that has not been accessed (unopened) or may be empty

- 8 046057 and take the liquid after accessing the kit. Optionally, the kit may include a label or package insert with printed or digital instructions for using the kit, for example, to carry out a method of the invention.

Kits may include packaging material that is compartmentalized to receive one or more containers, such as vials, tubes, and the like, each container(s) including one of the individual items to be used in the method described herein. Packaging materials for use in packaging pharmaceutical products include, by way of example only, packaging materials according to US Pat. Nos. 5,323,907, 5,052,558, and 5,033,252. Examples of pharmaceutical packaging materials include blister packs, bottles, tubes, pumps, bags, vials, light-tight seal containers , syringes, bottles and any suitable packaging material for, but not limited to, the selected drug and the intended route of administration and treatment.

This kit may include one or more additional containers, each with one or more than one of different commercially and user-desirable materials for use of the compositions described herein. Non-limiting examples of such materials include, but are not limited to, buffers, diluents, carrier, packaging, container, vial and/or tube, labels listing contents and/or instructions for use, and package inserts with instructions for use.

The label may be on or associated with the container. The label may be on the container when the letters, numbers or other characters forming the label are attached, molded or engraved onto the container itself; a label may be associated with a container when it is present within a container or carrier that also contains the container, for example, in the form of a package insert. The label may be used to indicate that the contents are intended for a particular therapeutic use. The label may also provide directions for use of the contents, such as in the methods described herein.

In some embodiments of this kit, the liquid may be present in a package or dispensing device, which may contain one or more unit dosage forms containing the composition disclosed herein. This packaging may, for example, contain metal or plastic foil, such as a blister pack. The package or dosing device may be accompanied by instructions for administration.

Corneal opacity

Severe OSD may involve clouding of the cornea. This liquid can partially or completely increase transparency (reduce cloudiness) and prevent or delay the onset of drying of the ocular surface. Advantageously, this liquid can help avoid the need for a nurse to add water to the eye during an exam or procedure.

Corneal opacities may include complete opacities or partial opacities and may involve the entire ocular surface or part of the ocular surface.

Corneal opacities may have one or more than one of a number of etiological or contributing factors. In some embodiments, corneal opacities are caused by corneal edema, such as edema caused by glaucoma; birth injury or Fuchs' dystrophy.

In some embodiments, corneal opacities are caused by corneal scars.

In some embodiments, corneal opacities include congenital corneal opacities. Congenital corneal opacities can be caused, for example, by birth trauma; Peters anomaly; dermoid tumor (limbal dermoid); sclerocornea; congenital hereditary endothelial dystrophy (CHED); mucopolysaccharidoses; congenital glaucoma, microphthalmia, infection with metabolic disease or inflammation.

In some embodiments, corneal opacification is caused by a lack of blinking. For example, failure to blink may be due to a birth defect in a child who does not have a blink reflex. In some embodiments, the subject has Stevens-Johnson syndrome.

In some embodiments, corneal opacification is caused by inflammation; sensitivity to non-infectious bacteria; eye ulcer; infection; keratitis; trachoma; onchocerciasis (river blindness); dry eye due to Sjögren's syndrome, vitamin A deficiency, LASIK, LASEK or PRK eye surgery; dystrophy (hereditary metabolic disease); keratoconus or eye damage (for example, chemical burn, welding injury, etc.).

It is possible that this fluid may be given in combination with another intervention to treat corneal haze or treatment for the cause of the haze (eg, antibiotic, steroid, phototherapeutic keratectomy (PTK), corneal transplant). Other interventions may occur before, during, or after administration of the fluid. If the other intervention involves the administration of a bioactive agent, the bioactive agent may be included in a liquid or administered in a separate composition through a suitable route for the bioactive agent.

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Acute and chronic inflammation of the ocular surface

Acute or chronic inflammation of the ocular surface can cause or contribute to severe ocular surface disease. Ocular inflammation can take the form of numerous ocular disorders of varying severity, depending on the location of the inflammation. OSDs that can be attributed to ocular inflammation include, but are not limited to, uveitis, conjunctivitis, episcleritis, optic neuritis, retrobulbar neuritis, keratitis, blepharitis, and the like. Many of these conditions may occur secondary to an infection of the eye, such as a bacterial, viral, fungal, or protozoal (eg, amoebic) infection. Ocular inflammation can also occur after ophthalmic surgical procedures or eye trauma resulting from physical damage to the eye.

Inflammation is a normal component of the immune response and a necessary component of the healing process, but is harmful if it occurs at an inappropriate level or for an inappropriate duration. Acute leukocyte inflammation is triggered within hours of exposure to an etiological factor (eg, antigen, ocular wound, or other lesion) and represents a normal, time-limited inflammatory response. The end of this phase varies, but reduced inflammation provides an indirect sign of improvement and slow recovery to the previous state.

In contrast to acute ocular inflammation, chronic ocular inflammation is a condition that is not just quantitatively different in duration (ie, long-lasting), but also qualitatively different in appearance. The differences between acute ocular inflammation and chronic ocular inflammation are significant, similar to the differences between immunological events in acute, healing wounds and chronic, non-healing wounds (see, for example, Tarnuzzer RW and Schultz GS, Biochemical analysis of acute and chronic wound environments, Wound Repair Regen., 1996, Jul-Sep, 4(3):321-325). These differences in immunological events, particularly in conjunctival and subconjunctival tissue (as opposed to the cornea), underlie the diversity of ocular surface disorders and explain why some patients within a population with a disease or disorder are difficult to treat using an otherwise effective plan treatment.

Ocular surface homeostasis is regulated by resident lymphocytes (CD8' T cells, gamma delta cells and natural killer T cells) and CD4+ regulatory T cells, among other factors. They interact with anti-inflammatory factors such as interleukin receptor antagonist (IL)-1, transforming growth factor (TGF)-beta 2 and matrix protease inhibitors such as inhibitor of metalloproteinase (TIMP)-1. Stressors including environmental stimuli, infections, endogenous stress, autoimmunity, and genetic factors can all disrupt the finely tuned homeostatic balance existing at the ocular surface and activate an acute inflammatory response. The method of the invention provides a comprehensive approach for establishing, restoring and maintaining ocular surface homeostasis and thereby attenuating or delaying the onset of severe ocular surface disease. Thus, before or after initiation, topical administration of this fluid may result in attenuation and long-term relief of severe ocular surface disease.

Proinflammatory cytokines of epithelial origin activate immature resident antigen presenting cells (APCs), which are mainly dendritic cells, on the ocular surface. Mature APCs migrate to regional lymph nodes and initiate the adaptive immune response by priming naïve CD4+ T cells, including T helper (Th)1 and Th17 cells. Through activated angiogenesis and lymphangiogenesis, these inflammatory mediators are transported back to the ocular surface, where increased production of cytokines: Th1-secreted interferon (III)-gamma and Th17-secreted IL-17 (interleukin-17) induces apoptosis of epithelial and goblet cells and alters conjunctival homeostasis, maintaining chronic inflammatory process. In a state of goblet cell deficiency, depletion of gel-forming mucins leads to increased friction, thus perpetuating inflammation (Pflugfelder SC et al., Epithelial-immune cell interaction in dry eye, Cornea, 2008, 27 Suppl 1:S9-11).

While acute inflammation of the ocular surface is characterized by a rapid onset and relatively short duration (typically from a few minutes to many days), proteinaceous exudate and cellular infiltrate of the conjunctival and subconjunctival tissue, representing mainly neutrophils, chronic inflammation of the ocular surface is characterized by a longer duration. duration (from many days to years), fewer neutrophils, cellular infiltrate, consisting mainly of macrophages and lymphocytes, proliferation of blood vessels, fibrosis and tissue necrosis. Indeed, the primary cells of chronic inflammation of the ocular surface are macrophages and lymphocytes on the conjunctiva and subconjunctiva.

Typically, chronic ocular surface inflammation may also be identified by markers of ocular surface inflammation including one or more of the following: tear film hyperosmolarity; increased expression of matrix metalloproteinase-9 (MMP-9) epithelium

- 10 046057 lyal cells and infiltrating leukocytes on the ocular surface; increased activity of MMP-9 on the ocular surface (its enzymatic activity mediated by MMP-3 and TIMP-1); increased levels of interferon-gamma; overexpression of human leukocyte antigen-related antigen D (HLA-DR) by conjunctival epithelial cells; and intracellular adhesion molecule 1 (ICAM-1) by conjunctival epithelial cells, increased numbers of activated lymphocytes and decreased numbers of goblet cells.

Steroids (eg, corticosteroids) are considered the gold standard treatment for ocular inflammation. Commonly used drugs include dexamethasone, prednisolone, triamcinolone acetonide, fluocinolone acetonide, and loteprednol etabonate, which act through different mechanisms, such as inhibition of many inflammatory cytokines, fibrin deposition, polymorphonuclear leukocyte migration, and antiangiogenic effects through inhibition of the nuclear factor kappa B (NF-κB) signaling pathway. (Nakao et al., Am J Pathol. 2007; 171(3):1058-65).

It is believed that the anti-inflammatory effect of steroids is due to an interfering effect on the metabolism of arachidonic acid, i.e. through inhibition of phospholipase A2, which causes the release of arachidonic acid from the tissue phospholipid pool. Although steroids are effective in treating ocular inflammation, their long-term use is hampered by severe side effects, the most common of which are cataract formation, glaucoma, and eye infections (Kymionis GD et al., Treatment of chronic dry eye: treatment of cyclosporine , Clin Ophthalmol. 2008 Dec; 2(4): 829-836; Schultz C, Safety and efficacy of cyclosporine in the treatment of chronic dry eye, Ophthalmol Eye Dis. 2014; 6: 37-42). Likewise, immunomodulatory drugs such as cyclosporine and anti-inflammatory drugs such as tetracycline and its derivatives may cause ocular pain and irritation in some patients (eg, burning and itching) that may be difficult to tolerate in the inflamed eye.

Advantageously, local administration of high molecular weight hyaluronic acid (HA), e.g. 3-4 MDa, can be used as an effective natural immunomodulator to restore ocular surface immune homeostasis in groups of patients with chronic ocular surface inflammation or seasonal allergic keratoconjunctivitis, without the above-mentioned agents or their side effects. effects. In particular, the liquids of the invention can be used to restore ocular surface immune homeostasis in these patients. In addition, other immunomodulatory agents may be administered to the subject before, during, or after administration of the high molecular weight HA, and the high molecular weight HA may make the ocular surface environment more conducive to the activity of the immunomodulatory agent, enhancing or facilitating the action of the immunomodulatory agent.

The influence of the molecular weight of HA molecules in eye drops on their biochemical function has recently become the focus of ophthalmic research. Because of its function in the extracellular matrix, NA plays an important role in keratinocyte proliferation and differentiation, corneal wound healing, and corneal epithelial homeostasis. The predominance of dry keratitis in older people is probably associated with a significant decrease in free NA in the extracellular matrix, starting from the age of forty years. In addition, NA acts as a signaling molecule. While high molecular weight HA (3-4 MDa) is antiangiogenic and immunosuppressive, mid-molecular weight HA has inflammatory, immunostimulatory, and antiangiogenic properties (Stern R et al., Hyaluronan fragments: An information-rich system, European Journal of Cell Biology, 2006, 85:699715; and Noble PW, Hyaluronan and its catabolic products in tissue injury and repair, Matrix Biology, 2002, 21:25-29). Elevated levels of the enzyme in chronic inflammation cause increased hydrolysis of HA and thus a shift to a lower molecular weight. High molecular weight NA in eye drops may help minimize this inflammation-related shear by reducing friction on the ocular surface and supporting down-regulation of the inflammatory process. Reduced friction may also result in a reduction in nociceptive neurogenic stimuli that may trigger the maintenance or initiation of pathways that support neurogenic inflammation.

It is well known that during acute and chronic inflammation, various putative inflammatory mediators are released by inflamed tissues and leukocytes. The concentrations of these mediators and leukocytes indicate the level or degree of inflammation. Likewise, a decrease in the concentration of these mediators and leukocytes is an indication of the effectiveness of the drug in treating inflammation. Examples of ocular surface inflammatory markers include those listed above, i.e. hyperosmolarity of the tear film; increased expression of matrix metalloproteinase-9 (MMP-9) by epithelial cells and infiltrating leukocytes on the ocular surface; increased activity of MMP-9 on the ocular surface (its enzymatic activity mediated by MMP-3 and TIMP-1); increased levels of interferon-gamma; overexpression of human leukocyte antigen-related antigen D (HLA-DR) by conjunctival epithelial cells; and intracellular adhesion molecule 1 (ICAM-1) by conjunctival epithelial cells, but are not limited to increased numbers of activated lymphocytes and decreased numbers of goblet cells.

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Optionally, before administering the fluid of the invention, the method of the invention may further include identifying the subject/eye as having chronic ocular surface inflammation by detecting or measuring one or more of these ocular surface inflammatory markers. Optionally, the method may further include detecting or measuring one or more of these ocular surface inflammatory markers one or more times after administration of a fluid of the invention in order to monitor the inflammatory status of the eye(s) over time and control the frequency and the duration of further administration of the liquid according to the invention.

Liquid preparation

As stated above, the hyaluronic acid of this liquid has an intrinsic viscosity of more than 2.5 m ³ /kg and a concentration of less than 0.2% w/v. In some embodiments, the hyaluronic acid has an intrinsic viscosity greater than 2.9 m ³ /kg.

Viscoelasticity is defined as the characteristics of a fluid that has both viscous and elastic properties. Zero shear viscosity is defined as a stable plateau of shear viscosity with a vanishing shear rate. For highly viscous drugs, measurement with a voltage-controlled rheometer is preferred.

The relationship between molecular weight and intrinsic viscosity [η] in m ³ /kg is given by the Mark-Houwink equation:

[q] = K (M _rm ) ^a where M _rm represents the molecular weight in MDa and the coefficients k = 1.3327 10' ⁴ and a = 0.6691 whose values for k and a were found to be the most predictive.

This liquid can be obtained through the following operations: sterilization of the filling line; adding purified water or water for injection (WFI) to a stainless steel mixing container; adding salts while stirring; slowly add HA and stir until a homogeneous solution/liquid is achieved; adjusting the pH value by adding NaOH or HCl, if necessary, while continuing the mixing process; transfer of the solution through a filter cartridge with a pore size of 1 micron into a sterile storage container; and aseptic filling of the solution by sterilizing filtration into a sterile primary container (monodose or vial). In the case of monodoses, this can be accomplished through the blow-fill-seal (BFS) method.

Preferably, the liquid is at least substantially free of mucin or, in other words, has a mucin concentration of less than 0.3% w/v. This means that the flow characteristics or properties are essentially achieved or corrected by the hyaluronan, rather than the mucin, naturally present in the subject's tear fluid and are primarily responsible for its flow characteristics.

It is preferable that when adding substances that increase viscosity, they are added closer to either during or as a final step. Mixing is carried out in such a way as to achieve a homogeneous mixture. Alternatively or additionally, it is preferable to initially provide purified water or water for injection as a base and then optionally add electrolytes, buffers and substances that do not increase viscosity first to the purified water or water for injection.

HA is further described in the monograph European Pharmacopoeia 9.0, page 3583 (sodium hyaluronate), which is incorporated herein by reference in its entirety.

In one embodiment, the liquid used in the method and kit of the invention has the characteristics listed in table. 2:

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table 2

Characteristic Specification Method of analysis Appearance Transparent and colorless solution containing no visible impurities Ph.Eur. pH value 6.8-7.6 Ph.Eur. Osmolality 240 - 330 mOsmol/kg Ph.Eur. NA concentration 0.10 - 0.19% w/v. Ph.Eur. NaCI concentration 7.6-10.5 g/l Ph.Eur. Sterility Sterile Ph.Eur. Phosphate concentration 1.0-1.4 mmol/l Ph.Eur.

Illustrated by examples of implementation:

Embodiment 1. A method for attenuating or delaying the onset of a severe ocular surface disease, comprising topically administering a liquid containing high molecular weight hyaluronic acid to the ocular surface of the eye of a human or non-human subject, wherein the hyaluronic acid has an intrinsic viscosity greater than 2.5 ^m3 /kg and a concentration of less than 0.2% w/v.

Embodiment 2. The method of embodiment 1, wherein the liquid is administered prophylactically before severe ocular surface disease occurs.

Embodiment 3. The method of Embodiment 2, wherein the subject at the time of administration has a mild or moderate ocular surface disease, and the liquid is administered prophylactically to prevent or delay the progression of the ocular surface disease to a state of severe ocular surface disease.

Embodiment 4. The method of embodiment 1, wherein the liquid is administered therapeutically after the occurrence of a severe ocular surface disease.

Embodiment 5. The method according to any one of embodiments 1-4, wherein the severe ocular surface disease has one or more of the following characteristics: leukocyte invasion on the ocular surface and tears, up-regulation of CD44 on the ocular surface, and activation of an immune cascade that includes one or more than one of the following: IL-1, IL-2, IL-5, IL-6, IL-8, CXCL8, IL-10, IL-12, IL-16, IL-33, MCP1, CCL2, MIP1d (also known as CCL15), ENA-78, CXCL5, sILR1, sIL-6R, sgp sEGFR, sTNFR, I-17A, IL-21, IL-22, CXCL9, MIG, CXCL11, I-TAC, CXCL10, IP- 10, MIP-ίβ, CCL4, RANTES and CCL5.

Embodiment 6. The method of any one of embodiments 1-5, wherein the severe ocular surface disease is caused by an external stimulus resulting from disruption of the smoothness and/or integrity of the ocular surface (e.g., medical therapy, ocular surgery, non-surgical trauma, contact lens wear, infection (eg, bacterial, viral or fungal), allergen, hapten, toxic agent or irritant).

Embodiment 7. The method of any one of embodiments 1-5, wherein the severe ocular surface disease is caused by an internal stimulus (eg, a hormonal disorder, a rheumatic disease, epithelial-mesenchymal transition (EMT), or an autoimmune disease).

Embodiment 8. The method according to any one of embodiments 1-7, wherein the severe ocular surface disease is caused by an eye wound.

Embodiment 9. The method of embodiment 8, wherein the wound is caused by physical trauma, chemical trauma, or radiation (radiation damage).

Embodiment 10. The method of embodiment 8, wherein the wound is caused by eye surgery.

Embodiment 11. The method of embodiment 10, wherein the ocular surgery is selected from natural or artificial corneal transplantation, corneal implantation (eg, intracorneal rings (ICR) and keratoprosthesis), glaucoma surgery, cataract surgery (eg, phacoemulsification, extracapsular cataract surgery, or intracapsular surgery), refractive surgery (eg, radial keratotomy or refractive corneal incision), retinal surgery, strabismus surgery, laser vision correction surgery (eg, laser-assisted in situ keratomileusis (LASIK) or photorefractive keratectomy (PRK) ), and stitching surgery.

Embodiment 12. The method according to any of embodiments 1-11, wherein severe ocular surface disease is accompanied by acute inflammation of the ocular surface.

Embodiment 13. The method according to any of embodiments 1-11, wherein severe ocular surface disease is accompanied by chronic inflammation of the ocular surface.

Embodiment 14. The method according to any one of embodiments 1-6, wherein the severe ocular surface disease is an ocular allergy.

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Embodiment 15. The method of any one of embodiments 1-6, wherein the severe ocular surface disease is severe allergic keratoconjunctivitis (eg, seasonal or non-seasonal) that causes one or more of the following in the subject: ocular pain; visual impairment; acute loss of tissue homeostasis due to dysfunction of the normal regulatory mechanism that maintains cellular hydration in the tissues around the eye; and release of IgE and histamine.

Embodiment 16. The method according to any one of embodiments 1-15, wherein the severe ocular surface disease includes corneal opacification.

Embodiment 17. The method of Embodiment 16, wherein the corneal opacification is caused by corneal edema.

Embodiment 18. The method of embodiment 17, wherein corneal edema is caused by trauma; glaucoma; birth injury or Fuchs' dystrophy.

Embodiment 19. The method of embodiment 17, wherein corneal edema is caused by corneal scars.

Embodiment 20. The method of embodiment 16, wherein the corneal opacification includes congenital corneal opacities.

Embodiment 21. The method according to embodiment 16 or 20, wherein the corneal opacification is caused by a birth injury; Peters anomaly; dermoid tumor (limbal dermoid); sclerocornea; congenital hereditary endothelial dystrophy (CHED); mucopolysaccharidoses; congenital glaucoma, microphthalmia, infection with metabolic disease or inflammation.

Embodiment 22. The method of embodiment 16, wherein the corneal opacification is caused by a lack of blinking (eg, due to a birth defect in a child without a blink reflex).

Embodiment 23. The method of embodiment 16, wherein the subject has Stevens-Johnson syndrome.

Embodiment 24. The method of embodiment 16, wherein corneal opacification is caused by inflammation; sensitivity to non-infectious bacteria; ulcer on the eye; infection; keratitis; trachoma; onchocerciasis (river blindness); dry eye due to Sjögren's syndrome, vitamin A deficiency, LASIK, LASEK or PRK eye surgery; dystrophy (hereditary metabolic disease); keratoconus or eye damage (for example, chemical burn, welding injury, etc.).

Embodiment 25. The method of embodiment 16, wherein the fluid is administered in combination with another intervention to treat corneal opacities or treat the cause of the opacities (eg, antibiotic, steroid, phototherapeutic keratectomy (PTK), corneal transplant).

Embodiment 26. The method of any one of embodiments 1-25, wherein the severe ocular surface disease causes discomfort such as itching or ocular pain.

Embodiment 27. The method of any one of embodiments 1-26, wherein the subject is immunocompromised.

Embodiment 28. The method of any one of embodiments 1-27, wherein the liquid does not contain another bioactive agent (eg, does not contain a hydrophobic active ingredient).

Embodiment 29. The method of any one of embodiments 1-28, wherein the liquid does not contain another immunomodulatory agent, immunosuppressive agent or antibiotic.

Embodiment 30. The method of any one of embodiments 1-27, wherein the liquid further comprises a bioactive agent (eg, a hydrophobic active ingredient).

Embodiment 31. The method of embodiment 30, wherein the bioactive agent is irritating or damaging to the eye.

Embodiment 32. The method according to any of embodiments 1-27, 29, 30 or 31, wherein the liquid further contains a preservative or detergent.

Embodiment 33. The method of embodiment 32, wherein the preservative or detergent is irritating or damaging to the eye.

Embodiment 34. The method of any one of embodiments 1-33, wherein the liquid is administered before, during and/or after administration of a composition containing: a bioactive agent (eg, a hydrophobic active ingredient), a preservative, a detergent, or a combination of two or more from those described above.

Embodiment 35. The method of embodiment 34, wherein the bioactive agent, preservative, detergent, or combination is irritating or damaging to the eye.

Embodiment 36. The method of any one of embodiments 32-35, wherein the preservative or detergent is a chemical preservative or an oxidative preservative.

Embodiment 37. The method of any one of embodiments 32-36, wherein the preservative or detergent is a preservative or detergent that kills sensitive microbial cells by disrupting the lipid structure of the microbial cell membrane, thereby increasing the permeability of the microbial cell membrane.

Embodiment 38. The method of any one of embodiments 32-37, wherein the preservative or detergent is a preservative or detergent that causes damage to corneal tissue.

Embodiment 39. The method of any one of embodiments 32-38, wherein the preservative or detergent is selected from the group consisting of a quaternary ammonium preservative (for example, benzalkonium chloride

- 14 046057 (BAK)), chlorobutanol, edetate disodium (EDTA), polyquaternary-1 (e.g. Polyquad™ preservative), stabilized oxidizing agent (e.g. stabilized oxychlor complex (e.g. Purite™ preservative)), ionic buffered preservative (e.g. sofZia™ preservative), polyhexamethylene biguanide (PHMB), sodium perborate (e.g. GenAqua™ preservative) and sorbate.

Embodiment 40. The method of any one of embodiments 1-39, wherein the liquid is administered directly to the ocular surface in the form of drops or as a wash (eg, lavage).

Embodiment 41. The method according to embodiment 40, in which 1 to 3 drops are administered 1 to 3 times a day.

Embodiment 42. The method according to any one of embodiments 1-40, wherein severe ocular surface disease is accompanied by chronic inflammation of the ocular surface, and wherein 1 to 3 drops are administered 4, 5, 6, 7, 8, 9 or 10, or more 10 times a day.

Embodiment 43. The method of any one of embodiments 1 to 39, wherein the liquid is administered to the ocular surface indirectly through a delivery agent (liquid delivery agent) that is topically administered to the ocular surface or another part of the eye (for example, a particle that is coated with the liquid and /or secretes this fluid onto the ocular surface).

Embodiment 44. The method according to any of embodiments 1-43, wherein the hyaluronic acid has an intrinsic viscosity greater than 2.9 m ³ /kg.

Embodiment 45. The method according to any of embodiments 1-27, wherein the liquid further contains a preservative.

Embodiment 46. The method of any one of embodiments 1-27, wherein the liquid further does not contain a preservative (ie, the liquid is devoid of a preservative).

Embodiment 47. The method of any one of embodiments 1-27, wherein the liquid further comprises an additional glycosaminoglycan (GAG), an electrolyte (eg, sodium chloride), a buffer (eg, phosphate buffer), or a combination of two or more of the above.

Embodiment 48. The method of any one of embodiments 1-47, wherein the subject's eye does not have tear deficiency (ATD) at the time of said administration (ie, in the absence of ATD).

Embodiment 49. The method of any one of embodiments 1-48, wherein the subject's eye does not have high-grade dry keratitis at the time of said administration (ie, in the absence of high-quality dry keratitis).

Embodiment 50. The method of any one of embodiments 1-49, wherein the subject's eye does not have dry keratitis at the time of said administration (ie, in the absence of tear deficiency or high-grade dry keratitis).

Embodiment 51. The method of any one of embodiments 1-50, wherein the subject does not suffer from tear deficiency (ATD), and wherein the subject has an ocular surface abnormality (topographic abnormality) including elevations on the cornea or elsewhere on the ocular surface that is not covered by normal tear film (tear film with normal surface tension and viscosity), resulting in areas of friction on the ocular surface, and where the injected fluid reduces this friction.

Embodiment 52. The method of any one of embodiments 1-51, wherein the subject's eye is in homeostasis on the ocular surface during said administration.

Embodiment 53. The method of any one of embodiments 1-52, further comprising applying a bandage contact lens to the eye before, during or after said administration.

Embodiment 54. The method of Embodiment 53, wherein the liquid is administered and bandage contact lenses are applied after eye surgery.

Embodiment 55. The method according to any of embodiments 1-54, in which the introduced liquid increases the visual performance of the eye.

Embodiment 56. The method of Embodiment 54, wherein the fluid is administered before, during, and/or after eye surgery, and wherein the subject recovers visual performance after eye surgery (i.e., recovers greater visual performance after eye surgery than this the subject would have had in the absence of administration of this fluid).

Embodiment 57. The method of any one of embodiments 1-56, wherein the hyaluronic acid has a molecular weight of at least 3 million Daltons.

Embodiment 58. The method of any one of embodiments 1-57, wherein the hyaluronic acid has a molecular weight in the range of 3 million to 4 million Daltons.

Embodiment 59. A kit comprising: the liquid of any of embodiments 1-48 and one or more bandage contact lenses.

The present invention also relates to a liquid (topical liquid) for local administration to the ocular surface.

Embodiment 60. A liquid for use in reducing or delaying the onset of severe ocular surface disease, wherein the liquid contains high molecular weight hyaluronic acid having an intrinsic viscosity of greater than 2.5 m ³ /kg and a concentration of less than 0.2% w/v, and wherein the liquid is topically administered to the ocular surface of the eye of a human subject or non-human animal subject.

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Embodiment 61. The liquid of embodiment 60, wherein the liquid is administered prophylactically before severe ocular surface disease occurs.

Embodiment 62. The liquid of embodiment 61, wherein at the time of administration the subject has mild or moderate ocular surface disease, and the liquid is administered prophylactically to prevent or delay the progression of the ocular surface disease to a state of severe ocular surface disease.

Embodiment 63. The liquid of embodiment 60, wherein the liquid is administered therapeutically following the occurrence of a severe ocular surface disease.

Embodiment 64. The liquid according to any one of embodiments 60-63, wherein the severe ocular surface disease has one or more of the following characteristics: invasion of leukocytes on the ocular surface and tears, upregulation of CD44 on the ocular surface, and activation of an immune cascade that includes one or more more than one of the following: IL-1, IL-2, IL-5, IL-6, IL-8, CXCL8, IL-10, IL-12, IL-16, IL-33, MCP1, CCL2, MIP1d ( also known as CCL15), ENA-78, CXCL5, sILR1, sIL-6R, sgp sEGFR, sTNFR, I-17A, IL-21, IL-22, CXCL9, MIG, CXCL11, I-TAC, CXCL10, IP-10 , MP-Τβ, CCL4, RANTES and CCL5.

Embodiment 65. The liquid of any one of embodiments 50-63, wherein severe ocular surface disease is caused by an external stimulus resulting in disruption of the smoothness and/or integrity of the ocular surface (e.g., medical therapy, ocular surgery, non-surgical trauma, contact lens wear, microbial infection, allergen, hapten, toxic agent or irritant).

Embodiment 66. The liquid according to any one of embodiments 60-64, wherein the severe ocular surface disease is caused by an internal stimulus (eg, a hormonal disorder, a rheumatic disease, epithelial-mesenchymal transition (EMT), or an autoimmune disease).

Embodiment 67. The liquid according to any one of embodiments 60-65, wherein severe ocular surface disease is caused by an eye injury.

Embodiment 68. The liquid of embodiment 67, wherein the wound is caused by physical trauma, chemical trauma, or radiation (radiation damage).

Embodiment 69. The liquid of embodiment 67, wherein the wound is caused by eye surgery.

Embodiment 70. The liquid of embodiment 69, wherein the ocular surgery is selected from natural or artificial corneal transplantation, corneal implantation (eg, intracorneal rings (ICR) and keratoprosthesis), glaucoma surgery, cataract surgery (eg, phacoemulsification, extracapsular cataract surgery, or intracapsular surgery ), refractive surgery (eg, radial keratotomy or refractive corneal incision), retinal surgery, strabismus surgery, laser vision correction surgery (eg, laser-assisted in situ keratomileusis (LASIK) or photorefractive keratectomy (PRK)) and stitching surgery.

Embodiment 71. The liquid according to any one of embodiments 60-63, wherein severe ocular surface disease is an acute inflammation of the ocular surface.

Embodiment 72. The liquid according to any one of embodiments 60-70, wherein severe ocular surface disease is accompanied by chronic inflammation of the ocular surface.

Embodiment 73. The liquid according to any one of embodiments 60-52, wherein the severe ocular surface disease is an ocular allergy.

Embodiment 74. The liquid according to any one of embodiments 60-64, wherein the severe ocular surface disease is severe allergic keratoconjunctivitis (eg, seasonal or non-seasonal) that causes one or more of the following in the subject: ocular pain; visual impairment; acute loss of tissue homeostasis due to dysfunction of the normal regulatory mechanism that maintains cellular hydration in the tissues around the eye; and release of IgE and histamine.

Embodiment 75. The liquid of any one of embodiments 60-65, wherein the severe ocular surface disease causes discomfort such as itching or ocular pain.

Embodiment 76. The liquid of any one of embodiments 60-65, wherein the liquid is administered prophylactically to prevent or delay the onset of severe ocular surface disease, and where the subject is immunocompromised.

Embodiment 77. The liquid of any one of embodiments 60-66, wherein the liquid does not contain another bioactive agent (eg, does not contain a hydrophobic active ingredient).

Embodiment 78. The liquid of any one of embodiments 60-67, wherein the liquid does not contain another immunomodulatory agent, immunosuppressive agent, or antibiotic.

Embodiment 79. The liquid of any one of embodiments 60-68, wherein the liquid further comprises a bioactive agent (eg, a hydrophobic active ingredient).

Embodiment 80. The liquid of embodiment 79, wherein the bioactive agent is irritating or damaging to the eye.

Embodiment 81. The liquid according to any of embodiments 60-64, where the liquid further contains a preservative or detergent.

Embodiment 82. The liquid of embodiment 81, wherein the preservative or detergent is an irritant.

- 16 046057 harmful or damaging to the eye.

Embodiment 83. The liquid of any one of embodiments 60-64, wherein the liquid is administered before, during and/or after administration of a composition comprising: a bioactive agent (eg, a hydrophobic active ingredient), a preservative, a detergent, or a combination of two or more of the above.

Embodiment 84. The liquid of embodiment 83, wherein the bioactive agent, preservative, detergent, or combination is irritating or damaging to the eye.

Embodiment 85. The liquid of embodiment 81, wherein the preservative or detergent is a chemical preservative or an oxidative preservative.

Embodiment 86. The liquid of embodiment 81, wherein the preservative or detergent is a preservative or detergent that kills sensitive microbial cells by disrupting the lipid structure of the microbial cell membrane, thereby increasing the permeability of the microbial cell membrane.

Embodiment 87. The liquid of embodiment 81, wherein the preservative or detergent is a preservative or detergent that causes damage to corneal tissue.

Embodiment 88. The liquid of embodiment 82, wherein the preservative or detergent is selected from the group consisting of a quaternary ammonium preservative (e.g., benzalkonium chloride (BAC)), chlorobutanol, edetate disodium (EDTA), polyquaternary-1 (e.g., Polyquad™ preservative ), a stabilized oxidizing agent (e.g., stabilized oxychlor complex (e.g., Purite™ preservative)), an ionic buffered preservative (e.g., sofZia™ preservative), polyhexamethylene biguanide (PHMB), sodium perborate (e.g., GenAqua™ preservative), and sorbate.

Embodiment 89. The liquid of any one of embodiments 60-63, wherein the liquid is administered directly to the ocular surface in the form of drops or as a wash.

Embodiment 90. Liquid according to embodiment 89, where 1 to 3 drops are administered, 1 to 3 times a day.

Embodiment 91. The liquid according to any one of embodiments 60-63, wherein the inflammation is a chronic inflammation of the ocular surface, and wherein 1 to 3 drops are administered 4, 5, 6, 7, 8, 9 or 10, or more than 10 times per day .

Embodiment 92. The liquid of any one of embodiments 60-63, wherein the liquid is directly administered to the ocular surface via a delivery agent that is administered topically to the ocular surface or other part of the eye (e.g., a particle that is coated with liquid and/or secretes liquid onto the ocular surface ).

Embodiment 93. The liquid according to any of embodiments 60-63, wherein the hyaluronic acid has an intrinsic viscosity greater than 2.9 m ³ /kg.

Embodiment 94. The liquid according to any of embodiments 60-63, where the liquid further contains a preservative.

Embodiment 95. The liquid of any one of embodiments 60-63, wherein the liquid further does not contain a preservative (ie, the liquid is devoid of a preservative).

Embodiment 96. The liquid of any one of embodiments 60-63, wherein the liquid further comprises an additional glycosaminoglycan (GAG), an electrolyte (eg, sodium chloride), a buffer (eg, phosphate buffer), or a combination of two or more of the above.

Embodiment 97. The fluid of any one of embodiments 60-63, wherein the subject's eye does not have tear deficiency (ATD) at the time of said administration (ie, in the absence of ATD).

Embodiment 98. The liquid according to any one of embodiments 60-63, wherein the subject's eye does not have high-grade dry keratitis at the time of said administration (ie, in the absence of high-quality dry keratitis).

Embodiment 99. The fluid of any one of embodiments 60-63, wherein the subject's eye does not have dry keratitis at the time of said administration (ie, in the absence of tear fluid deficiency or high-grade dry keratitis).

Embodiment 100. The fluid of any one of embodiments 60-63, wherein the subject does not suffer from tear deficiency (ATD), and where the subject has an ocular surface abnormality (topographic abnormality) including elevations on the cornea or elsewhere on the ocular surface that are not covered by the normal tear film (tear film with normal surface tension and viscosity), resulting in areas of friction on the ocular surface, and where the injected fluid reduces this friction.

Embodiment 101. The liquid of any one of embodiments 60-63, wherein the subject's eye is in homeostasis on the ocular surface during said administration.

Embodiment 102. The liquid of any one of embodiments 60-63, further comprising applying a bandage contact lens to the eye before, during or after said administration.

Embodiment 103. The liquid of embodiment 102, wherein the liquid is administered and bandage contact lenses are applied after eye surgery.

Embodiment 104. The liquid according to any of embodiments 60-63, where the injected liquid increases the visual performance of the eye.

- 17 046057

Embodiment 105. The fluid of embodiment 104, wherein the fluid is administered before, during and/or after ocular surgery, and wherein the subject is restored to visual performance after ocular surgery.

Embodiment 106. The liquid according to any one of embodiments 60-105, wherein the hyaluronic acid has a molecular weight of at least 3 million Daltons.

Embodiment 107. The liquid according to any one of embodiments 60-106, wherein the hyaluronic acid has a molecular weight in the range of 3 million to 4 million Daltons.

Definitions

The singular and similar terms used in the context of the present invention (especially in the context of the claims) should be construed to cover both the singular and plural unless otherwise indicated herein or they are clearly inconsistent with the context. Thus, for example, a reference to a cell or connection should be construed to include both one cell or one connection and a plurality of cells and multiple connections unless otherwise indicated or the context clearly contradicts it. Likewise, what a word or includes is implied unless the context clearly indicates otherwise. Abbreviation e.g. is used herein to indicate a non-limiting example. Thus, reducing e.g. is synonymous with the term e.g.

The term effective amount, in the context of an administered fluid of the invention, means the amount of fluid required to produce a desired result, such as reducing or eliminating severe ocular surface disease, or reducing or eliminating mild to moderate ocular surface disease and preventing or delaying progression to severe ocular surface disease. In some embodiments, an effective amount may be an amount capable of preventing, delaying the onset of, treating, or ameliorating a severe ocular surface disease, or otherwise capable of producing the intended therapeutic effect.

The term isolated, when used as a composition modifier, means that the compositions are obtained through human intervention or isolated from the environment in which they occur naturally in vivo. In general, compositions so separated are substantially free of one or more substances with which they are typically associated in nature, eg, one or more than one protein, nucleic acid, lipid, carbohydrate, cell membrane. A substantially pure molecule may be combined with one or more other molecules. Thus, the term substantially pure does not exclude combinations of compositions. Substantial purity may be at least about 60% or more of the molecule by weight. The purity may also be about 70% or 80% or more, and may be greater, such as 90% or more. Purity can be determined by any suitable method, including, for example, UV (ultraviolet) spectroscopy, chromatography (for example, HPLC (gas phase), gel electrophoresis (for example, with silver or Coomassie staining) and sequence analysis (for nucleic acid and peptide).

The term homeostasis, as used herein, refers to the ability of a physiological system to maintain internal stability, or a state of stability itself, through the coordinated response of its parts to any situation or stimulus that would tend to disrupt its normal, non-pathological state or function.

The term hyaluronic acid (HA), as used herein, refers to a glycosaminoglycan composed of disaccharide repeats of N-acetylglucosamine and glucuronic acid found in nature, also known as hyaluronan (e.g., a straight-chain glycosaminoglycan polymer consisting of repeating units of the disaccharide [-Dglucuronic acid-YD-N-acetyl-O-glucosamine-YD-SH], as well as to hyaluronan derivatives having chemical modifications, such as hyaluronan esters, amide derivatives, aclylamine derivatives, low-molecular and high-molecular forms of hyaluronans , and cross-linked forms such as hylans. Thus, a given disaccharide chain may be linear or nonlinear. Hyaluronan can be cross-linked through the addition of cross-linking agents such as thiols, methacrylates, hexadecylamides and tyramines. Hyaluronan can also be directly cross-linked using formaldehyde and divinyl sulfone. Examples of hylans include hylan A (formaldehyde cross-linked glycosaminoglycan polymer), hylan B (divinyl sulfone cross-linked glycosaminoglycan polymer) and hylan C-F 20 (Cowman M.K. et al., Carbohydrate Polymers 2000, 41:229-235; Takigami S. et al., Carbohydrate Polymers, 1993, 22:153-160; Balazs E.A. et al., Hyaluronan, its cross-linked derivative-Hylan-and their medical applications, in Cellulosics Utilization: Research and Rewards in Cellulosics, Proceedings of Nisshinbo International Conference on Cellulosics Utilization in the Near Future (Eds Inagaki, H and Phillips GO), Elsevier Applied Science (1989), NY, pp.233-241; Koehler L. et al., Scientific Reports, 2017, 7, article no. 1210 and Pavan M et al., Carbohydr Polym, 2013, 97(2): 321-326, each of which is incorporated herein by reference in its entirety).

- 18 046057

The term hyaluronic acid or HA includes HA itself and its pharmaceutically acceptable salts. HA can be prepared in the forms of pharmaceutically acceptable salts. Pharmaceutically acceptable HA salts can be prepared using conventional techniques.

The term high molecular weight or HMW in the context of the hyaluronic acid of the invention refers to hyaluronic acid having an intrinsic viscosity greater than 2.5 m ³ /kg when determined by the method of European Pharmacopoeia 9.0, Sodium Hyaluronate, page 3584 (which is incorporated herein by reference in its entirety ). Briefly, the intrinsic viscosity [η] is calculated by linear least squares regression analysis using the Martin equation: Log1o(n _r -1/c)=log1o[n]+k[n]c. In some embodiments, the high molecular weight hyaluronic acid has an intrinsic viscosity greater than 2.9 m ³ /kg.

The term immunocompromised as used herein refers to a subject with a congenital, acquired or induced inability to mount a normal immune response. An immunocompromised subject therefore has a weakened or impaired immune system relative to one normal subject. A subject with a weakened or impaired immune system has an immunodeficiency or state of weakened immunity that is associated with a primary or secondary deficiency, induced or non-induced, in one or more than one element of the normal immune defense system. The immunocompromised state may be caused by medical treatment, for example, radiation therapy, chemotherapy or other immunosuppressive treatment, such as induced by treatment with steroids, cyclophosphamide, azathioprine, methotrexate, cyclosporine or rapamycin, particularly in connection with cancer treatment or treatment, or preventing transplant rejection. The presence of an immunocompromised state in a subject can be diagnosed by any suitable technique known to those skilled in the art. Strong indicators that an immunocompromised state may be present are when rare diseases occur or the subject becomes ill from organisms that do not normally cause disease, especially if the subject is infected repeatedly. Typically other possibilities such as newly acquired infections such as HIV (human immunodeficiency virus), hepatitis, tuberculosis, etc. are considered. Typically, however, evidence-based diagnoses rely on laboratory tests to determine the exact nature of the immunocompromised condition. Most tests are performed on blood samples. Blood contains antibodies, lymphocytes, phagocytes, and complement components, all of the major immune components that can cause immunodeficiency. A blood test can be used to determine whether the number of phagocytic cells or lymphocytes is below normal. Fewer than normal numbers of either of these two cell types correlate with a state of weakened immunity. Blood cells are also typically checked for their appearance. Sometimes a subject may have a normal number of cells, but the cells are structurally defective. When the lymphocyte count is low, additional testing is usually done to determine whether the level of any particular type of lymphocyte is less than normal. Lymphocyte proliferation assays can be performed to determine whether lymphocytes can respond to stimuli. Failure to respond to stimulants correlates with a state of weakened immunity. Antibody levels and complement levels can also be determined to diagnose the presence of an immunocompromised condition.

The term ocular surface as used herein refers to the cornea, conjunctiva and parts thereof, including the conjunctiva covering the upper and lower eyelids. The liquid may be administered topically to one or more parts of the ocular surface, including, for example, the entire ocular surface.

The term pharmaceutically acceptable salt includes both acid addition salts and base addition salts. A pharmaceutically acceptable salt of HA or any of the other compounds described herein is intended to include any and all pharmaceutically acceptable salt forms. Preferred pharmaceutically acceptable salts described herein are pharmaceutically acceptable acid addition salts and pharmaceutically acceptable base addition salts.

The term pharmaceutically acceptable acid addition salt refers to those salts that retain the biological effectiveness and properties of free bases that are neither biologically nor otherwise undesirable and that are formed with inorganic acids such as hydrochloric acid, hydrobromic acid, sulfuric acid, nitric acid acid, phosphoric acid, hydroiodic acid, hydrofluoric acid, phosphoric acid and the like. Also included are salts which are formed with organic acids, such as aliphatic mono- and dicarboxylic acids, phenyl-alkanoic acids, hydroxyalkanoic acids, alkanedicarboxylic acids, aromatic acids, aliphatic and aromatic sulfonic acids, etc., and include, for example, acetic acid acid, trifluoroacetic acid, propionic acid, glycolic acid, pyruvic acid, oxalic acid, maleic

- 19 046057 acid, malonic acid, succinic acid, fumaric acid, tartaric acid, citric acid, benzoic acid, cinnamic acid, mandelic acid, methanesulfonic acid, ethanesulfonic acid, p-toluenesulfonic acid, salicylic acid and the like. Typical salts thus include sulfates, pyrosulfates, bisulfates, sulfites, bisulfites, nitrates, phosphates, monohydrogen phosphates, dihydrogen phosphates, metaphosphates, pyrophosphates, chlorides, bromides, iodides, acetates, trifluoroacetates, propionates, caprylates, isobutyrates, oxalates, malonates, succinates , suberates, sebacates, fumarates, maleates, mandelates, benzoates, chlorobenzoates, methyl benzoates, dinitrobenzoates, phthalates, benzenesulfonates, toluenesulfonates, phenylacetates, citrates, lactates, malates, tartrates, methanesulfonates and the like. Also contemplated are amino acid salts such as arginates, gluconates, and galacturonates (see, e.g., Berge S. M. et al., Pharmaceutical Salts, Journal of Pharmaceutical Science, 66:1-19 (1997), which is hereby incorporated by reference in its entirety ). Acid addition salts of basic compounds can be prepared by contacting the free base forms with a sufficient amount of the desired acid to form a salt according to methods and techniques with which one skilled in the art is familiar.

The term pharmaceutically acceptable base addition salt refers to those salts that retain the biological effectiveness and properties of the free acids that are not biologically or otherwise undesirable. These salts are obtained by adding an inorganic base or an organic base to the free acid. Pharmaceutically acceptable base addition salts can be formed with metals or amines, such as alkali and alkaline earth metals or organic amines. Salts derived from inorganic bases include, but are not limited to, sodium, potassium, lithium, ammonium, calcium, magnesium, iron, zinc, copper, manganese, aluminum and the like. Salts derived from organic bases include salts of primary, secondary and tertiary amines, substituted amines, including naturally occurring substituted amines, cyclic amines and basic ion exchange resins, for example, isopropylamine, trimethylamine, diethylamine, triethylamine, tripropylamine, ethanolamine, diethanolamine, 2 -dimethylaminoethanol, 2-diethylaminoethanol, dicyclohexylamine, lysine, arginine, histidine, caffeine, procaine, N.N-dibenzylethylenediamine. but are not limited to, chloroprocaine, hydrabamine, choline, betaine, ethylenediamine, ethylene dianiline, N-methylglucamine, glucosamine, methylglucamine, theobromine, purines, piperazine, piperidine, N-ethylpiperidine, polyamine resins and the like. See Berge et al., supra. In some embodiments, the pharmaceutically acceptable salt is a sodium salt (see Sodium Hyaluronate on page 3583 of European Pharmacopoeia 9.0, which is incorporated herein by reference).

The terms subject, patient and individual as used herein refer to a human or non-human animal. The term subject also refers, for example, to primates (eg, humans), cows, sheep, goats, horses, dogs, cats, rabbits, rats, mice, fish, birds, and the like. In some embodiments, the subject is a mammal. In some embodiments, the subject is a human. In some embodiments, the subject is a bird or fish. Thus, these methods can be carried out in a medical institution and a veterinary institution. The non-human animal subject may be, for example, a pet or an animal model of an ocular or non-ocular disease.

In some embodiments, the subject's eye does not have tear deficiency (ATD) at the time of said administration (ie, in the absence of ATD).

In some embodiments, the subject's eye does not have graded dry keratitis at the time of said administration (ie, no graded dry keratitis).

In some embodiments, the subject's eye does not have dry keratitis at the time of said administration (ie, in the absence of tear deficiency or high-grade dry keratitis).

In some embodiments, the subject does not suffer from tear deficiency (ATD), and where the subject has an ocular surface abnormality (topographic abnormality) including elevations on the cornea or elsewhere on the surface of the eye that are not covered by normal tear film (tear film with normal surface tension and viscosity), leading to areas of friction on the ocular surface, and where the injected fluid reduces this friction.

In some embodiments, the subject is immunocompromised, i.e. is in a weakened immune state.

The phrase local administration is used herein in its traditional sense to refer to local delivery to a desired anatomical site, such as the ocular surface. The liquid containing high molecular weight hyaluronic acid can be applied directly or indirectly to the ocular surface by any method that provides contact of an effective amount of the liquid and the ocular surface. For example, the liquid may be directly applied to the ocular surface, such as through eye drops or rinsing, or applied indirectly through a delivery agent (ie, a liquid delivery agent) that is brought into contact with the ocular surface or other part of the eye. An example of a delivery agent is a particle

- 20 046057 (for example, microparticles or nanoparticles) that are coated with liquid and/or release this liquid onto the ocular surface. Such particles can consist of different substances, such as natural or synthetic polymers. In some embodiments, the delivery agent itself may be administered in the form of drops.

This invention is described by way of example only by way of embodiments in the specification and drawings and is not limited to or, but rather includes all variations, modifications, substitutions and combinations that an expert can obtain from the complete documents of this pending application and/or combination with his particular knowledge.

All patents, patent applications, provisional applications and publications referenced or cited herein are incorporated by reference in their entirety, including all graphics and tables, to the extent not inconsistent with express ideas of this specification.

The following is an example that illustrates procedures for putting the present invention into practice. These examples should not be construed as limiting. All percentages are by weight and all solvent mixture proportions are by volume unless otherwise noted.

Example 1 - multicenter, multinational, prospective clinical trial in patients with severe keratitis sicca - the HYLAN M study

A multicenter, multinational, prospective, randomized clinical trial in patients with severe keratitis sicca (according to primary ODISSEY criteria), called the HYLAN M trial, is being conducted at 12 study sites in 9 countries. Within this study, patients were randomized into two groups: a group remaining with the most effective previously identified treatment for individual patients, another group switched to eye drops with high molecular weight hyaluronic acid (comfort Shield® preservative-free sodium hyaluronate eye drops (i.com medical GmbH, Munich, Germany), which correspond to the embodiment of Table 1 in this document.

These patients (192 registered) were already receiving the best treatment their ophthalmologists could offer. All patients were on stable therapy at the time of their inclusion in this study, i.e. their therapy had not changed over the period of time prior to enrollment in this study. These patients were randomized into two groups: one group of patients remaining with their current therapy for keratitis sicca, and a second group of patients who were treated with the liquid drops described above (Comfort Shield® eye drops) instead of replacing their tears.

Study objectives included: (1) to compare objective and subjective symptoms of dry keratitis when treated with Comfort Shield® eye drops relative to tear replacement eye drops patients were treated with before presentation to the investigator (equal to current therapy) for conditions of severe dry keratitis; and (2) observation of objective efficacy, subjective patient acceptance, and adverse events associated with the eye drops. For each patient, both eyes were tested, and the eye with the higher corneal fluorescein staining score when tested at the baseline time point was scored.

Patients at one study site participating in the HYLAN M trial have not yet achieved adequate relief of signs and symptoms with all commercially available eye drops tested by treating physicians before deciding whether to treat with autologous serum eye drops. They included 11 patients treated with autologous serum eye drops in this study. Of these 11 patients, 6 were randomized to the Comfort Shield® arm, i.e. Autologous serum eye drops were replaced by Comfort Shield® for a period of 8 weeks. Of these 6 patients, 2 discontinued their participation in the study because Comfort Shield® eye drops did not provide adequate symptom relief. Two continued therapy with Comfort Shield® eye drops throughout the eight-week study but chose to return to their original autologous serum therapy. The remaining two patients preferred Comfort Shield® eye drops over autologous serum eye drops and chose to use Comfort Shield® eye drops outside of this study.

Patients suffering from severe dry keratitis exhibit significant symptoms and usually undergo multi-stage therapeutic treatment as described in the TFOS DEWS II Guidelines and Therapy Report (see in particular Fig. 1 on page 608 and Table 16 on page 609 ). The HYLAN M study included only patients suffering from severe sicca keratitis who were also stable on treatment at the time of enrollment. As stated above, patients in this study were randomized into two groups: (a) control group and (b) Comfort Shield® group. The control group continued their therapy as at the time of inclusion, while the Comfort Shield® group replaced their tear substitute used at the time of inclusion with Comfort Shield® eye drops. In this comprehensive controlled clinical study, signs and

- 21 046057 symptoms of sicca keratitis are assessed at baseline, after 4 weeks and after 8 weeks. Symptoms of dry keratitis were assessed by using the Ocular Surface Disease Index (OSDI) with an OSDI score equal to or greater than 33 as the inclusion criterion (Baudouin C. et al., Diagnosing the severity of dry eye: a clear and practical algorithm, Br J Ophthalmol ., 2014 Sep;98(9):116876, which is incorporated herein by reference in its entirety).

In table Figure 3 shows the progression of symptoms over time within the statistical evaluation interval. After 8 weeks of treatment with Comfort Shield® eye drops, the OSDI score improved by an average of 15.3 points, while the OSDI score of patients in the control group improved only by an average of 4.1 points. This result supports the conclusion that Comfort Shield® eye drops provide relief in the stage of severe sicca keratitis when other tear substitutes fail to do so.

Table 3

Control group (N = 32) Comfort Shield Group (N = 29) Total (N=61) VISIT IN WEEK 4 31 28 59 Mean (standard deviation) -7.3 (13.2) -12.1 (21.2) -9.6 (17.5) Median (interquartile range) -6.6 (-13.3;0.0) -6.3 (-20.4:0.9) -6.3 (-16.7:0.0) [Min. - Max.] [-34.1-25.8] [-68.8-17.4] [-68.8-25.8] Missing data 1 1 2 VISIT IN WEEK 8 28 27 55 Mean (standard deviation) -4.1 (16.0) -15.3 (25.9) -9.6 (22.0) Median (interquartile range) -3.2 (-13.5;3.8) -12.5 (-30.0:1.7) -5.3 (-18.8:2.3) [Min. - Max.] [-43.0-40.9] [-84.1-27.1] [-84.1-40.9] Missing data 4 2 6

Data provided by Coronis, GmbH, the sponsor of this study.

It should be understood that the examples and embodiments described herein are for illustrative purposes only, and that various modifications or changes in light thereof will be suggested to those skilled in the art and are intended to be included within the spirit and scope of this application and the scope of the appended claims. inventions. In addition, any elements or limitations of any invention or embodiment disclosed herein may be combined with any and/or all other elements or limitations (individually or in any combination), or any other invention or embodiment disclosed herein. document, and all such combinations are contemplated within the scope of this invention without limitation.

Claims (24)

1. A method of attenuating or delaying the onset of a severe ocular surface disease, comprising topically administering a liquid containing high molecular weight hyaluronic acid to the ocular surface of the eye of a human or non-human animal subject, wherein said hyaluronic acid has an intrinsic viscosity greater than 2.9 m. ³ /kg and a concentration of less than 0.2% w/v, and the said liquid does not contain another bioactive agent, and a severe disease of the ocular surface is caused by an external stimulus leading to disruption of the smoothness and/or integrity of the ocular surface, medical therapy, keratoconus, eye surgery, non-surgical trauma, contact lens wear, infection, allergens, haptens, toxic agents or irritants, or internal stimulus, hormonal disorder, rheumatic disease, epithelial-mesenchymal transition (EMT) or autoimmune disease. 2. The method according to claim 1, in which the specified liquid is administered prophylactically, before the occurrence of severe disease of the ocular surface. 3. The method of claim 2, wherein at the time of administration, said subject has a mild or moderate degree of ocular surface disease, and said liquid is administered prophylactically to prevent or delay the progression of the ocular surface disease to a state of severe ocular surface disease. 4. The method according to any one of claims 1 to 3, wherein the severe ocular surface disease is caused by an external stimulus leading to disruption of the smoothness and/or integrity of the ocular surface, medical therapy, ocular surgery, non-surgical trauma, contact lens wear, infection, allergens, haptens, toxic agents or irritants. - 22 046057 5. The method according to any one of claims 1 to 3, wherein the severe ocular surface disease is caused by an internal stimulus, a hormonal disorder, a rheumatic disease, epithelial mesenchymal transition (EMT) or an autoimmune disease. 6. The method according to any one of claims 1 to 3, wherein the severe ocular surface disease is caused by an eye wound or eye surgery. 7. A set containing a liquid containing high molecular weight hyaluronic acid having an intrinsic viscosity of more than 2.9 m ³ /kg and a concentration of less than 0.2% w/v, and said liquid does not contain another bioactive agent, and one or more one bandage contact lens intended for the treatment of severe dry keratitis or severe ocular surface disease caused by external stimuli resulting in disruption of the smoothness and/or integrity of the ocular surface, medical therapy, ocular surgery, non-surgical trauma, contact lens wear, infection, allergens, haptens , toxic agents or irritants, or internal stimulus, hormonal disorder, keratoconus, rheumatic disease, epithelial-mesenchymal transition (EMT) or autoimmune disease. 8. The use of a liquid to reduce or delay the onset of a severe ocular surface disease, wherein said liquid contains high molecular weight hyaluronic acid having an intrinsic viscosity of greater than 2.9 m ³ /kg and a concentration of less than 0.2% w/v, and the specified the liquid is administered topically to the ocular surface of the eye of a human or non-human animal subject, and the liquid does not contain another bioactive agent, and the severe ocular surface disease is caused by an external stimulus resulting in disruption of the smoothness and/or integrity of the ocular surface, medical therapy, ocular surgery, non-surgical trauma, contact lens wear, infection, allergens, haptens, toxic agents or irritants, or internal stimulus, hormonal disorder, keratoconus, rheumatic disease, epithelial-mesenchymal transition (EMT) or autoimmune disease. 9. Method according to any one of claims 1 to 6, wherein said hyaluronic acid has a molecular weight of at least 3 million Daltons. 10. The kit according to claim 7, wherein said hyaluronic acid has a molecular weight of at least 3 million Daltons. 11. Use according to claim 8, wherein said hyaluronic acid has a molecular weight of at least 3 million Daltons. 12. A method of treating severe dry keratitis, comprising topical administration of a liquid containing high molecular weight hyaluronic acid to the ocular surface of the eye of a human or non-human animal subject, wherein said hyaluronic acid has an intrinsic viscosity of more than 2.9 m ³ /kg and concentration less than 0.2% w/v. 13. The method of claim 12, wherein said hyaluronic acid has a molecular weight of at least 3 million Daltons. 14. The method according to claim 12 or 13, in which said liquid has a pH of 6.8-7.6; osmolarity of 240-330 mOsmol/kg; sodium chloride concentration of 7.6-10.5 g/l; and buffer. 15. The method according to claim 14, in which the buffer is a phosphate buffer with a concentration of 1.0-1.4 mmol/L. 16. The method according to any one of claims 12-15, in which the subject is a person. 17. The use of a liquid for the treatment of severe dry keratitis, wherein said liquid contains high molecular weight hyaluronic acid having an intrinsic viscosity of more than 2.9 m ³ /kg and a concentration of less than 0.2% w/v, and wherein said liquid is locally administered to the eye the ocular surface of a human or non-human animal subject having severe dry keratitis. 18. Use according to claim 17, wherein said hyaluronic acid has a molecular weight of at least 3 million Daltons. 19. Use according to claim 17 or 18, where said liquid has a pH of 6.8-7.6; osmolarity of 240-330 mOsmol/kg; sodium chloride concentration of 7.6-10.5 g/l; and buffer. 20. Use according to claim 19, where the buffer is a phosphate buffer with a concentration of 1.0-1.4 mmol/L. 21. Use according to any one of claims 17 to 20, where the subject is a human. 22. Use according to any one of claims 17 to 21, where said liquid does not contain another bioactive agent. 23. The method according to any one of claims 12 to 16, wherein said liquid does not contain another bioactive agent. 24. The kit according to claim 7, where the kit is intended for use in the treatment of severe dry keratitis.