EP1420791A1

EP1420791A1 - Use of compounds for treating conditions resulting from injury to the corneal nerve after lasik and other ocular surgeries or trauma

Info

Publication number: EP1420791A1
Application number: EP02756710A
Authority: EP
Inventors: Mark R. Hellberg; Iok-Hou Pang; John M. Yanni
Original assignee: Alcon Inc
Current assignee: Alcon Inc
Priority date: 2001-08-29
Filing date: 2002-07-23
Publication date: 2004-05-26
Also published as: CA2455896A1; MXPA04001255A; AR036194A1; JP2005502678A; EP1420791A4; BR0212151A; ZA200400837B; PL368565A1; WO2003020281A1; CN1549718A

Abstract

The present invention provides methods for the treatment of conditions resulting from injury to the corneal nerve after LASIK and other ocular surgeries or trauma.

Description

Use of Compounds for Treating Conditions Resulting from Injury to the Corneal Nerve after LASIK and Other Ocular Surgeries or Trauma

BACKGROUND OF THE INVENTION

1. Field of the Invention

The present invention is directed to the use of compounds that promote neuron

regeneration or neurite outgrowth for the treatment of conditions resulting from injury to

corneal nerves following Laser In Situ Keratomileusis (LASIK) or other surgeries where the

corneal nerves are damaged.

2. Description of the Related Art

Patients frequently experience a decrease in corneal sensitivity and mild to moderate

dry eye after LASIK surgery. In most patients, this is an acute problem lasting for only a few

days. However, in a significant number of patients, the problem may persist for several

months or more (Yu 2000). This iatrogenic change most likely results from the severing of

corneal nerves during surgery (Wilson 2001; Ambrosio & Wilson 2001). Current treatment

methods for surgery-induced dry eye include symptomatic reliefs such as the frequent local

application of artificial tears, such as Tears Naturale or Bion Tears®, or other artificial

moisturizing agents. These treatments reduce discomfort but do not treat the underlying

pathology. No acceptable therapy of the decrease in corneal sensitivity is known to the

inventors at this time.

Neurotrophic factors are peptide molecules which stimulate or otherwise maintain

growth of neuronal tissue. The transport of neurotrophic factors from the brain to the cell body

of neurons is essential to the survival of most ocular nerves. Deprivation of neurotrophic factors

can induce apoptosis of neurons (Raff et al. 1993).

The neurotrophin (NT) family of peptides include nerve growth factor (NGF), brain-

derived neurotrophic factor (BDNF), NT-3, NT-4/5 and NT-6. They act by binding to the neurotrophin receptors (NT-receptors), such as TrkA, TrkB, TrkC and p75NTR. The Trk

receptors are tyrosine kinases. TrkA is selective for NGF, TrkB is selective for both BDNF and

NT-4/5, whereas TrkC is selective for NT-3. After binding, the NT-receptor complex is

internalized and transported via the axon to the soma. These receptors undergo ligand-induced

phosphorylation and dimerization, and activate a cascade of Ras protein-mediated signal

transduction events that affect multiple vital functions of the neuron (Lewin et al. 1997; Segal et

al. 1996; Ebadi et al. 1997; Kaplan et al. 1997). Thus, these receptors play a fundamental role

in the regulation of survival and differentiation of developing neurons and contribute to the maintenance of neuronal machinery in life.

In the ocular tissue, for example, mRNA of both TrkA and TrkB has been observed in

retinal ganglion cells (RGC), dopaminergic amacrine cells and the optic nerve. Their

expression was shown to be highly regulated during neuronal development (Jelsma et al. 1993;

Rickman et al. 1995; Ugolini et al. 1995; Cellerino et al. 1997). The TrkB receptor-selective

ligands, BDNF and NT-4/5, have been shown to be efficacious for the protection of RGC.

Numerous studies have shown that these NTs not only improve the survival and neurite

outgrowth of RGC in culture, but also significantly reduce axotomy-induced in vivo damage of

the optic nerve and RGC, as well as stimulate the growth of axonal branches from regenerating

RGC (Anderson et al. 1974; Quigley et al. 1976; Mansour-Robaey et al. 1994; Meyer-Franke et

al. 1995; and Cui et al. 1994). For example, a single intravitreal injection of 5 μg of BDNF

prevented the death of the axotomized ocular nerves when administered during the first five

days after injury (Mansour Robaey 1994; Gao et al. 1997).

Ciliary neurotrophic factor (CNTF) and Basic Fibroblast Growth Factor (bFGF) are

other neurotrophic factors that support survival of neurons. They are structurally unrelated to neurotrophins. They have also been shown to prevent lesion-induced death of neurons and

axons (Mey et al 1993; Weibel et al. 1995).

In normal human and rat corneas, neurotrophic factors, such as NGF, were found to be

present (Lambiase et al. 2000). Human and rat corneal epithelial cells produce, store and

release NGF and also express the TrkA receptor (Lambiase et al. 1998, Lambiase et al. 2000).

These trophic factors appear to play an important role in the biology of the cornea. In the

cornea of TrkA knockout mice, there was a drastic reduction in the number of nerve trunks,

branches and thin nerve terminals. The blinking response of these mice to mechanical, thermal

and chemical noxious stimuli was also significantly reduced (De Castro et al. 1998).

Thus, neurotrophic factors are important for the health and normal function of the

cornea. These trophic factors, however, are peptide molecules, and are therefore difficult to

exploit pharmaceutically due to bioavailability problems generally resident in the

pharmaceutical administration of peptides. What are needed, therefore, are non-peptide

molecules which stimulate neurotrophic activity in compromised retinal tissues, without the

bioavailability problems attendant to the natural peptides.

SUMMARY OF THE INVENTION

The present invention overcomes these and other drawbacks of the prior art by

providing compositions and methods for treating conditions resulting from injury to corneal

nerves. The compositions comprise one or more compound that promotes neuron

regeneration or neurite outgrowth in a pharmaceutically acceptable vehicle.

As used herein, "compounds that promote neuron regeneration or neurite outgrowth"

refers to those compounds which increase the in situ production or activity of neurotrophic

factors in the ocular tissue, especially the cornea. As used herein, "neurotrophic factor" refers to NGF, BDNF, NT-3, NT-4/5, NT-6, CNTF, bFGF or other trophic factors which prevent,

treat or ameliorate cornea neuropathy or promotes the re-growth of damaged cornea neurons.

Examples of neurotrophic factor stimulators include: AIT-082 (neotrofin), idebenone, CB-

1093, NS521 ((l-(l-butyl)-4-(2-oxo-l-benzimidazolone) piperidine), SS-701, and KT-711 (all

shown below), ONO-2506, and clenbuterol. The most preferred neurotrophin stimulator of the

present invention is AIT-082 (neotrofin). The preceding molecules may be obtained

commercially or may be synthesized by methods known to those skilled in the art.

The methods of the present invention comprise administering to a human patient one

or more compounds that promote neuron regeneration or neurite outgrowth, such as

neurotrophic factor stimulators, for the treatment of conditions resulting from corneal nerve

damage due to surgery.

The methods of the present invention are particularly directed to the use of neuron

regeneration or neurite outgrowth promoting compounds for the treatment of dry eye, and

other conditions resulting from corneal nerve damage, such as a decrease in corneal

sensitivity.

The neuron regeneration or neurite outgrowth promoting compounds of the present

invention may be contained in various types of pharmaceutical compositions, in accordance

with formulation techniques known to those skilled in the art. In general, the neuron

regeneration or neurite outgrowth promoting compounds will be formulated in solutions or

suspensions for topical ophthalmic or intraocular administration, or as tablets, capsules or

solutions for systemic administration (e.g., oral or intravenous). Preferably, the compounds

of the invention will be formulated in a solution or suspension for topical ophthalmic

application. DETAILED DESCRIPTION PREFERRED EMBODIMENTS

LASIK, and other vision-correction surgeries have allowed numerous corrective lens-

wearing people to cease their use of corrective lenses. This is advantageous for many

reasons. For people in some professions, such as art, science and construction work,

corrective lenses can be a nuisance because of the dirt, paints, and chemicals with which they

must work. However, patients frequently experience a decrease in corneal sensitivity and

mild to moderate dry eye after LASIK surgery. In most patients, this is an acute problem

lasting for only a few days. However, in a significant number of patients, the problem may

persist for several months or more (Yu 2000). This problem is most likely the result of injury

to the corneal nerves during surgery (Wilson 2001; Ambrosio & Wilson 2001). The present

inventors have discovered that treatment of the injured corneal nerves after surgery with

compounds that promote neurite outgrowth or that stimulate the regeneration of the severed

or injured nerves can shorten the duration of, or reduce the incidence of, dry eye. Such

treatment can also attenuate the decrease in corneal sensitivity caused by LASIK or other

surgeries in which corneal nerves are damaged.

The present invention is directed at the use of compounds that promote the

regeneration of severed nerves and/or neurite outgrowth to treat dry eye and the reduction in

corneal sensitivity induced by cornea surgery. The compounds that promote the regeneration

of severed neuron or promote neurite outgrowth do so by stimulating the production of, or by

increasing the activity of, neurotrophic factors. The compounds used in the present invention

may also promote the regeneration of severed nerves and/or neurite outgrowth by direct

action on the injured nerves.

Several neurotrophic factor stimulators have been reported in the scientific literature,

for example, AIT-082 (Graul & Castaner 1997), idebenone (Nabeshima et al. 1994), ONO- 2506 (Matsui et al. 1998), NS521 (Gronborg et al. 1998), CB-1093 (Aimone et al. 1998) and

Clenbuterol (Culmsee et al. 1998). However, nowhere in the art has it been disclosed or

suggested to use neurotrophic factor stimulators to treat dry eye or other iatrogenic injury

following Lasik surgery or other surgeries.

Topical ocular formulations of the neuron regeneration or neurite outgrowth promoting compounds are preferred due to ease of administration. Topical ocular

formulations may be in solutions or suspensions. In general, topical formulations will contain

the active neurotrophin factor stimulator and inert excipients.

The compositions of the present invention may be administered intraocularly following

damage to the corneal nerve, such as by LASIK or other surgeries. Compositions useful for

intraocular administration will generally be intraocular injection compositions or surgical

irrigating solutions. Intraocular injection compositions will generally be comprised of an

aqueous solution, e.g., balanced salt irrigating solutions, discussed below.

When the neuron regeneration or neurite outgrowth promoting compounds are

administered after surgical procedures, such as through retrobulbar or periocular injection and

intraocular perfusion or injection, the use of balanced salt irrigating solutions as vehicles are

most preferred. BSS® Sterile Irrigating Solution and BSS Plus® Sterile Intraocular

Irrigating Solution (Alcon Laboratories, Inc., Fort Worth, Texas, USA) are examples of

physiologically balanced intraocular irrigating solutions. The latter type of solution is

described in United States Patent No. 4,550,022, the entire contents of which are incorporated

herein by reference. Retrobulbar and periocular injections are known to those skilled in the

art and are described in numerous publications including, for example, Ophthalmic Surgery:

Principles of Practice (1990). The preferred route of administration is ocular topical

application. Thus, pharmaceutically effective amounts of the above compounds or their active analogs in solutions or suspensions will be formulated for topical ophthalmic

administration by methods known to those skilled in the art.

In general, the doses utilized for the above described purposes will vary, but will be in

an effective amount to prevent, reduce or ameliorate the dry eye or decrease in cornea

sensitivity related to surgery. As used herein, "pharmaceutically effective amount" refers to

that amount of a neurotrophin factor stimulator which prevents, reduces or ameliorates the

dry eye or decrease in cornea sensitivity related to surgery or trauma. The neurotrophic factor

stimulators will generally be contained in the topical formulations or pharmaceutically acceptable carrier contemplated herein in an amount of from about 0.001 to about 10.0%

weight/volume (%w/v). Preferred concentrations will range from about 0.1 to about 5.0 %

w/v. Topical formulations will generally be delivered to the eye one to six times a day, at the

discretion of a skilled clinician. Systemic administration compositions will generally contain

about 1-1000 mg of a neurotrophic factor stimulator, and can be taken 1-4 times per day, at

the discretion of a skilled clinician.

As used herein, the term "pharmaceutically acceptable carrier" refers to any formulation

which is safe, and provides the appropriate delivery of an effective amount of at least one

neurotrophic factor stimulator for the desired route of administration.

The compositions of the present invention may contain additional pharmaceutically

active agents or may be dosed concurrently with other pharmaceutical compositions. In

particular, when treating a mammal for the prevention, treatment or amelioration of conditions

resulting from injury to corneal nerves during surgery, the compositions of the present invention

may contain additional agents or may be dosed concurrently or sequentially with other agents or

compositions. Examples of agents include: artificial tear, artificial moisterizing solutions or

other appropriate agents known to those skilled in the art. EXAMPLES

The following example demonstrates the protective efficacy of a neurotrophic factor stimulator (propentofylline) against ocular tissue cell insult.

Example 1

The Compounds can be administered systemically or locally to the eye (e.g., topically,

intracamerally, or via an implant). The Compounds are preferrably incorporated into topical

ophthalmic formulations for delivery to the eye. The Compounds may be combined with

ophthalmologically acceptable preservatives, surfactants, viscosity enhancers, penetration

enhancers, buffers, sodium chloride, and water to form an aqueous, sterile ophthalmic

suspension or solution. Ophthalmic solution formulations may be prepared by dissolving a

Compound in a physiologically acceptable isotonic aqueous buffer. Further, the ophthalmic

solution may include an ophthalmologically acceptable surfactant to assist in dissolving the

Compound. Furthermore, the ophthalmic solution may contain an agent to increase viscosity,

such as, hydroxymethylcellulose, hydroxyethylcellulose, hydroxypropylmethylcellulose,

methyl-cellulose, polyvinylpyrrolidone, or the like, to improve the retention of the

formulation in the conjunctival sac. Gelling agents can also be used, including, but not

limited to, gellan and xanthan gum. In order to prepare sterile ophthalmic ointment

formulations, the active ingredient is combined with a preservative in an appropriate vehicle,

such as, mineral oil, liquid lanolin, or white petrolatum. Sterile ophthalmic gel formulations

may be prepared by suspending the active ingredient in a hydrophilic base prepared from the

combination of, for example, carbopol-940, or the like, according to the published

formulations for analogous ophthalmic preparations; preservatives and tonicity agents can be

incorporated.

The Compounds are preferably formulated as topical ophthalmic suspensions or

solutions, with a pH of about 5 to 8. The Compounds will normally be contained in these formulations in an amount 0.001% to 5% by weight, but preferably in an amount of 0.05% to

2% by weight. Thus, for topical presentation 1 to 2 drops of these formulations would be

delivered to the surface of the eye 1 to 4 times per day according to the routine discretion of a skilled clinician.

All of the compositions and/or methods disclosed and claimed herein can be made and

executed without undue experimentation in light of the present disclosure. While the

compositions and methods of this invention have been described in terms of preferred

embodiments, it will be apparent to those of skill in the art that variations may be applied to

the compositions and/or methods and in the steps or in the sequence of steps of the method

described herein without departing from the concept, spirit and scope of the invention. More

specifically, it will be apparent that certain agents which are both chemically and structurally

related may be substituted for the agents described herein to achieve similar results. All such

substitutions and modifications apparent to those skilled in the art are deemed to be within the

spirit, scope and concept of the invention as defined by the appended claims.

References

The following references, to the extent that they provide exemplary procedural or

other details supplementary to those set forth herein, are specifically incorporated herein by

reference.

United States Patents

4,550,022

Books

Ophthalmic Surgery: Principles of Practice, Ed., G.L. Spaeth, W.B. Sanders Co.,

Philadelphia, PA, U.S.A., pages 85-87 (1990). Other Publications

Aimone et al, The la,25(OH)2Ds analog CB-1093 induces nerve growth factor in non-

human primate brain, SOCIETY FOR NEUROSCI. ABSTRACTS, 24:292, (1998).

Ambrosio & Wilson, J. Refractive Surgery 17:350-380 (2001).

Anderson et al, Effect of intraocular pressure on rapid axoplasmic transport in monkey optic nerve, INVEST. OPHTHALMOL., 13:771-783 (1974).

Beck et al, Brain-derived neurotrophic factor protects against ischemic cell damage in the rat

hippocampus, J. CEREB. BLOOD FLOW METAB., 14:689-692 (1994).

Cellerino et al, Brain-derived neurotrophic factor/neurotrophin-4 receptor TrkB is localized on ganglion cells and dopaminergics amacrine cells in the vertebrate retina, J. COMP.

NEUROL., 386:149-160 (1997).

Cui et al, NT-4/5 reduces naturally occurring retinal ganglion cell death in neonatal rats,

NEUROREPORT, 5:1882-1884 (1994).

Culmsee et al, NGF antisense oligonucleotide blocks protective effects of clenbuterol against

glutamate-induced excitotoxicity in vitro and focal cerebral ischemia in vivo, SOCIETY

FOR NEUROSCI. ABSTRACTS, 24:295 (1998).

De Castro et al. , Corneal innervation and sensitivity to noxious stimuli in trkA knockout mice,

EUR. J. NEUROSCI., 10:146-152 (1998).

Ebadi et al, Neurotrophins and their receptors in nerve injury and repair, NEUROCHEM INT.,

30:347-374 (1997).

Gao et al, Elevated mRNA expression of brain-derived neurotrophic factor in retinal ganglion

cell layer after optic nerve injury, INVEST. OPHTHALMOL. VIS. SCI., 38:1840-1847

(1997).

Graul & Castaner, AIT-082, DRUGS OF THE FUTURE, 22:945-947 (1997). Gronborg et al, Neuroprotection by a novel compound, NS521, SOCIETY FOR NEUROSCI.

ABSTRACTS, 24:1551 (1998).

Jelsma et al, Different forms of the neurotrophin receptor trkB mRNA predominate in rat retina and optic nerve, J. NEUROBIOL., 24:1207-1214 (1993).

Kaplan et al, Signal transduction by the neurotrophin receptors, CuRR. OPIN. CELL BIOL.,

9:213-221 (1997).

Kirsch et al, Evidence for multiple, local functions of ciliary neurotrophic factor (CNTF) in

retinal development: expression of CNTF and its receptors and in vitro effects on target

cells, J. NEUROCHEM., 68:979-990 (1997).

Lambiase et al, Expression of nerve growth factor receptors on the ocular surface in healthy

subjects and during manifestation of inflammatory diseases, INVEST. OPHTHALMOL. VIS.

SCI, 39:1272-1275 (1998).

Lambiase et al, Nerve growth factor promotes corneal healing: structural, biochemical, and

molecular analyses of rat and human corneas, INVEST. OPHTHALMOL. VIS. SCI.,

41:1063-1069 (2000).

Lewin et al, Physiology of the neurotrophins, ANN. REV. NEUROSCI., 19:289-317 (1997).

Lindholm et al, Brain-derived neurotrophic factor is a survival factor for cultured rat

cerebellar granule neurons and protects them against glutamate-induced neurotoxicity,

EUR. J. NEUROSCI., 5:1455-1464 (1993).

Mansour-Robaey et al, Effects of ocular injury and administration of brain-derived

neurotrophic factor on survival and regrowth of axotomized retinal ganglion cells,

PROC. NATL. ACAD. SCI. USA, 91:1632-1636 (1994). Matsui et al, Protective effects of ONO-2506 on neurological deficits and brain infarct

volume following 1 week of permanent occlusion of middle cerebral artery in rats,

SOCIETY FOR NEUROSCI. ABSTRACTS, 24:254 (1998).

Mey et al, Intravitreal injections of neurotrophic factors support the survival of axotomized

retinal ganglion cells in adult rats in vivo, BRAIN RES., 602:304-317 (1993).

Meyer-Franke et al, Characterization of the signaling interactions that promote the survival

and growth of developing retinal ganglion cells in culture, NEURON, 15:805-819 (1995).

Nabeshima et al., Oral administration of NGF synthesis stimulators recovers reduced brain

NGF content in aged rats and cognitive dysfunction in basal-forebrain-lesioned rats,

GERONTOLOGY, 40(supp. 2):46-56 (1994).

Quigley et al, The dynamics and location of axonal transport blockade by acute intraocular

pressure elevation inprimate optic nerve, INVEST. OPHTHALMOL., 15:606-616 (1976).

Raff et al, Programmed cell death and the control of cell survival: lessons from the nervous

system, SCIENCE, 262:695-700 (1993).

Rickman et al, Expression of the protooncogene, trk, receptors in the developing rat retina,

VIS. NEUROSCL, 12:215-222 (1995).

Segal et al, Intracellular signaling pathways activated by neurotrophic factors, ANN. REV.

NEUROSCL, 19:463-489 (1996).

Ugolini et al, TrkA, TrkB and pi 5 mRNA expression is developmentally regulated in the rat

retina, BRAIN RES, 704: 121 - 124 (1995).

Unoki et al, Protection of the rat retina from ischemic injury by brain-derived neurotrophic

factor, ciliary neurotrophic factor, and basic fibroblast growth factor, INVEST.

OPHTHALMOL. VIS. Sci., 35:907-915 (1994). Weibel et al, Brain-derived neurotrophic factor (BDNF) prevents lession-induced axonal die-

back in young rat optic nerve, BRAIN RES., 679:249-254 (1995). Wilson, OPHTHALMOLOGY 108:1082-1087 (2001).

Yu, SYMPOSIUM ON CATARACT, IOL AND REFRACTORY SURGERY, Abstract 263 (2000).

Claims

We Claim:

1. A method for the treatment of dry eye resulting from injury to corneal nerves, said method comprising administering to a patient in need thereof a therapeutically effective amount of a composition comprising at least one compound that promotes neuron regeneration or neurite outgrowth.

2. The method of claim 1, wherein the injury to corneal nerves results from surgery.

3. The method of claim 2, wherein the surgery is LASIK surgery.

4. The method of claim 1, wherein the compound may be selected from the group consisting of propentofylline, AIT-082 (neotrofin), idebenone, ONO-2506, CB-1093, NS521 (l-(l-butyl)-4-(2-oxo-l-benzimidazone) pireridine, eliprodil, SR57746A (xaliproden hydrochloride) or pharmaceutically acceptable analogs thereof.

5. The method of claim 4, wherein the compound is AIT-082.

6. The method of claim 4, wherein the compound is eliprodil.

7. A method for the treatment of decrease in comea sensitivity resulting from injury to corneal nerves, said method comprising administering to a patient in need thereof a therapeutically effective amount of at least one composition comprising a compound that promotes neuron regeneration or neurite outgrowth.

8. The method of claim 7, wherein the injury to corneal nerves results from surgery.

9. The method of claim 8, wherein the surgery is LASIK surgery.

10. The method of claim 7, wherein the compound may be selected from the group consisting of propentofylline, AIT-082 (neotrofin), idebenone, ONO-2506, CB-1093,

NS521 (l-(l-butyl)-4-(2-oxo-l-benzimidazone) pireridine, eliprodil, SR57746A

(xaliproden hydrochloride) or pharmaceutically acceptable analogs thereof.

11. The method of claim 10, wherein the compound is AIT-082.

12. The method of claim 10, wherein the compound is eliprodil.

13. A method for the treatment of injury to corneal nerves comprising administering to a patient in need thereof a therapeutically effective amount of a composition comprising a compound that promotes neuron regeneration or neurite outgrowth.

14. The method of claim 13, wherein the injury to corneal nerves results from surgery.

15. The method of claim 14, wherein the surgery is LASIK surgery.

16. The method of claim 13, wherein the compound may be selected from the group consisting of propentofylline, AIT-082 (neotrofin), idebenone, ONO-2506, CB-1093,

NS521 (l-(l-butyl)-4-(2-oxo-l-benzimidazone) pireridine, eliprodil, SR57746A (xaliproden hydrochloride) or pharmaceutically acceptable analogs thereof.

17. The method of claim 16, wherein the compound is AIT-082.

18. The method of claim 16, wherein the compound is eliprodil.