EP4676597A2

EP4676597A2 - Ripasudil based ophthalmic treatments

Info

Publication number: EP4676597A2
Application number: EP24785646.1A
Authority: EP
Inventors: Kazuhito SUEHIRA; Gary Gordon; Tatsuhiko MAKINE; Shona Sanchita PENDSE
Original assignee: Kowa Co Ltd
Current assignee: Kowa Co Ltd
Priority date: 2023-04-04
Filing date: 2024-04-03
Publication date: 2026-01-14
Also published as: WO2024211322A3; WO2024211322A2

Abstract

The present disclosure relates to ripasudil-based ophthalmic treatments, particularly for use in patients following intra-ocular surgeries such as cataract surgery and descemetorhexis.

Description

RIPASUDIL BASED OPHTHALMIC TREATMENTS

FIELD

BACKGROUND

An estimated 95 million people globally have cataracts (Liu, 2017). It is the leading cause of blindness, reversible blindness, and impaired vision worldwide (Lam, 2015). Cataracts are particularly prevalent in middle- and low-income countries and in those with low socioeconomic status (Liu, 2017; Lam, 2015). Cataract extraction with insertion of an intraocular lens (IOL) is the most common eye surgery worldwide, with approximately 10 million procedures performed annually throughout the globe (Foster, 2000).

The standard of care for cataract removal is phacoemulsification with intraocular lens implantation, which uses energy from ultrasound to break up the eye’s innate lens into smaller pieces, which are then aspirated from the eye. The energy introduced into the eye during phacoemulsification can result in undesirable endothelial injury resulting in corneal edema and endothelial cell loss. Endothelial cell loss has been widely studied in the literature with mean percentages varying from 0.4 to 27.7% depending on the surgical technique (Tsorbatzoglou, 2007).

The corneal endothelium is a single layer of hexagonal cells that sit on a modified basement membrane (Descemet membrane) which lines the inner surface of the cornea. This monolayer forms a barrier between the aqueous humor of the anterior chamber of the eye and the cornea. The endothelial cells contain Na+/K+ pumps that return water to the aqueous humor, causing the corneal stroma to remain in a state of relative dehydration, thereby maintaining corneal transparency.

Corneal endothelial cells do not undergo mitosis in vivo in postnatal humans and are maintained in a state of mitotic arrest due to contact inhibition from neighboring cells. At birth endothelial cell density (ECD) is high at about 6,000 cells/mm². The ECD falls as the eye grows during childhood but then stabilizes, with average ECD of the human adult cornea in the range of 2,000 to 3,500 cells/mm² (lanchulev, 2018). During adulthood there is a continuous attrition of endothelial cells at the rate of about 0.6% per year. If the ECD decreases to below the threshold due to disease, trauma, or increased age, the pump function starts to decrease, the cornea thickens, and the resultant corneal edema leads to a visual haze due to impairment of corneal transparency (Van den Bogerd, 2018). Thus, endothelial damage due to intraocular surgery or implants can cause endothelial failure, ultimately necessitating corneal transplantation.

Ripasudil is a selective inhibitor of Rho-kinase (ROCK), a serine-threonine protein kinase which binds with low-molecular weight G protein Rho to form the Rho/Rho-kinase signalling system (Ishizaki, 1996). Okumura and colleagues tested the hypothesis that ripasudil could be used as a treatment for corneal injuries (Okumura, 2011). Fujimoto and colleagues conducted a retrospective observational study of 13 subjects (16 eyes) with glaucoma who had undergone cataract surgery with ripasudil prescribed from the day after surgery for 6 months. (Fujimoto, 2021). WO 2022/159533 (published July 28, 2022) discloses methods for treating Fuchs endothelial corneal dystrophy (“FECD”) with ripasudil, and the use of ripasudil to promote healing in FECD patients following descemetorhexis. US 9,844,556 B2 (published December 19, 2017), discloses the use of ripasudil for the prevention of secondary cataract and anterior capsule contraction. Ripasudil ophthalmic solution 0.4% has been marketed in Japan for the treatment of glaucoma and ocular hypertension since December 2014.

There is a medical need for medication that can speed healing after intra-ocular surgeries including cataract surgery and that can help establish a high, functional endothelial cell density to maintain corneal transparency.

SUMMARY

The present disclosure relates to ripasudil-based ophthalmic treatments following intraocular surgery. The method both improves post-surgical outcomes, particularly visual acuity following such surgeries, and reduces side effects including, but not limited to, ocular irritation and gastrointestinal upset or irritation.

Thus, in one embodiment the disclosure provides a method of improving visual acuity following intra-ocular surgery in a patient having confluent central guttae in the Descemet membrane and a cataractous lens in an eye, wherein the intraocular surgery comprises removing a central portion of the Descemet membrane from the eye and replacing the lens in the eye, comprising: (a) topically administering to the eye a therapeutically effective amount of ripasudil or a pharmaceutically acceptable salt thereof four times per day for twelve or more weeks following the surgery; and (b) improving the patient’s visual acuity.

In another embodiment the disclosure provides a method of returning corneal thickness to pre-surgery values, and maintaining said pre-surgery values following cessation of treatment, following intra-ocular surgery in a patient having confluent central guttae in the Descemet membrane and a cataractous lens in an eye, wherein the intraocular surgery comprises removing a central portion of the Descemet membrane from the eye and replacing the lens in the eye, comprising: (a) topically administering to the eye a therapeutically effective amount of ripasudil or a pharmaceutically acceptable salt thereof four times per day for twelve or more weeks following the surgery; (b) returning corneal thickness in the eye to pre-surgery values; and (c) maintaining corneal thickness at said pre-surgery levels following cessation of said administering.

In another embodiment the disclosure provides a method of returning corneal thickness to pre-surgery values, and maintaining said pre-surgery values following cessation of treatment, following intra-ocular surgery in a patient having a cataractous lens in an eye, wherein the intraocular surgery comprises replacing the lens in the eye, comprising: (a) topically administering to the eye a therapeutically effective amount of ripasudil or a pharmaceutically acceptable salt thereof four times per day for twelve or more weeks following the surgery; (b) returning corneal thickness in the eye to pre-surgery values; and (c) maintaining corneal thickness at said pre-surgery levels following cessation of said administering.

In another embodiment the disclosure provides a method of improving surgical outcomes from intra-ocular surgery in a patient having confluent central guttae in the Descemet membrane and a cataractous lens in an eye, wherein the intraocular surgery comprises removing a central portion of the Descemet membrane from the eye and replacing the lens in the eye, comprising: (a) topically administering to the eye a therapeutically effective amount of ripasudil or a pharmaceutically acceptable salt thereof four times per day for twelve or more weeks following the surgery; and (b) improving a surgical outcome selected from central corneal endothelial cell density, peripheral corneal endothelial cell density, endothelial cell coefficient of variation and hexagonality, return of central corneal thickness to pre-surgery baseline, clearance of corneal edema, best corrected distance visual acuity (BCVA), Visual Function Questionnaire-25 (VFQ- 25) domains and total score, and combinations thereof. In another embodiment the disclosure provides a method of preventing or reducing adverse events resulting from intra-ocular surgery in a patient in need thereof having an endothelial cellular density (ECD) greater than 1,500 cells/mm², comprising topically administering to the patient a therapeutically effective amount of ripasudil or a pharmaceutically acceptable salt thereof following the intra-ocular surgery.

In another embodiment the disclosure provides a method of preventing or reducing adverse events resulting from intra-ocular surgery in a patient at increased risk of such adverse events, comprising topically administering to the patient a therapeutically effective amount of ripasudil or a pharmaceutically acceptable salt thereof following the intra-ocular surgery, wherein: (a) the surgery comprises phacoemulsification with intraocular lens implantation; and (b) the patient is at increased risk of adverse events due to one or a combination of anterior chamber depth, phacoemulsification power and duration, hard and large nucleus, endothelial contact from nuclear fragments, IOL, air bubbles, irrigation fluid, implantation technique, type of IOL, short axial length, free radical release, small pupil, and toxicity of medications given during surgery.

In another embodiment the disclosure provides a method of improving post-surgical outcomes from intra-ocular surgery in a patient in need thereof having an endothelial cellular density (ECD) greater than 1,500 cells/mm², comprising topically administering to the patient a therapeutically effective amount of ripasudil or a pharmaceutically acceptable salt thereof following the intra-ocular surgery; wherein the post-surgical outcome is selected from: (a) central corneal endothelial cell density; (b) peripheral corneal endothelial cell density; (c) endothelial cell coefficient of variation and hexagonality; (d) return of central corneal thickness to pre-surgery baseline; (e) clearance of corneal edema; (f) best corrected distance visual acuity (BCVA); (g) Visual Function Questionnaire-25 (VFQ-25) domains and total score; and (h) combinations thereof.

In another embodiment the disclosure provides a method of improving post-surgical outcomes from intra-ocular surgery in a non-glaucomatous patient, comprising topically administering to the patient a therapeutically effective amount of ripasudil or a pharmaceutically acceptable salt thereof following the intra-ocular surgery; wherein the post-surgical outcome is selected from: (a) central corneal endothelial cell density; (b) peripheral corneal endothelial cell density; (c) endothelial cell coefficient of variation and hexagonality; (d) return of central corneal thickness to pre-surgery baseline; (e) clearance of corneal edema; (f) best corrected distance visual acuity (BCVA); (g) Visual Function Questionnaire-25 (VFQ-25) domains and total score; and (h) combinations thereof.

In another embodiment the disclosure provides a method of preventing adverse events from intra-ocular surgery comprising phacoemulsification with intraocular lens implantation in a non- glaucomatous patient in need thereof, comprising topically administering to the patient a therapeutically effective amount of ripasudil or a pharmaceutically acceptable salt thereof following the intra-ocular surgery.

In another embodiment the disclosure provides a method of preventing adverse events from intra-ocular surgery comprising phacoemulsification with intraocular lens implantation in a patient in need thereof, comprising topically administering to the patient four times daily a therapeutically effective amount of ripasudil or a pharmaceutically acceptable salt thereof following the intraocular surgery.

In another embodiment the disclosure provides a method of preventing or reducing adverse events resulting from intra-ocular surgery comprising phacoemulsification with intraocular lens implantation in a patient in need thereof having an endothelial cellular density (ECD) greater than 1,500 cells/mm², comprising topically administering to the patient a therapeutically effective amount of ripasudil or a pharmaceutically acceptable salt thereof following the intra-ocular surgery.

In another embodiment the disclosure provides a method of improving post-surgical outcomes from intra-ocular surgery comprising phacoemulsification with intraocular lens implantation in a patient in need thereof having an endothelial cellular density (ECD) greater than 1,500 cells/mm², comprising topically administering to the patient a therapeutically effective amount of ripasudil or a pharmaceutically acceptable salt thereof following the intra-ocular surgery; wherein the post-surgical outcome is selected from: (a) central corneal endothelial cell density; (b) peripheral corneal endothelial cell density; (c) endothelial cell coefficient of variation and hexagonality; (d) return of central corneal thickness to pre-surgery baseline; (e) clearance of corneal edema; (f) best corrected distance visual acuity (BCVA); (g) Visual Function Questionnaire-25 (VFQ-25) domains and total score; and (h) combinations thereof.

In another embodiment the disclosure provides a method of improving surgical outcomes from intra-ocular surgery in a patient having confluent central guttae in the Descemet membrane of any eye, comprising: (a) removing a central portion of the Descemet membrane from the eye; and (b) topically administering to the eye a therapeutically effective amount of ripasudil or a pharmaceutically acceptable salt thereof four times per day for twelve or more weeks following the surgery.

Yet another embodiment provides a preservative-free liquid solution of ripasudil hydrochloride comprising from 0.3% (w/v) to 0.5% (w/v) ripasudil hydrochloride, based on the weight of the free base of ripasudil excluding any waters of hydration.

In still another embodiment the disclosure provides a preservative-free liquid solution of ripasudil hydrochloride comprising: (a) from 0.3% (w/v) to 0.5% (w/v) ripasudil hydrochloride, based on the weight of the free base of ripasudil excluding any waters of hydration; (b) an optional pH buffer; (c) from 1.5% (w/v) to 2.0% (w/v) glycerol; (d) sodium hydroxide q.s. to a pH of from 4 to 7.5; and (e) purified water q.s. to 100%.

Additional advantages of the disclosure are set forth in part in the description which follows, and in part will be obvious from the description, or may be learned by practice of the disclosure. The advantages of the disclosure will be realized and attained by means of the elements and combinations particularly pointed out in the appended claims. It is to be understood that both the foregoing general description and the following detailed description are exemplary and explanatory only and are not restrictive of the disclosure, as claimed.

DETAILED DESCRIPTION

Definitions and Use o f Terms

As used in this specification and in the claims which follow, the singular forms “a,” “an” and “the” include plural referents unless the context clearly dictates otherwise.

As used in this specification and in the claims which follow, the word “comprise” and variations of the word, such as “comprising” and “comprises,” means “including but not limited to,” and is not intended to exclude, for example, other additives, components, integers or steps. When an element is described as comprising a plurality components, steps or conditions, it will be understood that the element can also be described as comprising any combination of such plurality, or “consisting of’ or “consisting essentially of’ the plurality or combination of components, steps or conditions.

“Approximately,” “about,” “ca.,” and terms of like import, when used to describe concentrations of components of a formulation, allow for variations in the recited concentrations that remain within the United States FDA’s requirements for a formulation that is qualitatively (QI) and quantitatively (Q2) the same as a reference formulation. I.e., unless otherwise specified, the term refers to a +/-5% difference in the recited concentration. However, it will be understood that the disclosure is not limited to +/-5% variability in the recited concentrations for a particular formulation. Thus, “approximately,” “about,” “ca.,” and terms of like import can also be substituted with +/-12%, or +/- 10%, +/-7%, +/-3%, or +/-1%..

“Therapeutically effective amount” means that amount which, when administered to a human for supporting or affecting a metabolic process, or for treating or preventing a disease, is sufficient to cause such treatment or prevention of the disease, or supporting or affecting the metabolic process.

When ranges are given by specifying the lower end of a range separately from the upper end of the range, or specifying particular numerical values, it will be understood that a range can be defined by selectively combining any of the lower end variables, upper end variables, and particular numerical values that is mathematically possible. In like manner, when a range is defined as spanning from one endpoint to another, the range will be understood also to encompass a span between and excluding the two endpoints.

When “drug therapy,” method of treatment, and terms of similar import is recited, it will be understood that the therapy can be accomplished through any suitable route of administration using any acceptable dosage form, and that the drug can be administered as the free base, a salt, or an ester or other prodrug moiety.

In the context of the present disclosure insofar as it relates to any of the disease conditions recited herein, the term “treatment” means to reduce the occurrence of a symptom or condition, or to relieve or alleviate at least one symptom associated with such condition, or to slow or reverse the progression of such condition, or to manage or affect the metabolic processes underlying such condition. Within the meaning of the present disclosure, the terms also denote to arrest, delay the onset (i.e., the period prior to clinical manifestation of a disease) and/or reduce the risk of developing or worsening a disease or adverse event. In like manner, “preventing” or “reducing” an adverse event will include reducing the risk of an adverse event, or reducing the severity of an adverse event, or delaying the onset of an adverse event, in a single patient or a patient population.

The phrase “acceptable” as used in connection with compositions of the disclosure, refers to molecular entities and other ingredients of such compositions that are physiologically tolerable and do not typically produce untoward reactions when administered to a subject (e g., a mammal such as a human).

Ripasudil, a derivative of fasudil, is a rho kinase inhibitor drug marketed in Japan as Glanatec® for the treatment of glaucoma and ocular hypertension. The compound has the following chemical structure: and is present in the preferred solutions of the present disclosure as a hydrochloride salt, more preferably the dihydrate hydrochloride salt.

When the term “ripasudil” is used herein, without any further qualifier, it will be understood to refer to ripasudil free base or any pharmaceutically acceptable salt or hydrate thereof, in any pharmaceutically acceptable crystalline or amorphous form.

When a concentration of ripasudil, ripasudil hydrochloride, or ripasudil hydrochloride dihydrate are expressed herein, it will be understood that the concentration is based on the weight of the anhydrous ripasudil free base, without considering the contributing weight of the hydrochloride ion or any waters of hydration, unless stated expressly to the contrary.

When treatment benefits are expressed in terms of established testing protocols or methodologies, it will be understood that the protocol or method used to evaluate benefit will be that version of the protocol in effect on August 8, 2022).

Discussion

The disclosure provides in one embodiment a method of improving visual acuity following intra-ocular surgery in a patient having confluent central guttae in the Descemet membrane and a cataractous lens in an eye, wherein the intraocular surgery comprises removing a central portion of the Descemet membrane from the eye and replacing the lens in the eye, comprising: (a) topically administering to the eye a therapeutically effective amount of ripasudil or a pharmaceutically acceptable salt thereof four times per day for twelve or more weeks following the surgery; and (b) improving the patient’s visual acuity.

In one embodiment the disclosure provides a method of returning corneal thickness to presurgery values, and maintaining said pre-surgery values following cessation of treatment, following intra-ocular surgery in a patient having confluent central guttae in the Descemet membrane and a cataractous lens in an eye, wherein the intraocular surgery comprises removing a central portion of the Descemet membrane from the eye and replacing the lens in the eye, comprising: (a) topically administering to the eye a therapeutically effective amount of ripasudil or a pharmaceutically acceptable salt thereof four times per day for twelve or more weeks following the surgery; (b) returning corneal thickness in the eye to pre-surgery values; and (c) maintaining corneal thickness at said pre-surgery levels following cessation of said administering.

In another embodiment the disclosure provides a method of improving surgical outcomes from intra-ocular surgery in a patient having confluent central guttae in the Descemet membrane and a cataractous lens in an eye, wherein the intraocular surgery comprises removing a central portion of the Descemet membrane from the eye and replacing the lens in the eye, comprising: (a) topically administering to the eye a therapeutically effective amount of ripasudil or a pharmaceutically acceptable salt thereof four times per day for twelve or more weeks following the surgery; and (b) improving a surgical outcome selected from central corneal endothelial cell density, peripheral corneal endothelial cell density, endothelial cell coefficient of variation and hexagonality, return of central corneal thickness to pre-surgery baseline, clearance of corneal edema, best corrected distance visual acuity (BCVA), Visual Function Questionnaire-25 (VFQ- 25) domains and total score, and combinations thereof.

In another embodiment the disclosure provides a method of preventing or reducing adverse events resulting from intra-ocular surgery in a patient in need thereof having an endothelial cellular density (ECD) greater than 1,500 cells/mm², comprising topically administering to the patient a therapeutically effective amount of ripasudil or a pharmaceutically acceptable salt thereof following the intra-ocular surgery.

In another embodiment the disclosure provides a method of improving post-surgical outcomes from intra-ocular surgery in a patient in need thereof having an endothelial cellular density (ECD) greater than 1,500 cells/mm², comprising topically administering to the patient a therapeutically effective amount of ripasudil or a pharmaceutically acceptable salt thereof following the intra-ocular surgery; wherein the post-surgical outcome is selected from: (a) central corneal endothelial cell density; (b) peripheral corneal endothelial cell density; (c) endothelial cell coefficient of variation and hexagonality; (d) return of central corneal thickness to pre-surgery baseline; (e) clearance of corneal edema; (f) best corrected distance visual acuity (BCVA);(g) Visual Function Questionnaire-25 (VFQ-25) domains and total score; and (h) combinations thereof.

In another embodiment the disclosure provides a method of improving post-surgical outcomes from intra-ocular surgery in a non-glaucomatous patient, comprising topically administering to the patient a therapeutically effective amount of ripasudil or a pharmaceutically acceptable salt thereof following the intra-ocular surgery; wherein the post-surgical outcome is selected from: (a) central corneal endothelial cell density; (b) peripheral corneal endothelial cell density; (c) endothelial cell coefficient of variation and hexagonality; (d) return of central corneal thickness to pre-surgery baseline; (e) clearance of corneal edema; (f) best corrected distance visual acuity (BCVA); (g) Visual Function Questionnaire-25 (VFQ-25) domains and total score; and (h) combinations thereof. In another embodiment the disclosure provides a method of preventing adverse events from intra-ocular surgery comprising phacoemulsification with intraocular lens implantation in a non- glaucomatous patient in need thereof, comprising topically administering to the patient a therapeutically effective amount of ripasudil or a pharmaceutically acceptable salt thereof following the intra-ocular surgery.

In another embodiment the disclosure provides a method of improving post-surgical outcomes from intra-ocular surgery comprising phacoemulsification with intraocular lens implantation in a patient in need thereof having an endothelial cellular density (ECD) greater than 1,500 cells/mm², comprising topically administering to the patient a therapeutically effective amount of ripasudil or a pharmaceutically acceptable salt thereof following the intra-ocular surgery; wherein the post-surgical outcome is selected from: (a) central corneal endothelial cell density; (b) peripheral corneal endothelial cell density; (c) endothelial cell coefficient of variation and hexagonality; (d) return of central corneal thickness to pre-surgery baseline; (e) clearance of corneal edema; (f) best corrected distance visual acuity (BCVA);(g) Visual Function Questionnaire-25 (VFQ-25) domains and total score; and (h) combinations thereof.

In another embodiment the disclosure provides a method of improving surgical outcomes from intra-ocular surgery in a patient having confluent central guttae in the Descemet membrane of any eye, comprising: (a) removing a central portion of the Descemet membrane from the eye; and (b) topically administering to the eye a therapeutically effective amount of ripasudil or a pharmaceutically acceptable salt thereof four times per day for twelve or more weeks following the surgery. Yet another embodiment provides a preservative-free liquid solution of ripasudil hydrochloride comprising from 0.3% (w/v) to 0.5% (w/v) ripasudil hydrochloride, based on the weight of the free base of ripasudil excluding any waters of hydration.

Patients Particularly Suitable for Treatment

The methods of the current disclosure can be further characterized based on various characteristics of the patient being treated. Thus, the methods can be practiced in individuals having endothelial cell density greater than 1,500 cells/mm². The methods also can be practiced in patients having an endothelial cell density greater than 1,750 or 2,000 cells/mm².

The methods also can be practiced based on the patient’s peripheral endothelial cell density. Thus, the methods can be practiced in individuals having peripheral endothelial cell density greater than 1,500 cells/mm². The methods also can be practiced in patients having a peripheral endothelial cell density greater than 1,750, 2,000, 2,250, or even 2,500 cells/mm².

The methods also can be practiced in glaucomatous and non-glaucomatous patients, preferably non-glaucomatous patients.

The patients also can be characterized by their risk of having an adverse event. Thus, for example, any of the current methods can be practiced with patients is at increased risk of adverse events due to one or a combination of anterior chamber depth, phacoemulsification power and duration, hard and large nucleus, endothelial contact from nuclear fragments, IOL, air bubbles, irrigation fluid, implantation technique, type of IOL, short axial length, free radical release, small pupil, and toxicity of medications given during surgery. The nuclear hardness graded by the Emery -Little classification can exceed 3, 4, or even 5. The duration of surgery might exceed 30, 45, 60, 75, or 90 minutes.

In one embodiment the patient has peripheral ECD ungradable in all areas (nasal, temporal, superior, and inferior) due to a medical reason such as guttae, corneal edema, or striae and baseline BCVA=0. In another embodiment the patient has peripheral ECD ungradable in all areas (nasal, temporal, superior, and inferior) due to a medical reason such as guttae, corneal edema, or striae and baseline BCVA>0.

In another embodiment the patient has average peripheral ECD <1200 cells/mm² and baseline BCVA=0.

In yet another embodiment the patient has average peripheral ECD <1200 cells/mm² and baseline BCVA>0.

In another embodiment the patient has average peripheral ECD >1200 cells/mm² and baseline BCVA=0.

In another embodiment the patient has average peripheral ECD >1200 cells/mm² and baseline BCVA>0.

Drug Administration

In any of the methods of the present disclosure, the drug is preferably administered dropwise, and is preferably administered as one drop per administration. While the drug will commonly be administered 4 times per day for optimum therapeutic benefit and minimization of side effects, the drug can also be administered at various daily frequencies, but preferably is administered from 2 to 8 times daily, from 4 to 6 times daily, from 2 to 4 times daily, or simply 2, 3, or 4 times daily.

While the drug will commonly be administered for 12 consecutive weeks following the surgery for optimum therapeutic benefit and minimization of side effects, the length of administration also can vary. Thus, in any of the first through sixth principal embodiments, the drug can be administered from 4 to 52 weeks, from 12 to 36 weeks, or from 18 to 36 weeks, at least 4 weeks, 6 weeks, 8 weeks, 12 weeks, 16 weeks, 20 weeks, 24 weeks, or 26 weeks, or simply 4 weeks, 6 weeks, 8 weeks, 12 weeks, 16 weeks, 20 weeks, 24 weeks, or 26 weeks.

An additional tapering period can be added to any of the foregoing lengths of administration, during which the dose is decreased over a period of from 1 to 4 weeks, preferably 2 weeks. During this “tapering phase,” the dose of the drug can be reduced in a stepwise fashion, or alternatively, the dose can simply be cut in 'A during this tapering phase, and reduced to zero at the end of the tapering phase.

The ripasudil can also be supplemented by an antibiotic and/or a steroid. Thus, the methods of the current invention may additionally further comprise after step (a) topically administering to the treated eye a broad-spectrum antibiotic, preferably 0.5% moxifloxacin hydrochloride and a glucocorticoid, preferably 1% prednisolone acetate.

The ripasudil can be administered following various intra-ocular surgeries to achieve the therapeutic endpoints or reduction in adverse events described herein. Thus, the methods can be practiced after intra-ocular surgery comprising phacoemulsification with intraocular lens implantation. The methods also can be practiced after intra-ocular surgery comprising descemetorhexis. The methods also can be practiced after intra-ocular surgery comprising descemetorhexis and phacoemulsification with intraocular lens implantation.

Therapeutic Endpoints and Adverse Events

Various endpoints can be used to evaluate the effectiveness of the methods of the current disclosure. The method can be improve post-surgical outcomes selected from: (a) central corneal endothelial cell density; (b) peripheral corneal endothelial cell density; (c) endothelial cell coefficient of variation and hexagonality; (d) return of central comeal thickness to pre-surgery baseline; (e) clearance of corneal edema; (f) best corrected distance visual acuity (BCVA);(g) Visual Function Questionnaire-25 (VFQ-25) domains and total score; and (h) combinations thereof.

The methods also can prevent or reduce or reduce the risk of adverse events. Thus, the methods also can be practiced to prevent or reduce or reduce the risk of one or more adverse events selected from corneal edema, endothelial cell loss, corneal scarring, reduced visual acuity, cystoid macular edema, increased intraocular pressure, posterior capsular opacification (secondary cataract), chronic uveitis, fibrin formation, protein leakage from the breakdown of the blood- aqueous barrier, retinal detachment, posterior vitreous detachment, photophobia, ocular irritation, gastrointestinal toxicities, and relapse edema.

The methods can be practiced to reduce or prevent corneal adverse events. Thus, for example, the methods can prevent or reduce an adverse event which is a comeal adverse event selected from comeal edema, endothelial cell loss, corneal scarring, and reduced visual acuity. In one particular embodiment, the methods are practiced to reduce corneal irritation or eye irritation associated with prior methods, particularly ocular discomfort or gritty sensations.

The methods also can be practiced to prevent or reduce an adverse event which is a non- corneal adverse event. Thus, for example, the methods can prevent or reduce an adverse event which is a a non-corneal adverse event selected from cystoid macular edema, increased intraocular pressure, posterior capsular opacification (secondary cataract), chronic uveitis, fibrin formation, protein leakage from the breakdown of the blood-aqueous barrier, retinal detachment, posterior vitreous detachment, photophobia, ocular irritation, gastrointestinal toxicities, and relapse edema.

In one particular embodiment, the methods are practiced to reduce gastrointestinal toxicities commonly associate with ROCK inhibitors such as gastrointestinal upset.

In another particular embodiment, the methods are practiced to reduce the incidence of relapse edema.

Formulations of the Present Disclosure

In general, any pharmaceutically acceptable solution of ripasudil, at a concentration of from 0.1 to 1.0% (w/v) ripasudil, is suitable for practicing the methods of the current disclosure. Preferably, the solution is free of preservatives such as benzalkonium chloride. In one embodiment, the solution is free of benzalkonium chloride. A preferred concentration of ripasudil is from 0.2 to 0.5% (w/v) or approximately 0.4% (w/v) in the solution. In one embodiment, the solution comprises less than 0.1%, 0.01%, 0.001%, 0.0001%, 0.00001%, or 0.000001% (w/v) preservatives. In another embodiment, the solution comprises less than 0.1%, 0.01%, 0.001%, 0.0001%, 0.00001%, or 0.000001% (w/v) benzalkonium chloride.

A preferred formulation will be preservative-free, and will further comprise glycerin, sodium dihydrogen phosphate and sodium hydroxide at a pH of from about 5 to about 7. The sodium dihydrogen phosphate can be hydrated or anhydrous, but in a preferred embodiment is the dihydrate. The glycerin can be biologically derived or synthetic, and may comprise up to 20% (v/v) water when added to the formulation, but is preferably synthetic and preferably comprises less than 1%, 0.5%, or 0.1% (v/v) water when added to the formulation. If water is present in the glycerin when added to the formulation, it will be understood that the water is not used in any of the calculations of glycerin concentration used in this document.

Pharmaceutically acceptable carriers include aqueous solutions, non-toxic excipients, including salts, preservatives, buffers and the like, as described, for instance, in Remington's Pharmaceutical Sciences, 15th ed., Easton: Mack Publishing Co., 1405-1412, 1461-1487 (1975), and The National Formulary XIV., 14th ed., Washington: American Pharmaceutical Association (1975), the contents of which are hereby incorporated by reference. The pH and exact concentration of the various components of pharmaceutical compositions can be adjusted according to routine skills in the art. See Goodman and Gilman's, The Pharmacological Basis for Therapeutics (7th ed.).

In a preferred embodiment, the formulation used in the methods of the current disclosure is the same formulation that constitutes the seventh principal embodiment of the present disclosure. Thus, in a preferred embodiment, the methods of the present disclosure are practiced with a preservative-free liquid solution of ripasudil hydrochloride comprising: (a) from 0.3% (w/v) to 0.5% (w/v) ripasudil hydrochloride, based on the weight of the free base of ripasudil excluding any waters of hydration; (b) an optional pH buffer; (c) from 1.5% (w/v) to 2.0% (w/v) glycerol;

(d) sodium hydroxide q.s. to a pH of from 4 to 7.5; and (e) purified water q.s. to 100%.

This preferred formulation can be more particularly characterized based on various parameters. Thus, in one subembodiment the formulation comprises from 0.35% (w/v) to 0.45% (w/v) ripasudil hydrochloride, based on the weight of the free base of ripasudil excluding any waters of hydration. In another subembodiment the formulation comprises from 0.35% (w/v) to 0.45% (w/v) sodium dihydrogen phosphate, excluding any waters of hydration;

A particularly preferred formulation comprises (a) approximately 0.4% (w/v) ripasudil hydrochloride, based on the weight of the free base of ripasudil excluding any waters of hydration;

(b) approximately 0.4% (w/v) sodium dihydrogen phosphate, excluding any waters of hydration;

(c) approximately 1.77% (w/v) glycerol; (d) sodium hydroxide q.s. to a pH of from 5 to 7; and (e) purified water q.s. to 100%.

Any of the foregoing embodiments or subembodiments can be further characterized by comprising: (a) approximately 0.49 g/100 mL ripasudil hydrochloride dihydrate; (b) approximately 0.52 g/100 mL sodium dihydrogen phosphate dihydrate; (c) the absence of any preservatives, anti-oxidants, or chelating agents; (d) the absence of benzalkonium chloride; and/or

(e) any combination thereof.

ADDITIONAL EXEMPLARY EMBODIMENTS

[Embodiment 1] A method of improving visual acuity following intra-ocular surgery in a patient having confluent central guttae in the Descemet membrane and a cataractous lens in an eye, wherein the intraocular surgery comprises removing a central portion of the Descemet membrane from the eye and replacing the lens in the eye, comprising: (a) topically administering to the eye a therapeutically effective amount of ripasudil or a pharmaceutically acceptable salt thereof four times per day for twelve or more weeks following the surgery; and (b) improving the patient’s visual acuity.

[Embodiment 2] A method of returning corneal thickness to pre-surgery values, and maintaining said pre-surgery values following cessation of treatment, following intra-ocular surgery in a patient having confluent central guttae in the Descemet membrane and a cataractous lens in an eye, wherein the intraocular surgery comprises removing a central portion of the Descemet membrane from the eye and replacing the lens in the eye, comprising: (a) topically administering to the eye a therapeutically effective amount of ripasudil or a pharmaceutically acceptable salt thereof four times per day for twelve or more weeks following the surgery; (b) returning corneal thickness in the eye to pre-surgery values; and (c) maintaining corneal thickness at said pre-surgery levels following cessation of said administering.

[Embodiment 3] A method of returning corneal thickness to pre-surgery values, and maintaining said pre-surgery values following cessation of treatment, following intra-ocular surgery in a patient having a cataractous lens in an eye, wherein the intraocular surgery comprises replacing the lens in the eye, comprising: (a) topically administering to the eye a therapeutically effective amount of ripasudil or a pharmaceutically acceptable salt thereof four times per day for twelve or more weeks following the surgery; (b) returning corneal thickness in the eye to pre- surgery values; and (c) maintaining corneal thickness at said pre-surgery levels following cessation of said administering.

[Embodiment 4] A method of improving surgical outcomes from intra-ocular surgery in a patient having confluent central guttae in the Descemet membrane and a cataractous lens in an eye, wherein the intraocular surgery comprises removing a central portion of the Descemet membrane from the eye and replacing the lens in the eye, comprising: (a) topically administering to the eye a therapeutically effective amount of ripasudil or a pharmaceutically acceptable salt thereof four times per day for twelve or more weeks following the surgery; and (b) improving a surgical outcome selected from central corneal endothelial cell density, peripheral corneal endothelial cell density, endothelial cell coefficient of variation and hexagonality, return of central corneal thickness to pre-surgery baseline, clearance of corneal edema, best corrected distance visual acuity (BCVA), Visual Function Questionnaire-25 (VFQ-25) domains and total score, and combinations thereof. [Embodiment 5] A method of preventing or reducing adverse events resulting from intraocular surgery in a patient in need thereof having an endothelial cellular density (ECD) greater than 1,500 cells/mm², comprising topically administering to the patient a therapeutically effective amount of ripasudil or a pharmaceutically acceptable salt thereof following the intra-ocular surgery.

[Embodiment 6] A method of preventing or reducing adverse events resulting from intraocular surgery in a patient at increased risk of such adverse events, comprising topically administering to the patient a therapeutically effective amount of ripasudil or a pharmaceutically acceptable salt thereof following the intra-ocular surgery, wherein: (a) the surgery comprises phacoemulsification with intraocular lens implantation; and (b) the patient is at increased risk of adverse events due to one or a combination of anterior chamber depth, phacoemulsification power and duration, hard and large nucleus, endothelial contact from nuclear fragments, IOL, air bubbles, irrigation fluid, implantation technique, type of IOL, short axial length, free radical release, small pupil, and toxicity of medications given during surgery.

[Embodiment 7] A method of improving post-surgical outcomes from intra-ocular surgery in a patient in need thereof having an endothelial cellular density (ECD) greater than 1,500 cells/mm², comprising topically administering to the patient a therapeutically effective amount of ripasudil or a pharmaceutically acceptable salt thereof following the intra-ocular surgery; wherein the post-surgical outcome is selected from: (a) central corneal endothelial cell density; (b) peripheral corneal endothelial cell density; (c) endothelial cell coefficient of variation and hexagonality; (d) return of central corneal thickness to pre-surgery baseline; (e) clearance of corneal edema; (f) best corrected distance visual acuity (BCVA); (g) Visual Function Questionnaire-25 (VFQ-25) domains and total score; and (h) combinations thereof.

[Embodiment 8] A method of improving post-surgical outcomes from intra-ocular surgery in a non-glaucomatous patient, comprising topically administering to the patient a therapeutically effective amount of ripasudil or a pharmaceutically acceptable salt thereof following the intraocular surgery; wherein the post-surgical outcome is selected from: (a) central corneal endothelial cell density; (b) peripheral corneal endothelial cell density; (c) endothelial cell coefficient of variation and hexagonality; (d) return of central corneal thickness to pre-surgery baseline; (e) clearance of corneal edema; (f) best corrected distance visual acuity (BCVA); (g) Visual Function Questionnaire-25 (VFQ-25) domains and total score; and (h) combinations thereof. [Embodiment 9] A method of preventing adverse events from intra-ocular surgery comprising phacoemulsification with intraocular lens implantation in a non-glaucomatous patient in need thereof, comprising topically administering to the patient a therapeutically effective amount of ripasudil or a pharmaceutically acceptable salt thereof following the intra-ocular surgery.

[Embodiment 10] A method of preventing adverse events from intra-ocular surgery comprising phacoemulsification with intraocular lens implantation in a patient in need thereof, comprising topically administering to the patient four times daily a therapeutically effective amount of ripasudil or a pharmaceutically acceptable salt thereof following the intra-ocular surgery.

[Embodiment 11] A method of preventing or reducing adverse events resulting from intraocular surgery comprising phacoemulsification with intraocular lens implantation in a patient in need thereof having an endothelial cellular density (ECD) greater than 1,500 cells/mm², comprising topically administering to the patient a therapeutically effective amount of ripasudil or a pharmaceutically acceptable salt thereof following the intra-ocular surgery.

[Embodiment 12] A method of improving post-surgical outcomes from intra-ocular surgery comprising phacoemulsification with intraocular lens implantation in a patient in need thereof having an endothelial cellular density (ECD) greater than 1,500 cells/mm², comprising topically administering to the patient a therapeutically effective amount of ripasudil or a pharmaceutically acceptable salt thereof following the intra-ocular surgery; wherein the post- surgical outcome is selected from: (a) central corneal endothelial cell density; (b) peripheral corneal endothelial cell density; (c) endothelial cell coefficient of variation and hexagonality; (d) return of central corneal thickness to pre-surgery baseline; (e) clearance of corneal edema; (f) best corrected distance visual acuity (BCVA); (g) Visual Function Questionnaire-25 (VFQ-25) domains and total score; and (h) combinations thereof.

[Embodiment 13] A method of improving surgical outcomes from intra-ocular surgery in a patient having confluent central guttae in the Descemet membrane of any eye, comprising: (a) removing a central portion of the Descemet membrane from the eye; and (b) topically administering to the eye a therapeutically effective amount of ripasudil or a pharmaceutically acceptable salt thereof four times per day for twelve or more weeks following the surgery.

[Embodiment 14] The method of embodiment 2 or 3, wherein said returning corneal thickness in the eye to pre-surgery values occurs following cessation of said administering. [Embodiment 15] The method of any of embodiments 1 -14, wherein the patient has peripheral ECD ungradable in all areas (nasal, temporal, superior, and inferior) due to a medical reason such as guttae, corneal edema, or striae and baseline BCVA=0.

[Embodiment 16] The method of any of embodiments 1-14, wherein the patient has peripheral ECD ungradable in all areas (nasal, temporal, superior, and inferior) due to a medical reason such as guttae, corneal edema, or striae and baseline BCVA>0.

[Embodiment 17] The method of any of embodiments 1-14, wherein the patient has average peripheral ECD <1200 cells/mm² and baseline BCVA=0.

[Embodiment 18] The method of any of embodiments 1-14, wherein the patient has average peripheral ECD <1200 cells/mm² and baseline BCVA>0.

[Embodiment 19] The method of any of embodiments 1-14, wherein the patient has average peripheral ECD >1200 cells/mm² and baseline BCVA=0.

[Embodiment 20] The method of any of embodiments 1-14, wherein the patient has average peripheral ECD >1200 cells/mm² and baseline BCVA>0.

[Embodiment 21] The method of any of embodiments 1-20, wherein the eye has a central corneal thickness < 670 pM.

[Embodiment 22] The method of any of embodiments 1-21, wherein the patient is at increased risk of adverse events due to one or a combination of anterior chamber depth, phacoemulsification power and duration, hard and large nucleus, endothelial contact from nuclear fragments, IOL, air bubbles, irrigation fluid, implantation technique, type of IOL, short axial length, free radical release, small pupil, and toxicity of medications given during surgery.

[Embodiment 23] The method of any of embodiments 1-22, further comprising improving a post-surgical outcome selected from: (a) central corneal endothelial cell density; (b) peripheral corneal endothelial cell density; (c) endothelial cell coefficient of variation and hexagonality; (d) return of central corneal thickness to pre-surgery baseline; (e) clearance of corneal edema; (f) best corrected distance visual acuity (BCVA); (g) Visual Function Questionnaire-25 (VFQ-25) domains and total score; and (h) combinations thereof.

[Embodiment 24] The method of any of embodiments 1-23, comprising reducing one or more adverse events selected from corneal edema, endothelial cell loss, corneal scarring, reduced visual acuity, cystoid macular edema, increased intraocular pressure, posterior capsular opacification (secondary cataract), chronic uveitis, fibrin formation, protein leakage from the breakdown of the blood-aqueous barrier, retinal detachment, posterior vitreous detachment, photophobia, ocular irritation, gastrointestinal toxicities, and relapse edema.

[Embodiment 25] The method of any of embodiments 1-24, wherein the patient is non- glaucomatous.

[Embodiment 26] The method of embodiments 1-25, wherein the intra-ocular surgery comprises phacoemulsification with intraocular lens implantation.

[Embodiment 27] The method of any of embodiments 1-26, comprising preventing or reducing an adverse event which is a corneal adverse event.

[Embodiment 28] The method of any of embodiments 1-27, comprising preventing or reducing an adverse event which is a corneal adverse event selected from corneal edema, endothelial cell loss, corneal scarring, and reduced visual acuity.

[Embodiment 29] The method of any of embodiments 1-28, comprising preventing or reducing an adverse event which is a non-corneal adverse event.

[Embodiment 30] The method of any of embodiments 1-29, comprising preventing or reducing an adverse event which is a non-corneal adverse event selected from cystoid macular edema, increased intraocular pressure, posterior capsular opacification (secondary cataract), chronic uveitis, fibrin formation, protein leakage from the breakdown of the blood-aqueous barrier, retinal detachment, posterior vitreous detachment, photophobia, ocular irritation, gastrointestinal toxicities, and relapse edema.

[Embodiment 31] The method of any of embodiments 1 -30, wherein the intra-ocular surgery comprises descemetorhexis.

[Embodiment 32] The method of any of embodiments 1-31, wherein the intra-ocular surgery comprises removing from 4.5 to 5.5 mm of the central portion of the Descemet membrane from the patient's eye.

[Embodiment 33] The method of any of embodiments 1-32, wherein the intra-ocular surgery comprises phacoemulsification with intraocular lens implantation.

[Embodiment 34] The method of any of embodiments 1-33, wherein the intra-ocular surgery comprises descemetorhexis and phacoemulsification with intraocular lens implantation.

[Embodiment 35] The method of any of embodiments 1-34, comprising administering the ripasudil or pharmaceutically acceptable salt thereof four times daily for a period of at least 12 weeks. [Embodiment 36] The method of any of embodiments 1-35, comprising administering the ripasudil or pharmaceutically acceptable salt thereof from four times daily for a period of 12 weeks followed by a two week taper phase at two times daily administration.

[Embodiment 37] The method of any of embodiments 1-36, further comprising after the ripasudil administration topically administering to said eye a broad-spectrum antibiotic, preferably 0.5% moxifloxacin hydrochloride and a glucocorticoid, preferably 1% prednisolone acetate.

[Embodiment 38] The method of any of embodiments 1-37, wherein the patient is at increased risk of adverse events due to one or a combination of anterior chamber depth, phacoemulsification power and duration, hard and large nucleus, endothelial contact from nuclear fragments, IOL, air bubbles, irrigation fluid, implantation technique, type of IOL, short axial length, free radical release, small pupil, and toxicity of medications given during surgery.

[Embodiment 39] The method of any of claims 1-38, wherein a therapeutically effective amount of ripasudil or a pharmaceutically acceptable salt thereof is in a preservative-free liquid solution.

[Embodiment 40] A preservative-free liquid solution of ripasudil hydrochloride comprising from 0.3% (w/v) to 0.5% (w/v) ripasudil hydrochloride, based on the weight of the free base of ripasudil excluding any waters of hydration.

[Embodiment 41] A preservative-free liquid solution of ripasudil hydrochloride comprising: (a) from 0.3% (w/v) to 0.5% (w/v) ripasudil hydrochloride, based on the weight of the free base of ripasudil excluding any waters of hydration; (b) an optional pH buffer; (c) from 1 .5% (w/v) to 2.0% (w/v) glycerol; (d) sodium hydroxide q.s. to a pH of from 4 to 7.5; and (e) purified water q.s. to 100%.

[Embodiment 42] The solution of embodiment 40 or 41, comprising from 0.35% (w/v) to 0.45% (w/v) sodium dihydrogen phosphate, excluding any waters of hydration.

[Embodiment 43] The solution of embodiment 40 or 41, comprising: (a) approximately 0.4% (w/v) ripasudil hydrochloride, based on the weight of the free base of ripasudil excluding any waters of hydration; (b) approximately 0.4% (w/v) sodium dihydrogen phosphate, excluding any waters of hydration; (c) approximately 1.77% (w/v) glycerol; (d) sodium hydroxide q.s. to a pH of from 5 to 7; and (e) purified water q.s. to 100%. [Embodiment 44] The solution of any of embodiments 40-42, comprising: (a) approximately 0.49 g/100 mL ripasudil hydrochloride dihydrate; and/or (b) approximately 0.52 g/100 mL sodium dihydrogen phosphate dihydrate.

[Embodiment 45] The solution of any of embodiments 40-44, in the absence of any preservatives, anti-oxidants, or chelating agents.

[Embodiment 46] The solution of any of embodiments 40-45, in the absence of benzalkonium chloride.

[Embodiment 47] The method of any of embodiments 1-39, wherein the ripasudil is administered from the solution of embodiment 40.

[Embodiment 48] The method of any of embodiments 1-39, wherein the ripasudil is administered from the solution of embodiment 41.

[Embodiment 49] The method of any of embodiments 1-39, wherein the ripasudil is administered from the solution of embodiment 42.

[Embodiment 50] The method of any of embodiments 1-39, wherein the ripasudil is administered from the solution of embodiment 43.

[Embodiment 51] The method of any of embodiments 1-39, wherein the ripasudil is administered from the solution of embodiment 44.

[Embodiment 52] The method of any of embodiments 1-39, wherein the ripasudil is administered from the solution of embodiment 45.

[Embodiment 53] The method of any of embodiments 1 -39, wherein the ripasudil is administered from the solution of embodiment 46.

EXAMPLES

In the following examples, efforts have been made to ensure accuracy with respect to numbers (e.g., amounts, temperature, etc.) but some errors and deviations should be accounted for. The following examples are put forth so as to provide those of ordinary skill in the art with a complete disclosure and description of how the methods claimed herein are made and evaluated, and are intended to be purely exemplary of the disclosure and are not intended to limit the scope of what the inventors regard as their invention.

Example 1. Optimized Ripasudil Eye Drop Formulation K-321 investigational medicinal product will be sterile non-preserved unit dose eye drops containing ripasudil hydrochloride dihydrate equivalent to 0.4% ripasudil.

• Active constituents: ripasudil hydrochloride dihydrate

• Other constituents: sodium dihydrogen phosphate dihydrate, glycerol 100%, sodium hydroxide, water for injections.

Example 2. Descemetorhexis of the Study Eye

As a condition of participating in the clinical study described in Example 3, each patient underwent descemetorhexis of a study eye selected by the investigator for surgery. A digital photo of the study eye was taken immediately before and immediately after the descemetorhexis. The investigator performed descemetorhexis to remove central confluent guttae, removing an area of Descemet membrane with a diameter of 4.5 to 5.5 mm. The longest diameter and the shortest diameter was recorded. Detailed procedures for performing descemetorhexis are described in several literature references, including, for example, Macsai MS, Shiloach M. Cornea. 2019;38:529-534, and Moloney G, Congote DG, Hirnschall N, et al. Cornea. 2020 Jul 31. doi: 10.1097/ICO.0000000000002437. Online ahead of print.

Recommended post-descemetorhexis concomitant therapy consisted of broad spectrum antibiotic (0.5% moxifloxacin hydrochloride) instilled at least once daily for 1 week and glucocorticoid (1% prednisolone acetate) instilled 3 times daily for the first 7 days, followed by once daily for the next 7 days, and terminated thereafter. The investigator was permitted to add antibiotic and glucocorticoid dosing after this 14 days as rescue therapy if the investigator judged it necessary. When more than 1 different eye drop was administered (including study drug), the study drug was required to be administered first, followed by any non-study eye drop (after at least 5 minutes have passed).

Example 3. A Double Masked, Randomized, Placebo Controlled, Parallel Group, 12 Week, Phase 2 Study to Investigate the Safety and Efficacy of Ripasudil Eye Drops After Descemetorhexis in Patients with Fuchs Endothelial Corneal Dystrophy _

In this U.S. FDA approved study, the primary objective was to investigate the effect of K- 321 dosed for 12 weeks on central ECD in patients with FECD after descemetorhexis. Secondary and exploratory objectives of this study included (i) investigating the effect of K-321 on central ECD, corneal thickness, and corneal clarity in patients with FECD at each visit after descemetorhexis out to 52 weeks, (ii) assessing the safety and tolerability of K-321 in patients with FECD at each visit after descemetorhexis out to 52 weeks, and (iii) investigating the effect of K- 321 on visual acuity, visual contrast sensitivity, corneal morphology, and vision related quality of life.

Study Design:

This was a multi-centre, double-masked, randomised, parallel-group, placebo-controlled, 2-period study of patients with FECD after descemetorhexis.

The first period was the treatment period, consisting of a screening visit within a 1-to 4- week screening period, a descemetorhexis and randomisation visit, a 12-week full treatment period containing 7 interim visits (including 1 optional visit at Week 2) and an end-of-treatment (EOT) visit scheduled for Week 12. During the 2 weeks immediately following the EOT visit, each enrolled patient tapered dosing of study drug to zero.

The second period was a follow-up observation period of 40 weeks, including the tapering phase and containing 4 interim visits and an end-of-study (EOS) visit. Patients were not to selfadminister study drug after approximately Week 14. Patients were considered to have completed the study with the completion of their EOS visit (scheduled for Week 52).

There were 3 treatment groups: K-321 ophthalmic solution 0.4% dosed 4 times daily (QID); K-321 ophthalmic solution 0.4% dosed 2 twice daily (BID); and placebo. After obtaining informed consent at Visit 1, the investigator selected one eye as the study eye and the patient came back for the descemetorhexis operation and random assignment to treatment after 1 to 4 weeks (Visit 2). At Visit 2, each patient’s eligibility for study participation was confirmed, including a successful descemetorhexis operation that meets the inclusion criteria.

After eligibility was confirmed, patients were randomly assigned to the 3 treatment groups (in a 1 : 1 :1 ratio). All patients were instructed to apply the study drug only to the study eye.

Except on days of study visits on Day 1 through Week 12 (not including Visit 9) during the treatment period, study drug was dosed by the patient 4 times per day: morning, mid-day, evening, and night. Each patient was provided with 2 sets of color-coded ampoule pouches, one set to be applied morning and night (M/N) and the other to be applied mid-day and evening (MD/E). On study visit days Visit 3 through Visit 9, patients did not apply any study drug until after all study measurements had been completed; thereafter on those days, patients started dosing with the dose closest in timing to the dosing regimen and continued with the remaining doses for the day. Additionally, on Visit 3 they applied study drug after the end of the descemetorhexis procedure on Day-1 (Visit2).

At Visit 9 (Week 12), patients entered the drug-tapering phase of the follow-up period, and new study drug was dispensed.

During the follow up period, patients attended 5 study visits, starting at Week 16 (Visit 10). A central corneal image analysis reading centre (CIARC) determined central ECD by analysing digital images of the corneal endothelium.

Main Inclusion Criteria:

Each patient was required to meet all of the following criteria to be enrolled in this study:

1. Is at least 18 years old at the screening visit.

2. Has a diagnosis of FECD.

3. Has confluent central guttae in the study eye that can be removed by descemetorhexis of a circular area of 5 mm diameter or less.

4. Has a study eye with best corrected visual acuity BCVA of 75 letters or fewer by Early Treatment Diabetic Retinopathy Study ETDRS testing (Snellen equivalent of 20/32 or worse).

5. The study eye descemetorhexis is confirmed to have excised a central area with confluent guttae and a diameter of 4.5 to 5.5 mm.

Main Exclusion Criteria:

Patients meeting any of the following criteria were excluded from the study:

1. Is a female patient pregnant or at risk of becoming pregnant.

2. Has a study eye with confluent guttae in the periphery or confluent guttae outside the stripped area (individual guttae are allowed).

Note that patients may have individual or small number of guttae remaining outside the stripped area, but there should be no areas of confluent guttae remaining after the descemetorhexis. For example, a patient who had 5 to 10 guttae remaining in a few spots around the circumference of the descemetorhexis would not be excluded by this criterion.

3. Has a study eye with a history of cataract surgery within 90 days, prior ocular surgery other than cataract, or plans to receive any surgical treatment on the study eye during study.

4. Plans to receive any surgical treatment for FECD or cataract on the non-study eye, or has had ocular surgery in the non-study eye within 30 days.

5. Has advanced corneal stromal oedema defined as the presence of widespread haze or bullae on slit lamp examination.

6. Has a study eye with central corneal thickness > 670 pm.

7. Has known severe comorbidities that may interfere with descemetorhexis (e.g., a bacterial, viral, or fungal ophthalmic infection).

Efficacy Assessments:

Efficacy assessments included corneal ECD, corneal thickness, corneal oedema , corneal morphology, BCVA, contrast sensitivity, and the Visual Function Questionnaire 25 (VFQ 25).

Safety Assessments:

Safety assessments included the identification of AEs ocular safety assessments of both eyes (including slit lamp examination without pupil dilation to evaluate the condition of the lids, conjunctiva, anterior chamber, and cornea; intra ocular pressure measurement; and ocular examination with pupil dilation using an indirect ophthalmoscope according to the current standard of practice to evaluate the condition of the vitreous, macula, retina, optic nerve, choroid, and retinal periphery); vital sign measurements; and laboratory examinations.

Study Drug, Dosage, and Route of Administration:

Study drug was either K-321 ophthalmic solution containing ripasudil 0.4% (K-321 0.4%) or matching placebo. The K-321 treatments comprised either BID or QID dosing of K-321.

Sample Size:

A total of 65 patients were randomly assigned to study drug, including 21 patients in the K-321 QID group and 22 patients each in the K-321 BID and placebo groups. Two (9.1%) patients discontinued treatment prior to Week 12 from the placebo group due to rescue keratoplasty; 3 (4.6%) patients were withdrawn from the study. Overall, 62 (95.4%) patients completed Week 52 (treatment and follow-up periods)

Primary Endpoint Results:

The median central corneal ECD at week 12 was higher in the K-321 QID group than in the K-321 BID group, indicating better improvement. The Hodges-Lehmann estimates for the K- 321 QID and K-321 BID groups were 336.55 cells/mm² (95% CI=69.10, 560.20) and 306.60 cells/mm² (95% CI=0.00, 531.80), respectively, with Moses 95% confidence intervals compared with the placebo group. There was a statistically significant difference noted for both the K-321 QID group (p=0.0065) and the K-321 BID group (p=0.0344) compared with the placebo group by Wilcoxon rank sum test.

Secondary Endpoints Results:

Central Corneal ECD

Over time, the median central corneal ECD increased for all treatment groups and there was statistically significant difference noted for both of the K-321 groups compared with the placebo group. The median central corneal ECD was higher in K-321 QID group than in K-321 BID group, indicating greater improvement at most of the visits. The proportion of patients who achieved central corneal ECD of 700 cells/mm² or more increased gradually during the course of the study in the K-321 groups compared with the placebo group from Week 7 onwards, with no statistically significant difference between the K-321 groups and the placebo group at most of the visits. Statistically significant differences were observed in the K-321 QID group versus the placebo group at Week 38 and Week 52.

A total of 16 (76.2%) patients in K-321 QID group, 12 (54.5%) patients in K-321 BID group, and 10 (45.5%) patients in the placebo group achieved a central corneal ECD of 700 cells/mm² or more, with a median duration of 141 days, 181 days, and 273 days, respectively. No statistically significant difference was observed in the K-321 groups compared with the placebo group.

Central Corneal Thickness A gradual decrease from baseline in median central corneal thickness was observed over time in K-321 groups beginning at Week 7 (-4.50, -16.00, and 132.00 pm for the K-321 QID, K- 321 BID, and placebo groups, respectively); a median decrease from baseline was not observed for the placebo group until Week 52 (-24.20, -37.70, and -15.00 pm for the K-321 QID, K-321 BID, and placebo groups, respectively). Similar results were observed in the percentage change from baseline in central corneal thickness.

Overall, the proportion of patients achieving a corneal thickness less than or equal to baseline corneal thickness gradually increased in all treatment groups from Week 3 onwards, with no statistically significant difference for the K-321 groups compared with the placebo group at most of the visits.

A total of 18 (85.7%) patients in K-321 QID group, 19 (86.4%) patients in K-321 BID group, and 13 (59.1%) patients in the placebo group had return of central corneal thickness of the study eye to less than or equal to baseline corneal thickness. A statistically significant difference was found in the K-321 QID (p=0.0259) and K-321 BID group (p=0.0068) compared with the placebo group.

Corneal Edema

No patients achieved no corneal edema until Week 3 (8 [38.1%], 0, and 1 [4.5%] patients in the K-321 QID, K-321 BID, and placebo groups, respectively). Gradual increases in the proportions of patients achieving no corneal edema occurred in all groups from Week 3 onwards, with a statistically significant difference compared with the placebo group at most visits through Week 38 for the K-321 QID group and through Week 16 for the K-321 BID group.

A total of 18 (85.7%) patients in the K-321 QID group, 16 (72.7%) patients in the K-321 BID group, and 14 (63.6%) patients in the placebo group achieved no corneal edema of the study eye, with median duration of 35 days, 51.5 days, and 267 days, respectively. A statistically significant difference versus the placebo group was observed for the K-321 QID group (p=0.0021).

Number (%) of Patients Requiring Intervention of Rescue Therapy

Two (9.5%) patients in the K-321 QID group, 4 (18.2%) patients in the K-321 BID group, and 6 (27.3%) patients in the placebo group required rescue therapy. Exploratory Endpoint:

Best Corrected Visual Acuity

A total of 19 (90.5%) patients in the K-321 QID group, 17 (77.3%) patients in the K-321 BID group, and 14 (63.6%) patients in the placebo group achieved BCVA by ETDRS letter score >70 letters, with a median duration of 23 days, 50.5 days, and 111 days, respectively. A statistically significant difference versus the placebo group was observed for the K-321 QID group (p=0.0092).

An ad-hoc analyses on the time to improvement to 40 ETDRS letters during the first 12 Weeks after descemetorhexis was performed by assuming 0 ETDRS letters at Day 1 as well as to 15-, 20-, 25-, 30-, 50-, 60-, 70-, and 80-letter thresholds. The results were consistently statistically significant for the K-321 QID group when compared to placebo for all thresholds except 80 ETDRS letters in both generalized Wilcoxon and log-rank tests.

Earlier improvements in BCVA were also notably seen with QID compared to BID, manifested by median time to BCVA>70 letters of 23.0 days in the QID-treated subjects compared to 50.5 days in the BID subjects and not applicable in placebo subjects, respectively (p=0.0078 for QID and p=0.2176 for BID compared to placebo using the Log rank test Sum Test). This earlier recovery of BCVA (change from baseline) was also seen by the higher BCVA at week 1 in QID subjects (-31.4 ± 24.05 letters) compared to BID and placebo (-53.4 ± 22.59 and -52.2 ± 22.39 letters for the BID and placebo subjects, respectively) with p=0.0270 for QID and p=0.8411 for BID compared to placebo using the Wilcoxon Rank Sum Test.

Responder analyses from this Phase II study are presented in Tables 1-3 below:

Table 1 Responder Analysis

Patients Achieved Corneal Thickness Less Than or Equal to Baseline Corneal

Thickness Table 2 Responder Analysis

Patients Achieved Central Corneal ECD of 700 Cells/mm² or More

Table 3 Responder Analysis

Patients Achieved no Corneal Edema

As can be seen, significant improvements continue to be seen relative to placebo even after the 9- week visit.

Given the significant numbers of gastrointestinal upset (24%) and ocular discomfort (43%) associated with a more intensive ripasudil / DSO regimen (6x/day administration) reported in the literature (Maloney et al., Cornea, Descemet Stripping Only Supplemented With Topical Ripasudil for Fuchs Endothelial Dystrophy 12-Month Outcomes of the Sydney Eye Hospital Study. 2021 Mar l;40(3):320-326), an additional analysis was undertaken of adverse events reported in the study. Out of 43 patients in the K-321 BID and QID arms, only 1 (2%) reported any gastrointestinal side effects and only 2 (5%) reported eye irritation.

Example 4: A Double-Masked, Randomized, Placebo-Controlled, Parallel-Group, 12-Week Treatment and 14-week Extension, Phase 3 Study to Investigate the Safety and Efficacy of Ripasudil Eye Drops After Cataract Surgery This was a double-masked, randomized, placebo-controlled, parallel -group, multi-center Phase III study to investigate the safety and efficacy of ripasudil (0.4%) eyedrops after cataract surgery with a 12-week treatment period and a follow-up period of up to 14 weeks Primary Objective(s):

• To assess the safety of K-321 in subjects after cataract surgery.

Secondary Objectives:

• To investigate the effect of K-321 on central and peripheral (nasal and temporal) corneal endothelial cell density (ECD), central and peripheral corneal endothelial cell parameters (Coefficient of Variation and Hexagonality), corneal thickness, corneal edema, visual acuity, and vision-related quality of life after cataract surgery

• To evaluate the systemic exposure of K-321 in subjects after cataract surgery

Subject Population:

Male and female subjects > 18 years of age who have undergone cataract surgery Number of Subjects:

Total 330 subjects:

• 220 subjects assigned to K-321 o 150 subjects followed for 16 weeks o 70 subjects followed for 26 weeks

• 110 assigned to placebo. o 75 subjects followed for 16 weeks o 35 subjects followed for 26 weeks

Dose Levels:

0.4% ripasudil ophthalmic solution QID

Placebo ophthalmic solution QID

Duration of Treatment:

The maximum total study duration for each enrolled subject was 30 weeks including the screening period

Criteria for Evaluation:

The baseline for all efficacy and safety variables is defined as the values/measurements obtained at the screening visit (Visit 1).

Select Efficacy Measures: • Change from baseline in central corneal ECD at each visit

• Change from baseline in peripheral corneal ECD change at each visit

• Change from baseline in parameters (Coefficient of Variation, Hexagonality) at each visit

• Time to return of corneal thickness to less than or equal to the baseline level.

• Time to complete clearance of corneal edema after cataract surgery, where corneal clearance is defined as achieving a central corneal thickness less than or equal to baseline central corneal thickness without any corneal edema

• Change from baseline in central corneal thickness at each visit

• Change from baseline in best corrected distance visual acuity (BCVA) (letters) by early treatment diabetic retinopathy study (ETDRS) score at each visit

• Time to achieve BCVA by ETDRS letter score >70 letters (Snellen equivalent better than 20/40) after cataract surgery

• Change from baseline in Visual Function Questionnaire-25 (VFQ-25) domains and total score at each visit

Safety:

• Adverse events

• Safety assessments by slit-lamp biomicroscopy (cornea, conjunctiva, anterior chamber, lens, lids and lashes), dilated

Results

No statistically significant difference between the treatment groups was found for change from baseline in central corneal ECD in the study eye at Week 12. However, a statistically greater proportion of all K-321 subjects compared to all placebo subjects achieved corneal thickness less than or equal to baseline in the study eye at each post-baseline visit during the treatment period: Week 1 (40.4% vs. 12.8%, p<0.0001); Week 2 (39.0% vs. 15.6%, p<0.0001); Week 3 (44.2% vs. 16.7%, p<0.0001); Week 7 (45.8% vs. 30.6%, p=0.0089); and Week 12 (48.4% vs. 34.6%, p=0.0207). During the follow-up period, a statistically greater proportion of subjects in the K-321 group compared to the placebo group maintained corneal thickness less than or equal to baseline in the study eye at Week 26 (56.9% vs. 33.3%; p=0.0281 ).

Example 5: A Double-Masked, Randomized, Placebo-Controlled, Parallel-Group, 12-Week Administration With Two-Week Gradual Dose Taper Phase and 38-Week Follow- Up Phase, Phase 3 Study to Investigate the Safety and Efficacy of Ripasudil (K- 321) Eye Drops After Descemetorhexis in Subjects with Fuchs Endothelial Corneal Dystrophy

This is a double-masked, randomized, placebo-controlled, parallel-group, multi-center, two-period study. Subjects eligible for randomization will be stratified by the average of peripheral (nasal, temporal, superior, inferior) baseline (measurements at screening and thus pre-Descemet stripping only [DSO]) endothelial cell density (ECD) and baseline (post-DSO) best corrected visual acuity (BCVA) values (ETDRS letters) in the study eye according to the following strata:

1. Peripheral ECD ungradable in all areas (nasal, temporal, superior, and inferior) due to a medical reason such as guttae, corneal edema, or striae and baseline BCVA=0

2. Peripheral ECD ungradable in all areas (nasal, temporal, superior, and inferior) due to a medical reason such as guttae, corneal edema, or striae and baseline BCVA>0

3. Average peripheral ECD <1200 cells/mm² and baseline BCVA=0

4. Average peripheral ECD <1200 cells/mm² and baseline BCVA>0

5. Average peripheral ECD >1200 cells/mm² and baseline BCVA=0

6. Average peripheral ECD >1200 cells/mm² and baseline BCVA >0

If any of the values (nasal, temporal, superior, or inferior) are ungradable due to a medical reason (eg, guttae, corneal edema, or striae), the ECD values that are available will be taken to calculate an average. If any of the areas are ungradable due to any reason other than a medical reason (eg, guttae, corneal edema, or striae) the subject will be excluded (eg, subjects with any ungradable images due to technical difficulties).

Subject Population:

Subjects with FECD who are planning to undergo Descemet Stripping Only (DSO)

Number of Subjects:

Total 100 (50 per arm)

Dose Levels:

0.4% K-321 ophthalmic solution four times daily (QID) Placebo ophthalmic solution QID

Duration o f Treatment: 12-week administration with a 2-week gradual dose taper phase followed by a 38-week follow-up period

Criteria for Evaluation:

The BCVA baseline will be measured 1 day after descemetorhexis and will be used in stratification for randomization. The peripheral ECD measurement to be used for stratification for randomization will be the peripheral ECD measurement at screening (pre-DSO). The baseline for central corneal ECD and central corneal endothelial cell parameters (Coefficient of Variation and Hexagonality) will be the post-operative cell density, since this will be zero in all subjects following descemetorhexis and thus will provide a useful baseline measurement. The baseline for all other efficacy and safety variables will be the values/measurements obtained at the screening visit (Visit 1).

Select endpoints for the study are as follows:

Primary Efficacy Endpoint:

The primary efficacy endpoint is time to >40 ETDRS letter improvement in BCVA during the first 12 weeks after descemetorhexis.

Key Secondary and Secondary Efficacy Endpoints:

The key secondary efficacy endpoints are:

• Time to >20 ETDRS letter improvement during the first 12 weeks after descemetorhexis.

• Time to achievement of >70 ETDRS letter improvement during the first 12 weeks after descemetorhexis.

• Central corneal ECD change from baseline at Week 12.

Other secondary efficacy endpoints are:

• Time to complete clearance of corneal edema in both areas (epithelial, stromal) during the first 12 weeks and during the 52-week period and after descemetorhexis.

• Time to return of central corneal thickness to less than or equal to baseline level during the first 12 weeks and during the 52-week period after descemetorhexis. • Time to failure of therapy (defined as events of rescue keratoplasty, rescue treatments other than keratoplasty, study drug discontinuation due to lack of efficacy, and withdrawal from the study due to lack of efficacy) during the 52-week period after descemetorhexis.

• Time to undergo rescue therapy (keratoplasty) or rescue treatment during the 52-week period after descemetorhexis.

Tertiary Efficacy Endpoints:

The tertiary efficacy endpoints are:

• Change from baseline in central comeal endothelial cell parameters (Coefficient of Variation and Hexagonality) at each visit.

• Proportion of subjects who achieve a central corneal ECD of 500, 700, and 1,000 cells/mm² or more at each visit.

• Time to achievement of central corneal ECD of 500, 700, and 1,000 cells/mm² or more during the first 12 weeks and during the 52-week period after descemetorhexis.

• Change from baseline in central corneal ECD at each visit.

• Change from baseline in central corneal ECD at each visit in only subjects with gradable central comeal ECD at pre-DSO.

• Change and percent change from baseline in peripheral (nasal, temporal, superior, inferior) corneal ECD at each visit.

• Change and percent change from baseline in peripheral (nasal, temporal, superior, inferior) comeal endothelial cell parameters (Coefficient of Variation and Hexagonality) at each visit.

• Change and percent change from baseline in peripheral (nasal, temporal, superior, inferior) corneal ECD at each visit in only subjects with gradable central ECD at pre-DSO.

• Time to complete clearance of corneal edema in each area (epithelial, stromal) during the 52-week period after descemetorhexis.

• Proportion of subjects who complete clearance of comeal edema in both areas and in each area (epithelial, stromal) at each visit.

• Change and percent change from baseline in central comeal thickness at each visit. • Proportion of subjects who experience failure of therapy (defined as events of rescue keratoplasty, rescue treatments other than keratoplasty, study drug discontinuation due to lack of efficacy, and withdrawal from the study due to lack of efficacy) at each visit.

• Proportion of subjects who undergo rescue therapy (keratoplasty) or rescue treatment at each visit.

• Proportion of subjects with gradable central corneal ECD at each visit.

• Change from baseline in Visual Function Questionnaire-25 (VFQ-25) domains and total score at each visit.

• Change from baseline in Visual Function and Corneal Health Status (V -FUCHS) Questionnaire at each visit.

• Change from baseline in FECD-related visual disability and symptoms at each visit.

Select Criteria for Inclusion:

Pre-DSO Criteria

Each subject who is planning to undergo descemetorhexis and must meet all of the following criteria to be enrolled in the study:

E Is at least 18 years old at the screening visit (Visit 1)

2. Has a diagnosis of FECD at Visit 1

3. Has confluent central guttae in the study eye that can be removed by descemetorhexis of a circular area of 5.5 mm diameter or less (at Visit 1)

4. Study eye with BCVA of 75 letters or fewer by ETDRS testing (Snellen equivalent of 20/32 or worse) at Visit 1

Post-DSO Criteria

5. The study eye descemetorhexis at Visit 2 is confirmed to have excised a central area with confluent guttae and a diameter of 4.5 to 5.5 mm

Select Criteria for Exclusion:

Subjects meeting any of the following criteria will be excluded from the study:

1. Has a study eye with confluent guttae in the periphery or confluent guttae outside the stripped area (individual guttae are allowed) after descemetorhexis (Note that subjects may have individual or a small number of guttae remaining outside the stripped area, but there should be no areas with confluent guttae remaining after the descemetorhexis. For example, a subject who has five to 10 guttae remaining in a few spots around the circumference of the descemetorhexis would not be excluded by this criterion.)

2. Has a study eye with baseline (pre-DSO) peripheral ECD ungradable for any area (nasal, temporal, superior, and inferior) due to any reason other than a medical reason (eg, guttae, corneal edema, or striae)

3. Has a study eye with a history of cataract surgery within 90 days of Visit 1

4. Has a study eye with a history of any previous intraocular surgery other than for cataract prior to Visit 1

5. Has a non-study eye with a history of any previous intraocular surgery within 30 days of Visit 1

6. Has a study eye with central corneal thickness >670 pm at Visit 1

Example 6: A Double-Masked, Randomized, Placebo-Controlled, Parallel-Group, 12-Week Administration With Two-Week Gradual Dose Taper Phase and 38-Week Follow- Up Phase, Phase 3 Study to Investigate the Safety and Efficacy of Ripasudil (K- 321) Eye Drops After Simultaneous Cataract Surgery and Descemetorhexis in Subjects with Fuchs Endothelial Corneal Dystrophy

3. Average peripheral ECD <1200 cells/mm² and baseline BCVA=0

4. Average peripheral ECD <1200 cells/mm² and baseline BCVA>0

5. Average peripheral ECD >1200 cells/mm² and baseline BCVA=0

6. Average peripheral ECD >1200 cells/mm² and baseline BCVA>0 If any of the values (nasal, temporal, superior, or inferior) are ungradable due to a medical reason (eg, guttae, corneal edema, or striae), the ECD values that are available will be taken to calculate an average. If any of the areas are ungradable due to any reason other than a medical reason (eg, guttae, corneal edema, or striae) the subject will be excluded (eg, subjects with any ungradable images due to technical difficulties).

Subject Population:

Subjects with FECD who are planning to undergo simultaneous cataract surgery and Descemet Stripping Only (DSO)

Number of Subjects:

Total 100 (50 per arm)

Dose Levels:

Duration o f Treatment:

12-week administration with a 2-week gradual dose taper phase followed by a 38-week follow-up period

Criteria for Evaluation:

The BCVA baseline will be measured 1 day after simultaneous cataract surgery and descemetorhexis and will be used in stratification for randomization. The peripheral ECD measurement to be used for stratification for randomization will be the peripheral ECD measurement at screening (before simultaneous cataract surgery and descemetorhexis). The baseline for central corneal ECD and central corneal endothelial cell parameters (Coefficient of Variation and Hexagonality) will be the post-operative cell density, since this will be zero in all subjects following simultaneous cataract surgery and descemetorhexis and thus will provide a useful baseline measurement. The baseline for all other efficacy and safety variables will be the values/measurements obtained at the screening visit (Visit 1). Select endpoints for the study are as follows:

Primary Efficacy Endpoint:

The primary efficacy endpoint is time to >40 ETDRS letter improvement in BCVA during the first 12 weeks after simultaneous cataract surgery and descemetorhexis.

Key Secondary and Secondary Efficacy Endpoints:

The key secondary efficacy endpoints are:

• Time to >20 ETDRS letter improvement during the first 12 weeks after simultaneous cataract surgery and descemetorhexis.

• Time to achievement of >70 ETDRS letter improvement during the first 12 weeks after simultaneous cataract surgery and descemetorhexis.

• Central corneal ECD change from baseline at Week 12.

Other secondary efficacy endpoints are:

• Time to complete clearance of corneal edema in both areas (epithelial, stromal) during the first 12 weeks and during the 52-week period and after simultaneous cataract surgery and descemetorhexis.

• Time to return of central corneal thickness to less than or equal to baseline level during the first 12 weeks and during the 52-week period after simultaneous cataract surgery and descemetorhexis.

• Time to failure of therapy (defined as events of rescue keratoplasty, rescue treatments other than keratoplasty, study drug discontinuation due to lack of efficacy, and withdrawal from the study due to lack of efficacy) during the 52-week period after simultaneous cataract surgery and descemetorhexis.

• Time to undergo rescue therapy (keratoplasty) or rescue treatment during the 52-week period after simultaneous cataract surgery and descemetorhexis.

Tertiary Efficacy Endpoints:

The tertiary efficacy endpoints are:

• Change from baseline in central corneal endothelial cell parameters (Coefficient of Variation and Hexagonality) at each visit. • Proportion of subjects who achieve a central corneal ECD of 500, 700, and 1 ,000 cells/mm² or more at each visit.

• Time to achievement of central corneal ECD of 500, 700, and 1,000 cells/mm² or more during the first 12 weeks and during the 52-week period after simultaneous cataract surgery and descemetorhexis.

• Change from baseline in central corneal ECD at each visit.

• Change from baseline in central corneal ECD at each visit in only subjects with gradable central corneal ECD at pre-DSO.

• Change and percent change from baseline in peripheral (nasal, temporal, superior, inferior) corneal endothelial cell parameters (Coefficient of Variation and Hexagonality) at each visit.

• Time to complete clearance of corneal edema in each area (epithelial, stromal) during the 52-week period after simultaneous cataract surgery and descemetorhexis.

• Proportion of subjects who complete clearance of corneal edema in both areas and in each area (epithelial, stromal) at each visit.

• Change and percent change from baseline in central corneal thickness at each visit.

• Proportion of subjects who experience failure of therapy (defined as events of rescue keratoplasty, rescue treatments other than keratoplasty, study drug discontinuation due to lack of efficacy, and withdrawal from the study due to lack of efficacy) at each visit.

• Proportion of subjects with gradable central corneal ECD at each visit.

• Change from baseline in Visual Function and Corneal Health Status (V-FUCHS) Questionnaire at each visit.

• Change from baseline in FECD-related visual disability and symptoms at each visit. Select Criteria for Inclusion:

Pre-Cataract Surgery /DSO Criteria

Each subject who is planning to undergo simultaneous cataract surgery and descemetorhexis and must meet all of the following criteria to be enrolled in the study:

1. Is at least 18 years old at the screening visit (Visit 1)

2. Has a diagnosis of FECD at Visit 1

5. Has a visually significant cataract in the study eye at Visit 1

Post-Cataract Surgery /DSO Criteria

6. The study eye descemetorhexis at Visit 2 is confirmed to have excised a central area with confluent guttae and a diameter of 4.5 to 5.5 mm

7. Completion of cataract surgery without complications.

Select Criteria for Exclusion:

Subjects meeting any of the following criteria will be excluded from the study:

1. Has a study eye with confluent guttae in the periphery or confluent guttae outside the stripped area (individual guttae are allowed) after simultaneous cataract surgery and descemetorhexis (Note that subjects may have individual or a small number of guttae remaining outside the stripped area, but there should be no areas with confluent guttae remaining after the descemetorhexis. For example, a subject who has five to 10 guttae remaining in a few spots around the circumference of the descemetorhexis would not be excluded by this criterion.)

2. Has had capsular rupture or infection in the study eye or any other complications or AEs during cataract surgery

3. Has a study eye with baseline (pre-DSO) peripheral ECD ungradable for any area (nasal, temporal, superior, and inferior) due to any reason other than a medical reason (eg, guttae, corneal edema, or striae) 4. Has a study eye with a history of any previous intraocular surgery other than for cataract prior to Visit 1

6. Has a study eye with central corneal thickness >670 pm at Visit 1

REFERENCES CITED

• Liu Y, Wilkins M, et al. Cataracts. The Lancet. 2017;390: 10094:600-612

• Lam D, Rao SK et al. Cataract. Nature Reviews Disease Primers. 2015; 1 : 15014

• Foster A. Vision2020: The Cataract Challenge. Community Eye Health. 2000; 13(34): 17- 19

• Tsorbatzoglou A, Kertesz K et al. Corneal endothelial function after phacoemulsification using the fluid-based system compared to conventional ultrasound technique. Nature - Eye. 2007;21 :727-732

• lanchulev T, Lane S, et al. Corneal endothelial cell density and morphology after phacoemulsification in patients with primary open-angle glaucoma and cataracts. Cornea. 2018 Dec;00(00): l

• Van den Bogerd, B., Dhubhghaill, S. N., et al. A review of the evidence for in vivo corneal endothelial regeneration. Survey Ophthalmol. 2018;63(2), 149-165

• Ishizaki T, Maekawa M, et al. The small GTP -binding protein Rho binds to and activates a 160 kDa Ser/Thr protein kinase homologous to myotonic dystrophy kinase. EMBO J. 1996;15: 1885-1893

• Okumura N, Koizumi N, Ueno M, et al. Enhancement of corneal endothelium wound healing by Rho-associated kinase (ROCK) inhibitor eye drops. Br J Ophthalmol. 201 1 ;95: 1006-1009

• Fujimoto H, Setoguchi Y, et al. The ROCK inhibitor ripsudil shows an endothelial protective effect in patients with low corneal endothelial cell density after cataract surgery. Trans Vis Sci Tech. 2021;10(4): 18

• WO 2022/159533 (published July 28, 2022) Throughout this application, various references are cited. The disclosures of these publications in their entireties are hereby incorporated by reference into this application in order to more fully describe the state of the art to which this disclosure pertains. It will be apparent to those skilled in the art that various modifications and variations can be made in the present disclosure without departing from the scope or spirit of the disclosure. Other embodiments of the disclosure will be apparent to those skilled in the art from consideration of the specification and practice of the disclosure disclosed herein. It is intended that the specification and examples be considered as exemplary only, with a true scope and spirit of the disclosure being indicated by the following claims.

Claims

1) A method of improving visual acuity following intra-ocular surgery in a patient having confluent central guttae in the Descemet membrane and a cataractous lens in an eye, wherein the intraocular surgery comprises removing a central portion of the Descemet membrane from the eye and replacing the lens in the eye, comprising: a) topically administering to the eye a therapeutically effective amount of ripasudil or a pharmaceutically acceptable salt thereof four times per day for twelve or more weeks following the surgery; and b) improving the patient’s visual acuity.

2) A method of returning corneal thickness to pre-surgery values, and maintaining said presurgery values following cessation of treatment, following intra-ocular surgery in a patient having confluent central guttae in the Descemet membrane and a cataractous lens in an eye, wherein the intraocular surgery comprises removing a central portion of the Descemet membrane from the eye and replacing the lens in the eye, comprising: a) topically administering to the eye a therapeutically effective amount of ripasudil or a pharmaceutically acceptable salt thereof four times per day for twelve or more weeks following the surgery; b) returning corneal thickness in the eye to pre-surgery values; and c) maintaining corneal thickness at said pre-surgery levels following cessation of said administering.

3) A method of returning corneal thickness to pre-surgery values, and maintaining said pre- surgery values following cessation of treatment, following intra-ocular surgery in a patient having a cataractous lens in an eye, wherein the intraocular surgery comprises replacing the lens in the eye, comprising: a) topically administering to the eye a therapeutically effective amount of ripasudil or a pharmaceutically acceptable salt thereof four times per day for twelve or more weeks following the surgery; b) returning corneal thickness in the eye to pre-surgery values; and c) maintaining corneal thickness at said pre-surgery levels following cessation of said administering. 4) A method of improving surgical outcomes from intra-ocular surgery in a patient having confluent central guttae in the Descemet membrane and a cataractous lens in an eye, wherein the intraocular surgery comprises removing a central portion of the Descemet membrane from the eye and replacing the lens in the eye, comprising: a) topically administering to the eye a therapeutically effective amount of ripasudil or a pharmaceutically acceptable salt thereof four times per day for twelve or more weeks following the surgery; and b) improving a surgical outcome selected from

• central corneal endothelial cell density;

• peripheral corneal endothelial cell density;

• endothelial cell coefficient of variation and hexagonality;

• return of central corneal thickness to pre-surgery baseline;

• clearance of corneal edema;

• best corrected distance visual acuity (BCVA);

• Visual Function Questionnaire-25 (VFQ-25) domains and total score; and

• combinations thereof.

5) A method of preventing or reducing adverse events resulting from intra-ocular surgery in a patient in need thereof having an endothelial cellular density (ECD) greater than 1,500 cells/mm², comprising topically administering to the patient a therapeutically effective amount of ripasudil or a pharmaceutically acceptable salt thereof following the intra-ocular surgery.

6) A method of preventing or reducing adverse events resulting from intra-ocular surgery in a patient at increased risk of such adverse events, comprising topically administering to the patient a therapeutically effective amount of ripasudil or a pharmaceutically acceptable salt thereof following the intra-ocular surgery, wherein: a) the surgery comprises phacoemulsification with intraocular lens implantation; and b) the patient is at increased risk of adverse events due to one or a combination of anterior chamber depth, phacoemulsification power and duration, hard and large nucleus, endothelial contact from nuclear fragments, IOL, air bubbles, irrigation fluid, implantation technique, type of IOL, short axial length, free radical release, small pupil, and toxicity of medications given during surgery. 7) A method of improving post-surgical outcomes from intra-ocular surgery in a patient in need thereof having an endothelial cellular density (ECD) greater than 1,500 cells/mm², comprising topically administering to the patient a therapeutically effective amount of ripasudil or a pharmaceutically acceptable salt thereof following the intra-ocular surgery; wherein the post-surgical outcome is selected from: a) central corneal endothelial cell density; b) peripheral corneal endothelial cell density; c) endothelial cell coefficient of variation and hexagonality; d) return of central corneal thickness to pre-surgery baseline; e) clearance of corneal edema; f) best corrected distance visual acuity (BCVA); g) Visual Function Questionnaire-25 (VFQ-25) domains and total score; and h) combinations thereof.

8) A method of improving post-surgical outcomes from intra-ocular surgery in a non- glaucomatous patient, comprising topically administering to the patient a therapeutically effective amount of ripasudil or a pharmaceutically acceptable salt thereof following the intra-ocular surgery; wherein the post-surgical outcome is selected from: a) central corneal endothelial cell density; b) peripheral corneal endothelial cell density; c) endothelial cell coefficient of variation and hexagonality; d) return of central corneal thickness to pre-surgery baseline; e) clearance of corneal edema; f) best corrected distance visual acuity (BCVA); g) Visual Function Questionnaire-25 (VFQ-25) domains and total score; and h) combinations thereof.

9) A method of preventing adverse events from intra-ocular surgery comprising phacoemulsification with intraocular lens implantation in a non-glaucomatous patient in need thereof, comprising topically administering to the patient a therapeutically effective amount of ripasudil or a pharmaceutically acceptable salt thereof following the intra-ocular surgery.

10) A method of preventing adverse events from intra-ocular surgery comprising phacoemulsification with intraocular lens implantation in a patient in need thereof, comprising topically administering to the patient four times daily a therapeutically effective amount of ripasudil or a pharmaceutically acceptable salt thereof following the intra-ocular surgery.

11) A method of preventing or reducing adverse events resulting from intra-ocular surgery comprising phacoemulsification with intraocular lens implantation in a patient in need thereof having an endothelial cellular density (ECD) greater than 1,500 cells/mm², comprising topically administering to the patient a therapeutically effective amount of ripasudil or a pharmaceutically acceptable salt thereof following the intra-ocular surgery.

12) A method of improving post-surgical outcomes from intra-ocular surgery comprising phacoemulsification with intraocular lens implantation in a patient in need thereof having an endothelial cellular density (ECD) greater than 1,500 cells/mm², comprising topically administering to the patient a therapeutically effective amount of ripasudil or a pharmaceutically acceptable salt thereof following the intra-ocular surgery; wherein the post-surgical outcome is selected from: a) central corneal endothelial cell density; b) peripheral corneal endothelial cell density; c) endothelial cell coefficient of variation and hexagonality; d) return of central corneal thickness to pre-surgery baseline; e) clearance of corneal edema; f) best corrected distance visual acuity (BCVA); g) Visual Function Questionnaire-25 (VFQ-25) domains and total score; and h) combinations thereof.

13) A method of improving surgical outcomes from intra-ocular surgery in a patient having confluent central guttae in the Descemet membrane of any eye, comprising: a) removing a central portion of the Descemet membrane from the eye; and b) topically administering to the eye a therapeutically effective amount of ripasudil or a pharmaceutically acceptable salt thereof four times per day for twelve or more weeks following the surgery.

14) The method of claim 2, 3, or 4, wherein said returning corneal thickness in the eye to presurgery values occurs following cessation of said administering. 15) The method of any of claims 1 -13, wherein the patient has peripheral ECD ungradable in all areas (nasal, temporal, superior, and inferior) due to a medical reason such as guttae, corneal edema, or striae and baseline BCVA=0.

16) The method of any of claims 1-13, wherein the patient has peripheral ECD ungradable in all areas (nasal, temporal, superior, and inferior) due to a medical reason such as guttae, corneal edema, or striae and baseline BCVA>0.

17) The method of any of claims 1-13, wherein the patient has average peripheral ECD <1200 cells/mm² and baseline BCVA=0.

18) The method of any of claims 1-13, wherein the patient has average peripheral ECD <1200 cells/mm² and baseline BCVA>0.

19) The method of any of claims 1-13, wherein the patient has average peripheral ECD >1200 cells/mm² and baseline BCVA=0.

20) The method of any of claims 1-13, wherein the patient has average peripheral ECD >1200 cells/mm² and baseline BCVA>0.

21) The method of any of claims 1-13 wherein the eye has a central corneal thickness < 670 pM.

22) The method of any of claims 1-13, wherein the patient is at increased risk of adverse events due to one or a combination of anterior chamber depth, phacoemulsification power and duration, hard and large nucleus, endothelial contact from nuclear fragments, IOL, air bubbles, irrigation fluid, implantation technique, type of IOL, short axial length, free radical release, small pupil, and toxicity of medications given during surgery.

23) The method of any of claims 1-13, further comprising improving a post-surgical outcome selected from: a) central corneal endothelial cell density; b) peripheral corneal endothelial cell density; c) endothelial cell coefficient of variation and hexagonality; d) return of central corneal thickness to pre-surgery baseline; e) clearance of corneal edema; f) best corrected distance visual acuity (BCVA); g) Visual Function Questionnaire-25 (VFQ-25) domains and total score; and h) combinations thereof. 24) The method of any of claims 1-13, comprising reducing one or more adverse events selected from corneal edema, endothelial cell loss, corneal scarring, reduced visual acuity, cystoid macular edema, increased intraocular pressure, posterior capsular opacification (secondary cataract), chronic uveitis, fibrin formation, protein leakage from the breakdown of the blood-aqueous barrier, retinal detachment, posterior vitreous detachment, photophobia, ocular irritation, gastrointestinal toxicities, and relapse edema.

25) The method of any of claims 1-13, wherein the patient is non-glaucomatous.

26) The method of claims 1-13, wherein the intra-ocular surgery comprises phacoemulsification with intraocular lens implantation.

27) The method of any of claims 1-13, comprising preventing or reducing an adverse event which is a corneal adverse event.

28) The method of any of claims 1-13, comprising preventing or reducing an adverse event which is a corneal adverse event selected from corneal edema, endothelial cell loss, corneal scarring, and reduced visual acuity.

29) The method of any of claims 1-13, comprising preventing or reducing an adverse event which is a non-corneal adverse event.

30) The method of any of claims 1-13, comprising preventing or reducing an adverse event which is a non-comeal adverse event selected from cystoid macular edema, increased intraocular pressure, posterior capsular opacification (secondary cataract), chronic uveitis, fibrin formation, protein leakage from the breakdown of the blood-aqueous barrier, retinal detachment, posterior vitreous detachment, photophobia, ocular irritation, gastrointestinal toxicities, and relapse edema.

31) The method of any of claims 1-13, wherein the intra-ocular surgery comprises descemetorhexis.

32) The method of any of claims 1-13, wherein the intra-ocular surgery comprises removing from 4.5 to 5.5 mm of the central portion of the Descemet membrane from the patient's eye.

33) The method of any of claims 1-13, wherein the intra-ocular surgery comprises phacoemulsification with intraocular lens implantation.

34) The method of any of claims 1-13, wherein the intra-ocular surgery comprises descemetorhexis and phacoemulsification with intraocular lens implantation.

35) The method of any of claims 1-13, comprising administering the ripasudil or pharmaceutically acceptable salt thereof four times daily for a period of at least 12 weeks.

36) The method of any of claims 1-13, comprising administering the ripasudil or pharmaceutically acceptable salt thereof from four times daily for a period of 12 weeks followed by a two week taper phase at two times daily administration.

37) The method of any of claims 1-13, further comprising after the ripasudil administration topically administering to said eye a broad-spectrum antibiotic, preferably 0.5% moxifloxacin hydrochloride and a glucocorticoid, preferably 1% prednisolone acetate.

38) The method of any of claims 1-13, wherein the patient is at increased risk of adverse events due to one or a combination of anterior chamber depth, phacoemulsification power and duration, hard and large nucleus, endothelial contact from nuclear fragments, IOL, air bubbles, irrigation fluid, implantation technique, type of IOL, short axial length, free radical release, small pupil, and toxicity of medications given during surgery.

39) The method of any of claims 1-13, wherein a therapeutically effective amount of ripasudil or a pharmaceutically acceptable salt thereof is in a preservative-free liquid solution.

40) A preservative-free liquid solution of ripasudil hydrochloride comprising from 0.3% (w/v) to 0.5% (w/v) ripasudil hydrochloride, based on the weight of the free base of ripasudil excluding any waters of hydration.

41) A preservative-free liquid solution of ripasudil hydrochloride comprising: a) from 0.3% (w/v) to 0.5% (w/v) ripasudil hydrochloride, based on the weight of the free base of ripasudil excluding any waters of hydration; b) an optional pH buffer; c) from 1.5% (w/v) to 2.0% (w/v) glycerol; d) sodium hydroxide q.s. to a pH of from 4 to 7.5; and e) purified water q.s. to 100%.

42) The solution of claim 40 or 41, comprising from 0.35% (w/v) to 0.45% (w/v) sodium dihydrogen phosphate, excluding any waters of hydration.

43) The solution of claim 40 or 41, comprising: a) approximately 0.4% (w/v) ripasudil hydrochloride, based on the weight of the free base of ripasudil excluding any waters of hydration; b) approximately 0.4% (w/v) sodium dihydrogen phosphate, excluding any waters of hydration; c) approximately 1 .77% (w/v) glycerol; d) sodium hydroxide q.s. to a pH of from 5 to 7; and e) purified water q.s. to 100%.

44) The solution of any of claims 40 or 41, comprising: a) approximately 0.49 g/100 mL ripasudil hydrochloride dihydrate; and/or b) approximately 0.52 g/100 mL sodium dihydrogen phosphate dihydrate.

45) The solution of any of claims 39 or 40, in the absence of any preservatives, anti-oxidants, or chelating agents.

46) The solution of any of claims 40 or 41, in the absence of benzalkonium chloride.

47) The method of claim 1, wherein the ripasudil is administered from the solution of claim 40.

48) The method of claim 1 , wherein the ripasudil is administered from the solution of claim 41.

49) The method of claim 1, wherein the ripasudil is administered from the solution of claim 42.

50) The method of claim 1, wherein the ripasudil is administered from the solution of claim 43.

51) The method of claim 1, wherein the ripasudil is administered from the solution of claim 44.

52) The method of claim 1, wherein the ripasudil is administered from the solution of claim 45.

53) The method of claim 1, wherein the ripasudil is administered from the solution of claim 46.