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• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K36/00—Medicinal preparations of undetermined constitution containing material from algae, lichens, fungi or plants, or derivatives thereof, e.g. traditional herbal medicines
  • A61K36/02—Algae
  • A61K36/05—Chlorophycota or chlorophyta (green algae), e.g. Chlorella
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P27/00—Drugs for disorders of the senses
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P27/00—Drugs for disorders of the senses
  • A61P27/02—Ophthalmic agents
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
  • A61P9/00—Drugs for disorders of the cardiovascular system
  • A61P9/10—Drugs for disorders of the cardiovascular system for treating ischaemic or atherosclerotic diseases, e.g. antianginal drugs, coronary vasodilators, drugs for myocardial infarction, retinopathy, cerebrovascula insufficiency, renal arteriosclerosis

Definitions

• This invention relates to methods of treating ophthalmic disorders, and to pharmaceutical compositions therefor.
• Rod cells are photoreceptor cells in the retina of the eye that can function in less intense light than can the other type of photoreceptor, cone cells. Being more light sensitive, rods are responsible for night vision. Named for their cylindrical shape, rods are concentrated in all parts of the retina except its center and thus provide peripheral vision. Cone cells, or cones, are photoreceptor cells in the center of the retina of the eye which function best in relatively bright light. The cone cells gradually become sparser towards the periphery of the retina.
• Diseases of the eye may affect one type of vision or the other or both. In certain diseases, first night vision is affected, while day vision is affected as the disease progresses.
• Retinitis pigmentosa comprises a group of relatively common inherited diseases characterized by progressive degeneration of the retina of the eye. The continually spreading destruction of the retina leads to increasingly severe visual loss. Vision gradually degenerates from the periphery [night vision, wide visual field] to the center [high definition day vision, colors]. Symptoms start with a decrease in dark adaptation leading to night blindness. There is a simultaneous reduction in the peripheral field of view up to tunnel vision. Central (day) vision is subsequently lost leading to total blindness. The rate of progression of RP varies according to the specific genetic defect. The visual impairment problem is much more prevalent than blindness. Currently, no treatment is recognized to improve the vision of RP patients. Vitamin A palmitate (15,000 U/d) is prescribed to slow the progress of RP by about 2% per year. Current clinical trials are underway to attempt to slow degeneration, and include: • Ciliary Neurotrophic Factor eye Implant
• Vitamin E Over the last 15 years, researchers have pinpointed defects in dozens of genes causing different forms of RP. Surprisingly, in some cases, patients with the same genetic defect can show different severities of vision loss and rates of disease progression. This effect is most dramatic across the retina of some individuals where regions with normal vision can abut regions of no vision. Environmental factors have been near the top of the suspect list for this variation in severity. An environmental factor experienced by all, but to varying extents, is exposure to light bright lights have been previously speculated to accelerate certain forms of RP.
• LCA Leber's congenital amaurosis
• AMD Age Related Macular Degeneration
• the X-linked type affects almost exclusively males and accounts for the predominance of males with congenital stationary night blindness.
• WO 2007/109824 discloses a process for preparing a stable packaged dosage form comprising an oxidation-sensitive material such as carotenes and carotenoids in whole dried algae of the genus Dunaliella.
• the dosage form is described as being useful in the treatment of a plurality of diseases including optical disorders such as macular degeneration or cataracts.
• rod light sensitivity was shown to be a function of the amount of regenerated isorhodopsin; high doses restored rod responses with normal sensitivity and kinetics. Syed M. Noorwez, Ritu Malhotra, J. Hugh McDowell, Karen A. Smith, Mark P.
• a method for improving day [photopic] vision and/or cone-derived visual field and visual functions in a subject suffering from a retinal disease or trauma comprising administering to the subject a pharmaceutically effective amount of crude Dunaliella powder.
• day vision or photopic vision relates to vision in bright light generated by the central portion of the retina, as opposed to night vision which is generated by the peripheral portion of the retina. Day vision is predominantly mediated by the cone cells in the retina.
• retinal disease or trauma may include all types of retinal dystrophies in which degeneration of the retina leads to deterioration in day vision. Acquired retinal degenerations such as Age-related Macular Degeneration may also be included in this term.
• retinal diseases which have a night vision stage or component are also included, but in such cases the invention relates only to the day vision stage or component.
• the retinal disease is a retinal degenerative disease.
• the active ingredient in accordance with the invention is a substantially crude
• Dunaliella algae preparation typically dried Dunaliella algae.
• the Dunaliella algae are preferably Dunaliella bardawil.
• Other species include D. salina, D. viridis, D. peircei,
• the substantially crude Dunaliella algae preparation contains ⁇ -carotene (BC) at an approximately 1 : 1 ratio of 9-cis to all-trans isomers of BC or greater than 1 : 1 ratio of 9-cis to all-trans isomers of BC.
• BC ⁇ -carotene
• the terms "treating” or “treatment” in the present specification should be understood as bringing about an improvement in the pathological symptoms of the disease, and in some cases curing the disease.
• an “effective amount” should be understood as an amount or dose of the active ingredient which is sufficient to achieve the desired therapeutic effect, i.e. treatment of the indicated diseases.
• the effective amount depends on various factors including the severity of the disease, the administration regimen, e.g. whether the preparation is given once or several times over a period of time, the physical condition of the subject; etc. The artisan should have no difficulties, by minimal experiments, to determine the effective amount in each case.
• the crude Dunaliella powder is preferably administered orally, for example in an encapsulated form.
• other forms of administration are contemplated such as Dunaliella powder formulated with pharmaceutically-acceptable excipients for topical, intravenous, intramuscular, intraperitoneal or subcutaneous administration.
• Suggested medical conditions for treatment in accordance with the present teachings include the following:
• Retinitis pigmentosa (RP), Leber congenital amaurosis (LCA), Age-related macular degeneration (AMD), recessive RP, Dominant retinitis pigmentosa, X-linked retinitis pigmentosa, Incomplete X-linked retinitis pigmentosa, dominant, Dominant Leber congenital amaurosis, Recessive ataxia, posterior column with retinitis pigmentosa, Recessive retinitis pigmentosa with para-arteriolar preservation of the RPE, Retinitis pigmentosa RP 12, Usher syndrome, Dominant retinitis pigmentosa with sensorineural deafness, Recessive retinitis punctata albescens, Recessive Alstr ⁇ m syndrome, Recessive Bardet-Biedl syndrome, Dominant spinocerebellar ataxia w/ macular dystrophy or retinal degeneration, Reces
• AMD age-related macular degeneration or dystrophy
• AMD refers to a debilitating disease, which include wet and dry forms of AMD.
• the dry form of AMD which accounts for about 90 percent of all cases, is also known as atrophic, nonexudative, or drusenoid macular degeneration.
• drusen typically accumulate in the retinal pigment epithelium (RPE) tissue beneath/within the Bruch's membrane. Vision loss can then occur when drusen interfere with the function of photoreceptors in the macula.
• RPE retinal pigment epithelium
• the dry form of AMD results in the gradual loss of vision over many years.
• the dry form of AMD can lead to the wet form of AMD.
• the wet form of AMD can progress rapidly and cause severe damage to central vision.
• the macular dystrophies include Stargardt Disease, also known as Stargardt Macular Dystrophy or Fundus Flavimaculatus, which is the most frequently encountered juvenile onset form of macular dystrophy, and Best dystrophy also known as vitelliform macular dystrophy, cone-rod dystrophy and others included in the list above.
• a further embodiment of this aspect of the invention is a pharmaceutical composition for improving day vision and/or visual field in a subject suffering from a retinal degenerative disease comprising crude Dunaliella powder.
• a method for improving night vision and/or rod derived visual field in a subject suffering from a retinal night vision disease comprising administering to the subject a pharmaceutically effective amount of crude Dunaliella powder. Patients with this disease have difficulty adapting to low light situations due to impaired photoreceptor transmission.
• the term night vision relates to vision in dim light generated by the peripheral portion of the retina. Night vision is predominantly mediated by the rod cells in the retina.
• the term retinal disease may include all types of retinal dystrophies which are stationary and which lead to deterioration in night vision. Examples of such diseases include congenital night vision disorder, congenital stationary night blindness, fundus albipunctatus and vitamin A deprivation syndrome.
• retinal degenerative diseases which have a day vision stage or component are also included, but in such cases the invention relates only to the night vision stage or component.
• the retinal disease is a retinal degenerative disease.
• the active ingredient in accordance with the invention is a substantially crude Dunaliella algae preparation, typically dried Dunaliella algae.
• the Dunaliella algae are preferably Dunaliella bardawil.
• Other species include D. salina, D. viridis, D. peircei,
• the substantially crude Dunaliella algae preparation contains ⁇ -carotene (BC) at an approximately 1 : 1 ratio of 9-cis to all-trans isomers of BC or greater than 1 : 1 ratio of 9-cis to all-trans isomers of BC.
• BC ⁇ -carotene
• a further embodiment of this aspect of the invention is a pharmaceutical composition for improving night vision and/or rod-derived visual field in a subject suffering from a retinal degenerative disease comprising crude Dunaliella powder.
• Fig. 1 is a dark-adapted chromatic visual field diagram of the left eye of an RP patient before treatment
• Fig. 2 is a dark-adapted chromatic visual field diagram of the left eye of an RP patient after 3 months of treatment
• Fig. 3 is a dark-adapted chromatic visual field diagram of the right eye of an RP patient before treatment
• Fig. 4 is a dark-adapted chromatic visual field diagram of the right eye of an RP patient after 3 months treatment
• Fig. 5 is a bar graph showing photoreceptor ERG response levels pre-treatment, after treatment and after a washout period of 3 months in the left and right eyes of an RP patient;
• Fig. 6 is a dark-adapted chromatic visual field diagram of the right eye of patient #4 before (A) and after 3 months (B) of Dunaliella treatment showing the Scotoma (blind spot);
• Fig. 7 is a bar graph showing the visual field mean deviation before and after treatment of normal subjects and patients.
• Fig. 8 is a bar graph showing the b-wave amplitude maximal responses before and after treatment of normal subjects and patients.
• Db Dunaliella bardawil
• BC ⁇ -carotene
• the algae were harvested by dislodging centrifuges into a concentrated paste. The paste was washed to remove the salt and sterilized, and then spray dried to yield Db powder comprising approximately 8% BC and less than 5% moisture.
• the powder was packaged in capsules of 250-300 mg algae containing 15-20 mg of BC each together with all of the natural components of the algae.
• the BC of the capsules retains the original ratio of isomers.
• the capsules are packaged in vacuum closed blisters which have a shelf life of up to three years.
• Example I The effect of oral administration of 9-cis rich powder of the alga Dunaliella bardawil on day vision visual functions in patients with RP
• 20 patients ages 50-75
• autosomal dominant retinitis pigmentosa with RHO trmtntinr ⁇ fu ⁇ r 1 ** a Hav fnr 1 9 wpplrc Half ⁇ f thp nfltipnt ⁇ ! rp.c.P. ⁇ /pA Dunaliella baraweil while the other half received placebo.
• the treatment period will be followed by a 12 week washout period and subsequently by a further 12 week period in which the patients who received Dunaliella baraweil will receive placebo, and vica versa.
• Four patients completed the first treatment period.
• Figs. 1-5 show the dark-adapted chromatic visual fields of the left and right eyes of the patient before and after the treatment. The subject is looking at the center and the observer shows him a small light stimulus in the periphery. The colored circles represent when the subject first observes the stimuli. Red stimulus is represented by a red circle and blue stimulus is represented by blue.
• the numbers IDC means size II (smaller compared to V), 3C represents the light intensity and the dash above C represents 100 times smaller light intensity.
• Photoreceptor ERG results are presented in Fig. 5. It may be seen that both eyes showed marked improvement after treatment. The ERG returned to pretreatment levels 3 months after cessation of treatment. This indicates that maintenance treatment is required to maintain visual function.
• Example II Further results in the day (cone) vision of patients enrolled in the clinical trial of Example I
• Table 1 Central (cone derived) visual field area
• Example IV The effect of oral administration of 9-cis rich powder of the alga Dunaliella bardawil on visual functions in patients with congenital stationary night blindness Subjects
• Normal subjects Five subjects without any pathology under ophthalmic examination, aged 58.6 ⁇ 5.6 years old, were treated daily for ninety days with four capsules of Dunaliella Bardawil as described above. The subjects were tested before treatment and after ninety days of treatment for visual acuity, biomicroscopic examination intraocular pressure and electroretinogram (ERG) tests. Normal subjects and patients performed visual fields central 24-2 threshold test before and after treatment in both eyes (the amblyopic eye was excluded).
• CSNB Congenital stationary night blindness
• the subjects were tested bilaterally before and after treatment by ERG (LKC Technologies, Inc., Gaithersburg, MD) using an ISCEV compliant protocol.
• the scotopic responses were recorded for dim single flash stimulus (0.023cd-s/m2) and bright single flash stimulus (2.44cd-s/m2).
• the patients were dark adapted for an additional 90 minutes after recording the scotopic ERG 30 minutes (total of 120 minutes dark adaptation) and were then light adapted.
• the amplitudes latencies of the wave form were measured and the percentages of change were calculated by subtraction of baseline ERG responses from post treatment responses and divided by the baseline responses for each eye.
• Electroretinogram (ERG) Electroretinogram
• the ERG percentage of change responses of the normal subjects are summarized in Table 3.
• the maximal scotopic a-wave and b-wave amplitude responses did not show any difference from baseline.
• the ERG responses in photopic conditions did not show any significant change from baseline.
• one subject showed a clinical significant improvement of 90% in the 30Hz response in both eyes. This improvement could not be statically evaluated in this small group of subjects.
• Table 3 ERG percentage of change
• the responses for the CSNB patients are summarized in Table 4.
• the maximal scotopic ERG responses for 30 minutes dark adaptation were not changed significantly from baseline (the a- and b-waves maximal rod responses were 15% ⁇ 55% and 42% ⁇ 109% respectively).
• the 120 minutes dark adaptation maximal ERG b-wave responses was doubled, the a- and b-waves maximal rod responses increased by 17% ⁇ 52% and 68% ⁇ 63% respectively.
• the average b-wave maximal response amplitude pre-treatment was 194 ⁇ 56 ⁇ V and post-treatment was 300 ⁇ 52 ⁇ V (pO.OOl, T-test).
• Example V Results in the night vision of patients enrolled in the clinical trial of Example I

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