Classifications

• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K31/00—Medicinal preparations containing organic active ingredients
  • A61K31/33—Heterocyclic compounds
  • A61K31/395—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins
  • A61K31/41—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins having five-membered rings with two or more ring hetero atoms, at least one of which being nitrogen, e.g. tetrazole
  • A61K31/4164—1,3-Diazoles
  • A61K31/4178—1,3-Diazoles not condensed 1,3-diazoles and containing further heterocyclic rings, e.g. pilocarpine, nitrofurantoin
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K9/00—Medicinal preparations characterised by special physical form
  • A61K9/0012—Galenical forms characterised by the site of application
  • A61K9/0048—Eye, e.g. artificial tears
• • 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
  • A61P27/00—Drugs for disorders of the senses
  • A61P27/02—Ophthalmic agents
  • A61P27/10—Ophthalmic agents for accommodation disorders, e.g. myopia
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K47/00—Medicinal preparations characterised by the non-active ingredients used, e.g. carriers or inert additives; Targeting or modifying agents chemically bound to the active ingredient
  • A61K47/02—Inorganic compounds
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K47/00—Medicinal preparations characterised by the non-active ingredients used, e.g. carriers or inert additives; Targeting or modifying agents chemically bound to the active ingredient
  • A61K47/06—Organic compounds, e.g. natural or synthetic hydrocarbons, polyolefins, mineral oil, petrolatum or ozokerite
  • A61K47/08—Organic compounds, e.g. natural or synthetic hydrocarbons, polyolefins, mineral oil, petrolatum or ozokerite containing oxygen, e.g. ethers, acetals, ketones, quinones, aldehydes, peroxides
  • A61K47/12—Carboxylic acids; Salts or anhydrides thereof
• • A—HUMAN NECESSITIES
  • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
  • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
  • A61K47/00—Medicinal preparations characterised by the non-active ingredients used, e.g. carriers or inert additives; Targeting or modifying agents chemically bound to the active ingredient
  • A61K47/06—Organic compounds, e.g. natural or synthetic hydrocarbons, polyolefins, mineral oil, petrolatum or ozokerite
  • A61K47/16—Organic compounds, e.g. natural or synthetic hydrocarbons, polyolefins, mineral oil, petrolatum or ozokerite containing nitrogen, e.g. nitro-, nitroso-, azo-compounds, nitriles, cyanates
  • A61K47/18—Amines; Amides; Ureas; Quaternary ammonium compounds; Amino acids; Oligopeptides having up to five amino acids
  • A61K47/186—Quaternary ammonium compounds, e.g. benzalkonium chloride or cetrimide

Definitions

• Presbyopia and other visual disorders have long been treated primarily with optical lenses and other such mechanical devices. As discussed in further detail herein, it would be advantageous to provide an alternative treatment that would avoid the use of such devices and the various disadvantages that these entail.
• Cholinergic agonists such as pilocarpine have been used to lower intraocular pressure (“IOP”) so as to treat primary open angle glaucoma.
• IOP intraocular pressure
• Such cholinergic agonists were a mainstay for treatments that sought to lower IOP until the introduction of timolol in 1978.
• compositions and methods for improving vision using pilocarpine are Described herein.
• a method of treating an ocular condition in a patient comprising administering to the patient an ophthalmic composition comprising pilocarpine hydrochloride.
• a method of treating an ocular condition in a patient in need thereof comprising administering to the patient a pharmaceutically acceptable ophthalmic composition comprising pilocarpine hydrochloride at a concentration from 1.0 to 1.5% w/v, wherein the formulation is administered topically to at least one eye of the patient, and wherein the ocular condition is selected from the group consisting of presbyopia, hyperopia, mydriasis, anisocoria, accommodative esotropia, myopia, and astigmatism.
• a method of improving at least one vision parameter in a patient in need thereof comprising administering to the patient a pharmaceutically acceptable ophthalmic composition comprising pilocarpine hydrochloride at a concentration from 1.0 to 1.5% w/v, wherein the formulation is administered topically to at least one eye of the patient, and wherein the at least one vision parameter is selected from the group consisting of near vision acuity, intermediate vision acuity, distance vision acuity, night vision, day vision, glare, and light scattering.
• a method for improvement of near vision in a patient with presbyopia in need thereof comprising administering to an eye of the patient a pharmaceutically acceptable ophthalmic composition comprising pilocarpine hydrochloride at a concentration from 1.0 to 1.5% w/v.
• the ocular condition is presbyopia. In some embodiments, the ocular condition is hyperopia. In some embodiments, the ocular condition is mydriasis. In some embodiments, the vision parameter is near vision acuity. In some embodiments, the vision parameter is intermediate vision acuity. In some embodiments, the vision parameter is distance vision acuity. In some embodiments, the vision parameter is night vision. Additional embodiments provide for the method resulting in an at least 3-line improvement from baseline under the condition of mesopic, high contrast UNVA. In some embodiments, the method results in an at least 2-line improvement from baseline under the condition of mesopic, high contrast UNVA.
• the method results in an increase in the average letter change from baseline under the condition of mesopic, high contrast UNVA. In some embodiments, the method results in an at least 2-line improvement from baseline under the condition of photopic, high contrast UNVA. In some embodiments, the method results in an at least 2-line
• the method results in an at least 3-line improvement from baseline under the condition of mesopic, high contrast DCNVA.
• the method may result in an at least 3-line improvement from baseline under the condition of photopic, high contrast DCNVA.
• the method results in an at least 3-line improvement from baseline under the condition of mesopic, high contrast DCIVA.
• the method may result in an at least 3 -line improvement from baseline under the condition of photopic, high contrast DCIVA.
• the method results in an improvement of at least one line in at least one selected from the group consisting of UNVA, UDVA, DCNVA, and DCIVA.
• the pharmaceutically acceptable ophthalmic composition to comprise pilocarpine hydrochloride at a concentration that is greater than or equal to 1% and less than 1.5% w/v.
• the pharmaceutically acceptable ophthalmic composition may comprise pilocarpine hydrochloride at a concentration of 1.25% w/v.
• pilocarpine hydrochloride being the sole active ingredient in the pharmaceutically acceptable ophthalmic composition.
• the pharmaceutically acceptable ophthalmic composition does not comprise a polymer.
• Administration of the pharmaceutically acceptable ophthalmic composition may in some embodiments result in a lower incidence of at least one of ocular blurring, ocular discomfort, eye pain, brow ache, blurry vision, light sensitivity, stinging, and itching, compared to administration of a second ophthalmic composition comprising pilocarpine and a polymer.
• the pharmaceutically acceptable ophthalmic composition further comprises boric acid, sodium citrate dihydrate, sodium chloride, hydrochloric acid and/or sodium hydroxide, and water.
• the pharmaceutically acceptable ophthalmic composition may be administered once daily.
• the pharmaceutically acceptable ophthalmic composition may be administered twice daily.
• the pharmaceutically acceptable ophthalmic composition may be administered to both eyes of the patient.
• the pharmaceutically acceptable ophthalmic composition may be administered to one eye of the patient.
• the pharmaceutically acceptable ophthalmic composition may be administered to the nondominant eye of the patient.
• the pharmaceutically acceptable ophthalmic composition may be administered to the dominant eye of the patient.
• An additional preferred embodiment provides for a composition for the treatment of an ocular condition, wherein the composition is pharmaceutically acceptable and comprises pilocarpine hydrochloride at a concentration from 1.0 to 1.5% w/v, and wherein the ocular condition is selected from the group consisting of presbyopia, hyperopia, mydriasis, anisocoria, accommodative esotropia, myopia, and astigmatism.
• the composition comprises 1.25% w/v pilocarpine
• the composition comprises 1.25% w/v pilocarpine hydrochloride, boric acid, sodium citrate dihydrate, sodium chloride, hydrochloric acid and/or sodium hydroxide, and water.
• the composition is applied once daily.
• the composition may be applied twice daily.
• the composition may be administered to both eyes of a patient.
• the composition may be administered to a nondominant eye of a patient.
• the composition may be administered to a dominant eye of a patient.
• pilocarpine hydrochloride is the sole active ingredient.
• the preservative may be benzalkonium chloride.
• the composition comprises about 1.25% w/v pilocarpine hydrochloride, about 1.0% w/v boric acid, about 0.015% w/v sodium citrate dihydrate, about 0.08% w/v sodium chloride, and about 0.0075% w/v benzalkonium chloride.
• the composition may consist essentially of 1.25% w/v pilocarpine hydrochloride, 1.0% w/v boric acid, 0.015% w/v sodium citrate dihydrate, 0.08% w/v sodium chloride, and 0.0075% w/v benzalkonium chloride, with a pH of 5.0.
• the composition in some embodiments reduces the incidence of at least one adverse event selected from the group consisting of ocular blurring, ocular discomfort, eye pain, brow ache, blurry vision, light sensitivity, ocular stinging, and ocular itching, compared to administration of a second ophthalmic composition comprising pilocarpine and a polymer.
• the second composition may comprise 1% w/v pilocarpine and the polymer may be hydroxy propyl methyl cellulose.
• compositions for improving at least one vision parameter wherein the composition is pharmaceutically acceptable and comprises pilocarpine hydrochloride at a concentration from 1.0 to 1.5% w/v, and wherein the at least one vision parameter is selected from the group consisting of near vision acuity, distance vision acuity, night vision, day vision, glare, and light scattering.
• the composition comprises 1.25% w/v pilocarpine
• the composition may comprise 1.25% w/v pilocarpine hydrochloride, and the vision parameter is distance vision acuity.
• the composition may comprise 1.25% w/v pilocarpine hydrochloride, boric acid, sodium citrate dihydrate, sodium chloride, hydrochloric acid and/or sodium hydroxide, and water.
• the composition may be applied once daily.
• the composition may be applied twice daily.
• the composition is administered to both eyes of a patient.
• the composition may be administered to a nondominant eye of a patient.
• the composition may be administered to a dominant eye of a patient.
• pilocarpine hydrochloride is the sole active ingredient.
• the composition may further comprise a preservative.
• the preservative may be benzalkonium chloride.
• the composition comprises about 1.25% w/v pilocarpine hydrochloride, about 1.0% w/v boric acid, about 0.015% w/v sodium citrate dihydrate, about 0.08% w/v sodium chloride, and about 0.0075% w/v
• the composition consists essentially of 1.25% w/v pilocarpine hydrochloride, 1.0% w/v boric acid, 0.015% w/v sodium citrate dihydrate,
• compositions for the improvement of near vision in a patient with presbyopia wherein the composition is pharmaceutically acceptable and comprises pilocarpine hydrochloride at a concentration from 1.0 to 1.5% w/v.
• the composition comprises 1.25% w/v pilocarpine
• the composition comprises 1.25% w/v pilocarpine hydrochloride, boric acid, sodium citrate dihydrate, sodium chloride, hydrochloric acid and/or sodium hydroxide, and water.
• the composition may be administered once daily.
• pilocarpine hydrochloride is the sole active ingredient.
• the composition may further comprise a preservative.
• the preservative may be benzalkonium chloride.
• the composition comprises about 1.25% w/v pilocarpine hydrochloride, about 1.0% w/v boric acid, about 0.015% w/v sodium citrate dihydrate, about 0.08% w/v sodium chloride, and about 0.0075% w/v benzalkonium chloride.
• the composition consists essentially of 1.25% w/v pilocarpine hydrochloride, 1.0% w/v boric acid, 0.015% w/v sodium citrate dihydrate, 0.08% w/v sodium chloride, and 0.0075% w/v benzalkonium chloride, with a pH of 5.0.
• a composition for the improvement of near vision in a patient with presbyopia comprising 1.25% w/v pilocarpine hydrochloride, 1.0% w/v boric acid, 0.015% w/v sodium citrate dihydrate, 0.08% w/v sodium chloride, 0.0075% w/v benzalkonium chloride, and water, with a pH of 3.0-5.5.
• the composition consists of 1.25% w/v pilocarpine
• a method for the improvement of near vision in a patient with presbyopia comprises administering to at least one eye of the patient a
• composition comprising pilocarpine as the sole active ingredient, wherein said composition does not contain any viscosity-enhancing polymers.
• the composition comprises pilocarpine hydrochloride.
• the composition may comprise 1.25% w/v pilocarpine hydrochloride.
• the composition comprises pilocarpine nitrate.
• the composition comprises 1.25% w/v pilocarpine hydrochloride or a molar equivalent pilocarpine salt.
• the composition may be administered once daily.
• the composition may be administered twice daily.
• the composition is administered to a nondominant eye of the patient.
• the composition is administered to a dominant eye of the patient.
• the composition may also be administered to both eyes of the patient.
• the composition does not contain hydroxy propyl methyl cellulose.
• administration of the pharmaceutically acceptable composition reduces the incidence of one or more adverse events compared to the administration of a pilocarpine composition comprising one or more viscosity enhancing polymers.
• the one or more adverse events may be selected from the group consisting of ocular blurring, ocular discomfort, eye pain, brow ache, blurry vision, light sensitivity, ocular stinging, and ocular itching.
• a pharmaceutically acceptable ophthalmic composition comprising a first amount of pilocarpine hydrochloride as the sole active ingredient, wherein such administration is made without previously administering a second amount of pilocarpine hydrochloride and/or subsequently administering a third amount of pilocarpine hydrochloride; wherein the second amount is lower than the first amount, and wherein the third amount is higher than the first amount.
• the first amount of pilocarpine hydrochloride is 1.25% w/v.
• the pharmaceutically acceptable ophthalmic composition may be administered to both eyes of the patient.
• the pharmaceutically acceptable ophthalmic composition may be administered once daily, or twice daily.
• FIG. 1 shows the average change from baseline of number of letters in mesopic UNVA (mITT, non-dominant eye, Clinical Study B using ANCOVA).
• FIG. 2 shows the average change from baseline of UNVA at each timepoint over a two- day dosing period in the pilocarpine 1% Group, where one drop of pilocarpine hydrochloride was administered at Hour 0 on Day 1 and Day 2.
• mITT non-dominant eye, Clinical Study B.
• FIG. 3 illustrates a model of the most effective pilocarpine concentration range for improving near vision.
• FIG. 4 shows the average letter change from baseline of UDVA over a 2-day dosing period in clinical study B.
• FIG. 5 illustrates a computational model of the most effective pilocarpine concentration range for improving distance vision.
• FIG. 6 shows the scheme of the study design in Clinical Study A.
• FIG. 7 illustrates a comparison of the change in UNVA number of letters read by timepoint following 1% pilocarpine administration with different concentrations of
• FIG. 8 shows a graph of 3-line improvement in mesopic UNVA (mITT population).
• FIG. 9 shows a graph of 2-line improvement in mesopic UNVA (mITT population).
• FIG. 10 shows the scheme of the study design in Clinical Study C.
• FIGS. 11 A and B illustrate the mean ocular blur and ocular discomfort, respectively, per timepoint for the two tested formulations at Assessment 1 in Clinical Study C.
• FIGS. 12A and B illustrate the mean ocular blur and ocular discomfort, respectively, across timepoints for the two tested formulations at Assessment 1 in Clinical Study C.
• FIGS. 13A and B illustrate the mean ocular blur and ocular discomfort, respectively, per timepoint for the two tested formulations at Assessment 2 in Clinical Study C.
• FIGS. 14A and B illustrate the mean ocular blur and ocular discomfort, respectively, across timepoints for the two tested formulations at Assessment 2 in Clinical Study C.
• terapéuticaally effective amount refers to an amount that is effective, when administered to an individual to treat one or more ocular conditions and/or improve at least one vision parameter.
• the extent of the vision improvement and/or success in the treatment of the ocular condition when a therapeutically effective amount of a compound and/or composition is administered to an individual would be readily identifiable to a skilled person as is described herein.
• the term“uncorrected near visual acuity” (“UNVA”) refers to a person’s ability, without any vision aid (such as eyeglasses or contact lenses), to see the details of objects within arm’s distance from the body (e.g., at 33-41 cm away from the eye).
• the term “distance corrected near visual acuity” (“DCNVA”) may be used to refer to a person’s ability to see the details of objects within arm’s distance from the body (e.g., at 33-41 cm away from the eye), with the use of vision aids such as eyeglasses or contact lenses that correct for distance vision issues.
• the terms“near visual acuity”,“near vision acuity”, and“near vision” may be used interchangeably.
• UDVA uncorrected distance visual acuity
• the terms“intermediate vision”,“intermediate vision acuity”, and“intermediate visual acuity” may be used to refer to a person’s ability to see the details of objects at distances between the near and far visual ranges. In other words, such a distance range would be between a distance approximately farther than arm’s distance (about 33-41 cm away from the eye) and less than approximately 4 meters from the eye. In some embodiments, for example, this may refer to the distance from a person’s eye to an object near a person’s feet.
• the term distance- corrected intermediate visual acuity (“DCIVA”) may be used to refer to a person’s ability to see the details of objects at intermediate distances with the use of vision aids such as eyeglasses or contact lenses that correct for distance vision issues.
• the term“2-line improvement from baseline” or“3 -line improvement from baseline” or similar improvement from baseline refers to a person’s ability to read 2 or 3 more lines of letters on a standard chart (e.g., Snellen, ETDRS, Logarithmic Visual Acuity Chart, etc.) after treatment with pilocarpine when comparing to the number of lines readable before treatment.
• a standard chart e.g., Snellen, ETDRS, Logarithmic Visual Acuity Chart, etc.
• the term“the number of letters correctly read” refers to the number of letters on a standard chart (e.g., Snellen, ETDRS, Logarithmic Visual Acuity Chart, etc.) that can be correctly read by a person.
• the term“increase from baseline in the number of letters correctly” refers to the increase from pre-treatment in the number of letters correctly read at certain post treatment time point.
• mITT refers to the modified intent-to-treat population, which is defined as all randomized patients with a baseline and at least 1 post baseline assessment of mesopic, high contrast, UNVA, and with a baseline UNVA of no greater than 3 lines across the 5 dosing periods.
• the term“vision parameter” may refer to any characteristic in a patient’s vision that may be measured and is susceptible to being improved by the compositions and methods described herein.
• Vision parameters that may be improved in the various embodiments described herein include but are not limited to near vision acuity, intermediate visual acuity, distance visual acuity, night vision, day vision, optical aberrations (e.g., glare, light scattering), and uncorrected refractive errors.
• Additional examples of vision parameters that may be improved in the various embodiments described herein also include without limitation night time glare, post-LASIK“star burst” glare, visual“halos” seen around light sources, and
• Vision or visual improvement including but not limited to near, intermediate, and/or distance visual acuity, may for example be reflected in the increase of number of letters correctly read at any time point post dosing, the increase in the average letter change, or 2-line or 3 -line improvement, all from baseline (i.e., from pre-treatment).
• Night vision improvement may be reflected in visual improvement for patients in dim or dark lighting (e.g., under mesopic or scotopic conditions).
• Day vision improvement may be reflected in visual improvement for patients in bright lighting as found during daylight hours or in sunshine (e.g., under photopic conditions).
• Vision improvement using the embodiments described herein may also be achieved in combination with or when using other visual aids and devices (especially those used for treating presbyopia), including but not limited to reading glasses, lens modifying medications, and surgical presbyopic options including intraocular lenses (IOLs).
• visual aids and devices especially those used for treating presbyopia
• IOLs intraocular lenses
• Ocular condition may refer to any condition, disease, or impairment which affects or involves the eye or one of the parts or regions of the eye, and includes optical issues causing refractive errors in the eye.
• Ocular conditions include, but are not limited to presbyopia, hyperopia, mydriasis, anisocoria, and accommodative esotropia, myopia, astigmatism, Adie’s tonic pupil, or other causes of parasympathetic denervation, accommodative insufficiency, and complications arising after refractive surgery, such as decentered ablations following LASIK or PRK, corneal scars, hazing, refractive errors, and so forth.
• Pilocarpine is a cholinergic muscarinic agonist represented by the following chemical structure:
• Pilocarpine may present in different salt forms, but is typically used with its hydrochloride salt. Other possible salts include, but are not limited to, nitrate, hydrate, and free acids. Unless specified otherwise, references to“pilocarpine” herein will mean“pilocarpine hydrochloride”. Additionally, references herein to compositions with pilocarpine, unless otherwise specified, should be interpreted as such an amount of a composition with pilocarpine hydrochloride in units of weight per volume. For example, 1.25% pilocarpine would mean a composition of 1.25% w/v pilocarpine hydrochloride.
• pilocarpine hydrochloride may be used in a composition in ranges of 1% to 1.5% w/v, more preferably above 1% w/v and below 1.5% w/v, for example 1.16% w/v to 1.32% w/v, or 1.1875% w/v to 1.3125% w/v. Additional ranges of pilocarpine hydrochloride that may be used include 0.95% w/v to 1.2% w/v, 1.1% w/v to 1.4% w/v, and 1.2% w/v to 1.3% w/v. A preferred amount of pilocarpine hydrochloride is 1.25% w/v.
• pilocarpine hydrochloride that may be used include for example and without limitation, 0.5% w/v, 0.6% w/v, 0.7% w/v, 0.8% w/v, 0.9% w/v, 0.95% w/v, 0.99% w/v, 1% w/v, 1.01% w/v, 1.05% w/v, 1.08% w/v, 1.1% w/v, 1.15% w/v, 1.2% w/v, 1.21% w/v, 1.22% w/v, 1.23% w/v, 1.24% w/v, 1.26% w/v, 1.27% w/v, 1.28% w/v, 1.29% w/v, 1.3% w/v, 1.31% w/v, 1.32% w/v, 1.35% w/v, 1.4% w/v, 1.45% w/v, 1.49% w/v, and 1.5% w/v, and ranges and ranges
• corresponding molar equivalent amounts of these other salts can be used.
• a 1.25% w/v pilocarpine hydrochloride composition (molecular weight of 244.72 g/mol) would be equivalent to a composition of 1.06% w/v pilocarpine when the weight of the hydrochloride is subtracted.
• a corresponding molar equivalent amount of the pilocarpine nitrate salt (molecular weight of 270.527 g/mol) would therefore have a concentration of 1.38% w/v. Similar molar conversion calculations may be made for other amounts and ranges disclosed herein.
• compositions may be administered once daily, twice daily, or more. Preferably, the compositions are administered once daily. When administered, the compositions preferably have a duration of action sufficient for an entire day. In some embodiments, the compositions may have a duration of effect of at least two hours, at least three hours, preferably at least four hours, more preferably at least six hours, more preferably at least eight hours, even more preferably at least 10 hours, as well as all intervening time points. Some embodiments may provide for a composition having a duration of action greater than 10 hours, for example 12 hours, or even 24 hours. The duration of action refers to the duration of time that the administered composition has an effect on at least one vision parameter or ocular condition (e.g., presbyopia).
• a vision parameter or ocular condition e.g., presbyopia
• the compound when pilocarpine is part of a composition, the compound is the sole active ingredient which has therapeutic activity for the treatment of an ocular condition or for improving a vision parameter.
• active ingredient refers to a component of a composition which is responsible for the therapeutic effect of composition, whereas the other components of the composition (e.g. excipients, carriers, and diluents) are not responsible for the therapeutic effect of composition, even if they have other functions in the composition which are necessary or desired as part of the formulation (such as lubrication, pH control, emulsification, stabilization, preservation, and other functions other than the effect of composition as described herein).
• compositions described herein in which pilocarpine is the sole active ingredient which has therapeutic activity are compositions in which there are no other components which would be considered to have therapeutic activity for the treatment of ocular conditions or improvement of vision parameters.
• compositions described herein may comprise a suitable preservative.
• suitable preservatives include benzalkonium chloride (“BAK”), Polyquaternium-l (Poly quad®), chlorobutanol, stabilized chlorine dioxide, and others.
• Stabilized chlorine dioxide also known as Purite®, may be described as an aqueous solution of sodium chlorite (NaClCh).
• U.S. Patent Number 5,424,078, which is incorporated herein by reference in its entirety, further discusses the use of stabilized chlorine dioxide as a preservative for ophthalmic formulations.
• Topical cholinergic agonists act on the ciliary muscle, located in the ciliary body of the eye, and which is one of the richest areas of cholinergic receptors in the central nervous system.
• Pilocarpine also acts on the muscarinic cholinergic receptors found on the iris sphincter muscle, causing the muscle to contract, resulting in pupil constriction (i.e., miosis) (Levin el ah, Adler’s Physiology of the Eye, 11 th edition by Saunders Elsevier (Edinburgh), pp. 56, 57, and 509-510).
• Pilocarpine with stimulation of the ciliary muscle, can cause a forward movement of the ciliary body with ciliary muscle contraction, relaxation of the zonules causing the central surfaces of the crystalline lens to steepen, and the central thickness of the lens to increase (anterior-posterior diameter) ⁇ Id, pp. 44-55).
• the net result is an increase in the diopter power of the lens which can lead to a number of patient complaints, including reduced visual acuity at near and far distances and ocular discomfort with higher concentrations of pilocarpine instilled in the eye.
• glaucoma management with pilocarpine typically begins with lower concentrations, with the dose strengths being individually titrated upwards so as to permit patients to achieve target IOP sufficient to prevent further visual field deterioration (Ritch et al, The Glaucomas, Mosby (St. Louis), p. 516, 1989 and Kini et al, Arch Ophthalmol., 89, pp. 190- 192, 1973).
• pilocarpine has an upwardly sloping dose response curve.
• escalating doses of pilocarpine in order to retain adequate IOP control often increases dose-dependent adverse events.
• blurry vision at near and far distances is a common side effect of commercial pilocarpine formulations.
• the prescribing information for Isoptocarpine notes that a common adverse reaction is blurred vision; additional potential visual disturbances noted in the label include accommodative change and“visual impairment (dim, dark, or‘jumping’ vision)”.
• the prescribing information warns patients to exercise caution in night driving or other situations with poor illumination, and, recognizing the risk of blurry vision, warn against driving or using machinery if the patient’s vision is not clear.
• pilocarpine with other active ingredients, such as alpha-2 adrenergic receptor agonists.
• other active ingredients such as alpha-2 adrenergic receptor agonists.
• such combinations may implicate additional side effects on top of those related to pilocarpine.
• common oxymetazoline side effects include ocular burning and stinging, blurry vision, watery eyes, headache, dizziness, and nervousness.
• Viscosity enhancing polymers are commonly used in topical ophthalmic preparations to reduce the clearance of pilocarpine through lacrimal drainage so as to increase the residency time of the drug on the cornea, thereby increasing bioavailability and IOP effect (Reddy, Ocular Therapeutics and Drug Delivery: A Multi-Disciplinary Approach, Technomic Publishing AG (Lancaster), pp. 387-389, 1996).
• Polymers may also be used as demulcents to increase the comfort of ophthalmic preparations once placed upon the eye, and are typically described as having a lubricant and/or soothing effect (Abelson et. al., Demystifying Demulcents, Review of Ophthalmology, 2006).
• Dosing frequencies and concentrations of pilocarpine, preferably as a monotherapy, that can effectively treat presbyopia without causing intolerable side effects such as severe headache and visual disturbances are therefore desired.
• Such embodiments have been discovered and are described in greater detail below.
• Clinical Study A The safety and efficacy of pilocarpine hydrochloride 1% w/v ophthalmic solution alone was evaluated in one arm of a multicenter, double-masked, randomized, vehicle-controlled study in patients with presbyopia in a clinical study.
• the clinical study is referred to herein as Clinical Study A and is summarized in Example 1 , and involved once or twice daily pilocarpine administration, each over a 3 -day study period.
• pilocarpine provided a greater improvement on reading ability with QD (once daily) dosing compared with BID (twice daily) dosing.
• the percentage of patients achieving a clinically relevant 2-line (10 letter) improvement from baseline in Uncorrected Near Visual Acuity (UNVA) at the majority of time points measured over an 8-hour period each day over the study period was 70.6% in the QD dosing group compared with 56.3% in the BID dosing group.
• Clinical Study B an additional clinical study, referred to as Clinical Study B and described in Example 2, was performed to examine the effects of multiple dose concentrations of pilocarpine in patients with presbyopia using the QD dosing frequency that appeared to be better than BID from the aforementioned Clinical Study A.
• Example 2 As detailed in Example 2, a multicenter, double-masked, randomized, vehicle- controlled clinical study in 160 patients with presbyopia was performed. This clinical study included arms receiving pilocarpine hydrochloride 0.5%, 1%, and 1.5% w/v with QD dosing over a 2-day study period. Additional arms also tested the effect of combining pilocarpine with varying concentrations of oxymetazoline. Uncorrected near vision was measured each day at 1, 3, 6, 8, and 10-hours post pilocarpine administration.
• the pilocarpine formulations used in the clinical studies described herein comprised no polymers, thereby limiting the potential for vision blur. Since viscosity is a surrogate for the blur potential of an ophthalmic formulation, the viscosity of an embodiment of a polymer-free pilocarpine formulation was compared to viscosity of commercially available polymer-containing pilocarpine formulation (Isoptocarpine, which contains hydroxy propyl methyl cellulose), as described in Example 4. Results showed that with equal drug concentrations of 1% pilocarpine, commercial polymer-containing formulations were approximately 20-fold more viscous than the polymer-free formulations described herein.
• pilocarpine usage in glaucoma requires an increase in dose strength (with formulations of up to 10% pilocarpine) and an increase in dosing frequency (up to four times daily) in order to provide adequate IOP reduction and control.
• pilocarpine has been found to adversely affect vision (at both near and far distances), and is also tied to more serious adverse events (such as headache) when used at the higher drug concentrations and dosing frequencies typically used for treating glaucoma.
• the removal of polymers was expected to have reduced the residence time of pilocarpine on the ocular surface and its subsequent effect, the polymer-free compositions described herein unexpectedly did not reduce pilocarpine’s duration of effect— to the contrary, once-daily dosing was discovered to better maintain the visual improvement over a 10-hour period than more frequent dosing (e.g., twice- daily administration).
• the removal of polymers also reduced the potential for vision blurring and other such issues.
• Clinical Study A is a multicenter, double-masked, randomized, vehicle-controlled study which determined the effect of once- or twice-daily dosing of pilocarpine. Seventeen patients were treated with pilocarpine hydrochloride 1.0% w/v followed by vehicle in the non-dominant eye, and vehicle alone in the dominant eye. The respective formulations used are set forth in Table 4 below. One patient discontinued the study, due to a nonocular adverse event.
• Study medication was administered once daily (QD) in each eye during office visits 1 through 3 at hour 0 (8 AM ⁇ 1 hour). Following a 5 ⁇ 2 day washout period, study medication was administered twice daily (BID) in each eye during office visits 5 through 7 at hour 0 (8 AM ⁇ 1 hour) and hour 5 (5 hours ⁇ 15 minutes after hour 0 dose administration). Patients returned on visit 8 for safety testing and exit from the study.
• QD once daily
• BID twice daily
• the primary efficacy variable was UNVA response at visit 3.
• a UNVA responder was defined as a patient with at least a 2-line improvement in mesopic, high contrast UNVA in the non-dominant eye from baseline (hour 0 of visit 1) at a majority (at least 3) of time points post dose.
• the percentage of patients achieving the primary endpoint, at least a 2-line improvement from baseline in mesopic, high contrast UNVA (hour 0 of visit 1) in the non-dominant eye at a majority (at least 3) of time points post dose was 70.6%.
• a multicenter, double-masked, parallel-group, randomized sequence, dose response, vehicle-controlled study in patients with presbyopia was conducted.
• Four treatment groups were defined based on the concentration of pilocarpine hydrochloride ophthalmic solution to which patients were randomly assigned (0%, 0.5%, 1%, or 1.5% w/v). Each dosing period lasted for two days.
• each of the tested pilocarpine concentrations was paired with four different concentrations of oxymetazoline hydrochloride ophthalmic solution (0%, 0.0125%, 0.05%, or 0.125% w/v) administered as an unfixed combination, as well as a group which received a fixed combination of pilocarpine hydrochloride 1% w/v in combination with oxymetazoline hydrochloride 0.125% w/v.
• Pilocarpine hydrochloride 0.5, 1, and 1.5% w/v ophthalmic solutions also contained benzalkonium chloride, boric acid, sodium citrate dihydrate, sodium chloride, hydrochloric acid/sodium hydroxide, and purified water
• pilocarpine hydrochloride 0% contained no pilocarpine or any salt thereof but only the excipients/carriers (i.e., benzalkonium chloride, boric acid, sodium citrate dihydrate, sodium chloride, hydrochloric acid/sodium hydroxide, and purified water).
• Oxymetazoline hydrochloride ophthalmic solution 0.0125, 0.05, or 0.125% w/v contained oxymetazoline hydrochloride, benzalkonium chloride, boric acid, sodium citrate dihydrate, sodium chloride, hydrochloric acid/sodium hydroxide, and purified water, whereas oxymetazoline hydrochloride 0% contained no oxymetazoline or any salt thereof but only the excipients/carriers (i.e., benzalkonium chloride, boric acid, sodium citrate dihydrate, sodium chloride, hydrochloric acid/sodium hydroxide, and purified water).
• Enrollment of approximately 160 patients with presbyopia was planned (40 per pilocarpine group).
• a total of 157 patients were enrolled, treated, and included in the mITT population (40, 37, 42, and 38 in the pilocarpine hydrochloride 0%, 0.5%, 1%, and 1.5% groups, respectively).
• 161 patients were included in the safety populations (41, 39, 42, and 39 in the pilocarpine hydrochloride 0%, 0.5%, 1%, and 1.5% groups, respectively). All patients in the mITT and safety populations completed the study except for 2, 2, 1, and 3 patients in the pilocarpine 0%, 0.5%, 1%, and 1.5% groups, respectively, who discontinued early due to withdrawal of consent and loss to follow-up.
• the primary efficacy measure was mesopic (defined by lighting 3.2 to 3.5 candelas [cd]/m 2 [10 to 11 lux] measured at the target), high contrast ETNVA in the nondominant eye.
• the primary efficacy variable was the average letter change from baseline under the condition of mesopic, high contrast UNVA in the non-dominant eye. Baseline was the Day 1 Hour 0 measure for each dosing period.
• the primary efficacy endpoint was the average letter change from baseline under the condition of mesopic, high contrast UNVA in the nondominant eye over 2-day periods between Hour 1 and Hour 10.
• Safety measures were adverse events (AEs), photopic high contrast UDVA, vital signs (blood pressure and heart rate), macroscopic hyperemia assessment, study drug tolerability and drop comfort assessments, temporal and supraorbital headache assessment, intraocular pressure (IOP), slit lamp biomicroscopy, dilated funduscopic examinations, and pregnancy tests for females of childbearing potential.
• IOP intraocular pressure
• slit lamp biomicroscopy dilated funduscopic examinations
• pregnancy tests for females of childbearing potential were collected only at screening for determination of patient eligibility: Schirmer's tear test (with anesthesia), pupillary response assessment, photopic pupil measurement (both eyes; distance; measured with Grand Seiko), sodium fluorescein corneal staining (Oxford scale), cycloplegic refraction (photopic distance), and gonioscopy angle assessment.
• the modified intent-to-treat (mITT) population was defined as all randomized patients with a baseline and at least 1 post baseline assessment of mesopic, high contrast, UNVA, and with a baseline UNVA that did not change by more than three lines over five dosing periods.
• the efficacy variables were analyzed using the mITT population on an as- randomized basis.
• the safety population was defined as all patients who received at least one dose of study treatment. All safety measures were analyzed using the safety population on an as-treated basis.
• Disposition and Demographics Patient disposition was summarized for all screened patients and overall and by treatment group for the mITT population. Important protocol deviations were summarized for the mITT population. Demographic variables were summarized for all screened patients and overall and by treatment group for the mITT, PP and safety populations. Medical history and prior and concomitant medications were summarized overall and by treatment group for the safety population. The National Eye Institute Visual Function Questionnaire 25 (NEI VFQ-25), administered at screening, was summarized for the safety population.
• NAI VFQ-25 National Eye Institute Visual Function Questionnaire 25
• Efficacy To examine the primary efficacy variable, the average change from baseline in mesopic, high contrast UNVA letters in the nondominant eye between Hour 1 and Hour 10 during each 2-day dosing period was examined using mixed-effects model for repeated measures (MMRM) with response surface and analysis of covariance (ANCOVA) modeling techniques.
• MMRM mixed-effects model for repeated measures
• ANCOVA analysis of covariance
• the proportions of patients with at least 1 line, 2 lines, and 3 lines of improvement from baseline, and the proportions of patients classified as 20/40 or better, 20/32 or better, 20/25 or better, and 20/20 or better during the mesopic, high contrast UDVA evaluation were calculated for the nondominant eye and binocular ly.
• mITT population The primary efficacy endpoint was the average change from baseline in mesopic, high contrast UNVA letters in the nondominant eye between Hour 1 and Hour 10 during each 2-day dosing period in the mITT population.
• the response surface method analysis revealed a significant dose response driven by the pilocarpine dose (p ⁇ 0.0001 and 0.0029), which was particularly evident up to the 1% dose level.
• the average letter change from baseline across multiple postdose timepoints increased as pilocarpine dose levels increased, and an average improvement of approximately 5 letters was observed for both the pilocarpine hydrochloride 1% and 1.5% dose levels.
• FIG. 1 illustrates the significant effect of pilocarpine hydrochloride dose on mesopic, high contrast UNVA letters correctly read with the non-dominant eye up to the 1% dose level, after which the effect stabilized.
• the vehicle and 0.5% pilocarpine concentrations showed a relatively weaker effect on vision, with mean improvements from baseline of 1.12 and 3.40 letters, respectively.
• Table 3 shows the proportion of patients with at least 2 lines of improvement from baseline in mesopic, high contrast UNVA at a majority of postdose timepoints in the
• Responder was defined as a patient with at least a 2-line improvement in mesopic, high contrast UNVA from baseline at a majority of postdose timepoints (6 or more) in the nondominant eye.
• FIG. 8 and FIG. 9 show the proportion of responders with 3-line or 2-line improvement in mesopic UNVA (mlTT population) at each time point for each tested group, respectively.
• mesopic UNVA mlTT population
• the proportion of patients with a three line improvement in mesopic UNVA was 24% and 19% for pilocarpine hydrochloride 1% and 1.5%, respectively.
• hour 1 the proportion of patients with a three line improvement in mesopic UNVA was 27% and 30% for pilocarpine hydrochloride 1% and 1.5%, respectively.
• FIG. 4 shows the average letter change from baseline under the condition of UDVA over a 2- day dosing period. While there were no significant effects on the change in UDVA from baseline for each treatment group, the average improvement in distance vision was numerically highest in the pilocarpine hydrochloride 1% group (mITT, non-dominant eye).
• FIG. 7 illustrates the change from baseline levels in letters read under UNVA mesopic conditions by timepoint, for 1% pilocarpine in combination with varying concentrations of oxymetazoline (0%, 0.0125%, 0.05%, 0.125% w/v, and in a fixed combination of 1% w/v pilocarpine hydrochloride and 0.125% w/v oxymetazoline hydrochloride). Similar results were seen for 1.5% pilocarpine in combination with oxymetazoline. With the exception of some minor timepoints, there was no significant difference in the duration of effect and change in letters read at a constant concentration of pilocarpine as the oxymetazoline concentration was varied. Moreover, there was no significant reduction in adverse events (e.g., headache) with the addition of oxymetazoline.
• adverse events e.g., headache
• compositions were prepared with the ingredients as set forth below:
• formulations 1 - 5 are within 0.99 - 1.00 g/mL at 25.00 °C. Hence, the composition ingredients in % w/v is equivalent to the % w/w.
• the pH range may be from 3.0 to 5.5. In a preferred embodiment, the target pH is 5.0.
• Isoptocarpine formulations were measured using an S18 spindle with a rotation speed of 60 rpm.
• the polymer-free Formulations 3 and 4 in accordance with the instant application were measured using an ultra-low viscosity spindle (00) with a rotation speed of 100 rpm.
• a calibration check was performed on the viscometer prior to analysis, and passed all requirements listed in the compendial chapter.
• the polymer-free Formulations 3 and 4 had identical viscosities of 1 centipoise (cps).
• the Isoptocarpine formulations showed much higher viscosities ranging from 21-23 cps.
• the Sandoz generic pilocarpine formulations also showed higher viscosities ranging from 19-23 cps.
• the commercial formulations were approximately 20-fold more viscous than the polymer-free Formulation 4. This higher viscosity, due to the presence of polymers in the formulation, is believed to cause greater vision blurring when administered to the eye.
• Formulation 4 which has a viscosity close to that of pure water (1 cps), is not likely to lead to significant vision blur. Accordingly, polymer-free pilocarpine formulations should cause substantially lower vision blurring or other vision impairments, especially when initially administered.
• 0 Normal may appear blanched to reddish pink without perilimbal injection (except at 12 and 6 o’clock positions) with vessels of the palpebral and bulbar conjunctiva easily observed
• Study procedures With reference to the study design illustrated in FIG. 10, the study consisted of a Screening visit followed by two Assessment visits. Treatments were administered by a different investigator than those administering questionnaires, so as to mask investigators to results of the study until its completion. Participants were also masked to the study treatments.
• the Assessment 1 visit occurred after at least 48 hours and up to 18 days following the Screening visit. Participants were randomized to receive Formulation 3 (1% pilocarpine) in the right or left eye, and 1% commercial pilocarpine in the contralateral eye. This assignment was continued on a per-patient basis throughout the study (except that as noted below, Formulation 4 replaced Formulation 3 at Assessment 2).
• the Assessment 1 visit involved a baseline biomicroscopic examination and a baseline Ocular Discomfort and Blurry Vision Questionnaire assessment (both detailed below). One drop of Formulation 3 was instilled in the randomized eye, and one drop of commercial pilocarpine 1% was instilled in the contralateral eye.
• the Ocular Discomfort and Blurry Vision Questionnaire was performed prior to drop instillation and at 30 seconds, 1 minute, 90 seconds, 2 minutes, 3 minutes, 4 minutes and 5 minutes after drop instillation, and answered simultaneously for both eyes independently. Biomicroscopic examination was performed at 5 minutes and 60 minutes in both eyes. Adverse Effects (AEs) were also assessed.
• AEs Adverse Effects
• the Assessment 2 visit occurred after at least 48 hours and up to 6 months following the Assessment 1 visit.
• This assessment compared the same in-eye characteristics as those evaluated in Assessment 1 using a slightly higher dose of the pilocarpine hydrochloride (i.e. 1.25%, Formulation 4) versus 1% commercial pilocarpine.
• the same eye randomly assigned to Formulation 3 at the Assessment 1 visit received Formulation 4 at the Assessment 2 visit.
• the procedures of Assessment 2 were otherwise the same as in Assessment 1. Participants exited the study at the end of the Assessment 2 visit.
• IOP intraocular pressure
• Ocular Discomfort and Blurry Vision Questionnaire Procedure Ocular Discomfort and Blurry Vision Questionnaires were conducted in Assessment 1 and 2 at baseline, then at 30 seconds, 1 minute, 90 seconds, 2 minutes, 3 minutes, 4 minutes and 5 minutes after instillation of the study drug.
• the questionnaires consist of two visual analog scales (“VAS”) to assess the degree of the participant’s ocular discomfort and blurry vision.
• Formulation 4 was shown to demonstrate less ocular blur on the VAS scale at each timepoint over five minutes, and less initial ocular discomfort for the first four timepoints, in comparison with the commercial pilocarpine formulation.
• FIG 14B also shows that
• the amounts of pilocarpine found to be effective for the improvement of vision parameters or treating certain ocular conditions mean that effective improvement or treatment is possible without requiring the polymers typically found in pilocarpine preparations for glaucoma. Additionally, even with a 25% higher concentration of pilocarpine used Formulation 4 (1.25%), this formulation nevertheless showed a lower incidence of ocular blurring, ocular discomfort, adverse events, and hyperemia compared to the 1% commercial pilocarpine formulation, while at the same time improving vision parameters and/or treating ocular conditions such as presbyopia better than formulations containing differing amounts of pilocarpine.
• certain ocular conditions e.g., presbyopia
• a Phase 3, multicenter, double-masked, randomized, vehicle-controlled, parallel-group study is conducted to evaluate the efficacy, safety, and pharmacokinetics of Formulation 4 (1.25% pilocarpine) dosed once daily and bilaterally, over a period of 30 days in participants with presbyopia.
• the study population consists of adult male and female participants with objective and subjective evidence of presbyopia, and approximately 266 participants are enrolled. Participants are randomized in a 1 : 1 ratio to receive either Formulation 4 or vehicle dosed once daily, in each eye, for 30 days. This randomization is stratified by age (two groups: ⁇ 50 years and > 50 years), baseline binocular DCNVA (two groups: 20/40 to 20/60 inclusively, and worse than 20/60), iris color (brown and non-brown), and emmetropes/non-emmetropes. This study consists of the following visits: screening (Days -30 to -1), Day 1 (baseline), and Days 3, 7, 14, and 30.
• Efficacy is evaluated using measures of mesopic and photopic high contrast distance- corrected near visual acuity (“DCNVA”) and high contrast distance-corrected intermediate visual acuity (“DCIVA”) for each eye and binocularly. Additionally, mesopic and photopic pupil diameter (distance and near) are evaluated, as well as depth of focus and patient-reported outcome questionnaires. These questionnaires include the following: Mesopic and Photopic Near Vision Presbyopia Task-based Questionnaire, Presbyopia Impact and Coping
• Safety and tolerability are evaluated by eliciting adverse events, as well as photopic and mesopic high contrast corrected distance visual acuity for each eye and binocularly, near contrast sensitivity, vital signs (blood pressure and heart rate), study drug tolerability and drop comfort assessments, temporal/supraorbital headache (visual analog scale), intraocular pressure, slit-lamp biomicroscopy, manifest refraction, dilated funduscopic examination, and a pregnancy test for women of childbearing potential (during screening). Pharmacokinetics are also evaluated by testing plasma concentrations of pilocarpine at selected sites.
• the results of this study show that 1.25% pilocarpine hydrochloride administered once daily is safe and effective for the improvement of at least one vision parameter (e.g., near vision acuity, distance vision acuity, etc.) and/or at least one ocular condition (e.g., presbyopia).
• at least one vision parameter e.g., near vision acuity, distance vision acuity, etc.
• at least one ocular condition e.g., presbyopia
• a 42 year old woman complains of an increasing inability to focus on text when reading documents at work.
• the woman is seen by an ophthalmologist who performs a visual acuity test in which she is asked to read lines of letters on an eye chart without the assistance of glasses or contacts (neither of which she wears). She finds that she is only able to read the first four lines on the chart, when a person with normal vison should be able to read six. Based on the woman's age and results of the test, she is diagnosed with presbyopia. The woman is reluctant to have to obtain reading glasses or wear contact lenses and asks if there are any other medical treatments. She is instructed to administer to her eyes the composition of Formulation 4, as set out in Table 4, once daily.
• a 31 year old man has been diagnosed with hyperopia, and consequently has difficulty reading documents and other text at a close distance (e.g., at arm’s length from the body), especially in dim lighting.
• a close distance e.g., at arm’s length from the body
• a polymer-free 1.25% w/v pilocarpine hydrochloride ophthalmic formulation for once daily use he finds that his near vision is improved. Moreover, he finds that he is able to see more easily in dim lighting and while driving at night.
• Clause 1 A method of treating an ocular condition in a patient in need thereof, comprising administering to the patient a pharmaceutically acceptable ophthalmic composition comprising pilocarpine hydrochloride at a concentration from 1.0 to 1.5% w/v, wherein the formulation is administered topically to at least one eye of the patient, and wherein the ocular condition is selected from the group consisting of presbyopia, hyperopia, mydriasis, anisocoria, accommodative esotropia, myopia, and astigmatism.
• a method of improving at least one vision parameter in a patient in need thereof comprising administering to the patient a pharmaceutically acceptable ophthalmic composition comprising pilocarpine hydrochloride at a concentration from 1.0 to 1.5% w/v, wherein the formulation is administered topically to at least one eye of the patient, and wherein the at least one vision parameter is selected from the group consisting of near vision acuity, intermediate vision acuity, distance vision acuity, night vision, day vision, glare, and light scattering.
• Clause 3 A method for improvement of near vision in a patient with presbyopia in need thereof, comprising administering to an eye of the patient a pharmaceutically acceptable ophthalmic composition comprising pilocarpine hydrochloride at a concentration from 1.0 to 1.5% w/v.
• Clause 4 The method of clause 1, wherein the ocular condition is presbyopia.
• Clause 5 The method of clause 1, wherein the ocular condition is hyperopia.
• Clause 6 The method of clause 1, wherein the ocular condition is mydriasis.
• Clause 7 The method of clause 03, wherein the vision parameter is near vision acuity.
• Clause 8 The method of clause 2, wherein the vision parameter is intermediate vision acuity.
• Clause 9 The method of clause 02, wherein the vision parameter is distance vision acuity.
• Clause 11 The method of any one of the preceding clauses, wherein the method results in an at least 3 -line improvement from baseline under the condition of mesopic, high contrast UNVA.
• Clause 12 The method of any one of the preceding clauses, wherein the method results in an at least 2-line improvement from baseline under the condition of mesopic, high contrast UNVA.
• Clause 13 The method of any one of the preceding clauses, wherein the method results in an increase in the average letter change from baseline under the condition of mesopic, high contrast UNVA.
• Clause 14 The method of any one of the preceding clauses, wherein the method results in an at least 2-line improvement from baseline under the condition of photopic, high contrast UNVA.
• Clause 15 The method of any one of the preceding clauses, wherein the method results in an at least 2-line improvement from baseline under the condition of photopic, high contrast UDVA.
• Clause 16 The method of any one of the preceding clauses, wherein the method results in an at least 3 -line improvement from baseline under the condition of mesopic, high contrast DCNVA.
• Clause 17 The method of any one of the preceding clauses, wherein the method results in an at least 3 -line improvement from baseline under the condition of photopic, high contrast DCNVA.
• Clause 18 The method of any one of the preceding clauses, wherein the method results in an at least 3 -line improvement from baseline under the condition of mesopic, high contrast DCIVA.
• Clause 19 The method of any one of the preceding clauses, wherein the method results in an at least 3 -line improvement from baseline under the condition of photopic, high contrast DCIVA.
• Clause 20 The method of any one of the preceding clauses, wherein the pharmaceutically acceptable ophthalmic composition comprises pilocarpine hydrochloride at a concentration that is greater than or equal to 1% and less than 1.5% w/v.
• pharmaceutically acceptable ophthalmic composition comprises pilocarpine hydrochloride at a concentration of 1.25% w/v.
• pharmaceutically acceptable ophthalmic composition does not comprise a polymer.
• Clause 24 The method of clause 23, wherein administration of the pharmaceutically acceptable ophthalmic composition results in a lower incidence of at least one of ocular blurring, ocular discomfort, eye pain, brow ache, blurry vision, light sensitivity, stinging, and itching, compared to administration of a second ophthalmic composition comprising pilocarpine and a polymer.
• pharmaceutically acceptable ophthalmic composition further comprises boric acid, sodium citrate dihydrate, sodium chloride, hydrochloric acid and/or sodium hydroxide, and water.
• composition is administered once daily.
• composition is administered twice daily.
• composition is administered to both eyes of the patient.
• Clause 29 The method of any one of clauses 1-27, wherein the pharmaceutically acceptable ophthalmic composition is administered to the nondominant eye of the patient.
• Clause 30 The method of any one of clauses 1-27, wherein the pharmaceutically acceptable ophthalmic composition is administered to the dominant eye of the patient.
• a composition for the treatment of an ocular condition wherein the composition is pharmaceutically acceptable and comprises pilocarpine hydrochloride at a concentration from 1.0 to 1.5% w/v, and wherein the ocular condition is selected from the group consisting of presbyopia, hyperopia, mydriasis, anisocoria, accommodative esotropia, myopia, and astigmatism.
• Clause 32 The composition of clause 31, wherein the composition comprises 1.25% w/v pilocarpine hydrochloride, and the ocular condition is presbyopia.
• Clause 33 The composition of clause 31, wherein the composition comprises 1.25% w/v pilocarpine hydrochloride, boric acid, sodium citrate dihydrate, sodium chloride, hydrochloric acid and/or sodium hydroxide, and water.
• Clause 34 The composition of any one of clauses 31-33, wherein the composition is applied once daily.
• Clause 35 The composition of any one of clauses 31-33, wherein the composition is applied twice daily.
• Clause 36 The composition of any one of clauses 31-35, wherein the composition is administered to both eyes of a patient.
• Clause 37 The composition of any one of clauses 31-35, wherein the composition is administered to a nondominant eye of a patient.
• Clause 38 The composition of any one of clauses 31-35, wherein the composition is administered to a dominant eye of a patient.
• Clause 39 The composition of any one of clauses 31-38, wherein pilocarpine hydrochloride is the sole active ingredient.
• Clause 40 The composition of any one of clauses 31-39, further comprising a preservative.
• Clause 41 The composition of clause 40, wherein the preservative is benzalkonium chloride.
• Clause 42 The composition of clause 31, wherein the composition comprises about 1.25% w/v pilocarpine hydrochloride, about 1.0% w/v boric acid, about 0.015% w/v sodium citrate dihydrate, about 0.08% w/v sodium chloride, and about 0.0075% w/v benzalkonium chloride.
• Clause 43 The composition of clause 42, wherein the composition consists essentially of 1.25% w/v pilocarpine hydrochloride, 1.0% w/v boric acid, 0.015% w/v sodium citrate dihydrate, 0.08% w/v sodium chloride, and 0.0075% w/v benzalkonium chloride, with a pH of 5.0.
• Clause 44 The composition of any one of clauses 31-43, wherein the composition reduces the incidence of at least one adverse event selected from the group consisting of ocular blurring, ocular discomfort, eye pain, brow ache, blurry vision, light sensitivity, ocular stinging, and ocular itching, compared to administration of a second ophthalmic composition comprising pilocarpine and a polymer.
• Clause 45 The composition of clause 44, wherein the second composition comprises 1% w/v pilocarpine and the polymer is hydroxy propyl methyl cellulose.
• Clause 46 A composition for improving at least one vision parameter, wherein the composition is pharmaceutically acceptable and comprises pilocarpine hydrochloride at a concentration from 1.0 to 1.5% w/v, and wherein the at least one vision parameter is selected from the group consisting of near vision acuity, distance vision acuity, night vision, day vision, glare, and light scattering.
• Clause 47 The composition of clause 46, wherein the composition comprises 1.25% w/v pilocarpine hydrochloride, and the vision parameter is near vision acuity.
• Clause 48 The composition of clause 46, wherein the composition comprises 1.25% w/v pilocarpine hydrochloride, and the vision parameter is distance vision acuity.
• Clause 49 The composition of clause 46, wherein the composition comprises 1.25% w/v pilocarpine hydrochloride, boric acid, sodium citrate dihydrate, sodium chloride, hydrochloric acid and/or sodium hydroxide, and water.
• Clause 50 The composition of any one of clauses 46-49, wherein the composition is applied once daily.
• Clause 51 The composition of any one of clauses 46-49, wherein the composition is applied twice daily.
• Clause 52 The composition of any one of clauses 46-51, wherein the composition is administered to both eyes of a patient.
• Clause 53 The composition of any one of clauses 46-51, wherein the composition is administered to a nondominant eye of a patient.
• Clause 54 The composition of any one of clauses 46-51, wherein the composition is administered to a dominant eye of a patient.
• Clause 55 The composition of any one of clauses 46-54, wherein pilocarpine hydrochloride is the sole active ingredient.
• Clause 56 The composition of any one of clauses 46-55, further comprising a preservative.
• Clause 57 The composition of clause 56, wherein the preservative is benzalkonium chloride.
• Clause 58 The composition of clause 46, wherein the composition comprises about 1.25% w/v pilocarpine hydrochloride, about 1.0% w/v boric acid, about 0.015% w/v sodium citrate dihydrate, about 0.08% w/v sodium chloride, and about 0.0075% w/v benzalkonium chloride.
• Clause 59 The composition of clause 58, wherein the composition consists essentially of 1.25% w/v pilocarpine hydrochloride, 1.0% w/v boric acid, 0.015% w/v sodium citrate dihydrate, 0.08% w/v sodium chloride, and 0.0075% w/v benzalkonium chloride, with a pH of 5.0.
• Clause 60 A composition for improvement of near vision in a patient with presbyopia, wherein the composition is pharmaceutically acceptable and comprises pilocarpine
• hydrochloride at a concentration from 1.0 to 1.5% w/v.
• Clause 61 The composition of clause 60, wherein the composition comprises 1.25% w/v pilocarpine hydrochloride, and the ocular condition is presbyopia.
• Clause 62 The composition of clause 60, wherein the composition comprises 1.25% w/v pilocarpine hydrochloride, boric acid, sodium citrate dihydrate, sodium chloride, hydrochloric acid and/or sodium hydroxide, and water.
• Clause 63 The composition of any one of clauses 60-62, wherein the composition is administered once daily.
• Clause 64 The composition of any one of clauses 60-63, wherein pilocarpine hydrochloride is the sole active ingredient.
• Clause 65 The composition of any one of clauses 60-64, further comprising a preservative.
• Clause 66 The composition of clause 65, wherein the preservative is benzalkonium chloride.
• Clause 67 The composition of clause 60, wherein the composition comprises about 1.25% w/v pilocarpine hydrochloride, about 1.0% w/v boric acid, about 0.015% w/v sodium citrate dihydrate, about 0.08% w/v sodium chloride, and about 0.0075% w/v benzalkonium chloride.
• Clause 68 The composition of clause 67, wherein the composition consists essentially of 1.25% w/v pilocarpine hydrochloride, 1.0% w/v boric acid, 0.015% w/v sodium citrate dihydrate, 0.08% w/v sodium chloride, and 0.0075% w/v benzalkonium chloride, with a pH of 5.0.
• Clause 69 A composition for the improvement of near vision in a patient with presbyopia, the composition comprising 1.25% w/v pilocarpine hydrochloride, 1.0% w/v boric acid, 0.015% w/v sodium citrate dihydrate, 0.08% w/v sodium chloride, 0.0075% w/v benzalkonium chloride, and water, with a pH of 3.0-5.5.
• Clause 70 The composition of clause 69, wherein the composition consists of 1.25% w/v pilocarpine hydrochloride, 1.0% w/v boric acid, 0.015% w/v sodium citrate dihydrate,
• Clause 71 The composition of clause 69 or 70, wherein the composition is topically administered to the patient once daily.
• Clause 72 A method for the improvement of near vision in a patient with presbyopia, wherein the method comprises administering to at least one eye of the patient a pharmaceutically acceptable ophthalmic composition comprising pilocarpine as the sole active ingredient, wherein said composition does not contain any viscosity-enhancing polymers.
• Clause 73 The method of clause 72, wherein the composition comprises pilocarpine hydrochloride.
• Clause 74 The method of clause 73, wherein the composition comprises 1.25% w/v pilocarpine hydrochloride.
• Clause 75 The method of clause 72, wherein the composition comprises pilocarpine nitrate.
• Clause 76 The method of any one of clauses 72-75, wherein the composition comprises 1.25% w/v pilocarpine hydrochloride or a molar equivalent pilocarpine salt.
• Clause 77 The method of any one of clauses 72-76, wherein the composition is administered once daily.
• Clause 78 The method of any one of clauses 72-76, wherein the composition is administered twice daily.
• Clause 79 The method of any one of clauses 72-78, wherein the composition is administered to a nondominant eye of the patient.
• Clause 80 The method of any one of clauses 72-78, wherein the composition is administered to a dominant eye of the patient.
• Clause 81 The method of any one of clauses 72-78, wherein the composition is administered to both eyes of the patient.
• Clause 82 The method of any one of clauses 72-81, wherein the polymer is hydroxy propyl methyl cellulose.
• Clause 83 The method of any one of clauses 72-82, wherein administration of the pharmaceutically acceptable composition reduces the incidence of one or more adverse events compared to the administration of a pilocarpine composition comprising one or more viscosity enhancing polymers.
• Clause 84 The method of clause 83, wherein the one or more adverse events are selected from the group consisting of ocular blurring, ocular discomfort, eye pain, brow ache, blurry vision, light sensitivity, ocular stinging, and ocular itching.
• Clause 85 A method comprising administering to at least one eye of a patient with presbyopia a pharmaceutically acceptable ophthalmic composition comprising a first amount of pilocarpine hydrochloride as the sole active ingredient, wherein such administration is made without previously administering a second amount of pilocarpine hydrochloride and/or subsequently administering a third amount of pilocarpine hydrochloride; wherein the second amount is lower than the first amount, and wherein the third amount is higher than the first amount.
• Clause 86 The method of clause 85, wherein the first amount of pilocarpine hydrochloride is 1.25% w/v.
• Clause 87 The method of any one of clauses 85-86, wherein the pharmaceutically acceptable ophthalmic composition is administered to both eyes of the patient.
• Clause 88 The method of any one of clauses 85-87, wherein the pharmaceutically acceptable ophthalmic composition is administered once daily.
• Clause 89 The method of any one of clauses 85-87, wherein the pharmaceutically acceptable ophthalmic composition is administered twice daily.
• a method of treating an ocular condition in a patient in need thereof comprising administering to the patient a pharmaceutically acceptable ophthalmic composition comprising pilocarpine hydrochloride at a concentration of about 1.25% w/v, wherein the formulation is administered topically to at least one eye of the patient, and wherein the ocular condition is selected from the group consisting of presbyopia, hyperopia, mydriasis, anisocoria, accommodative esotropia, myopia, and astigmatism.
• Clause 91 The method of claim 90, wherein the ocular condition is presbyopia.
• Clause 92 The method of claim 90, wherein the ocular condition is hyperopia.
• Clause 93 The method of claim 90, wherein the pharmaceutically acceptable ophthalmic composition is administered to both eyes of the patient.
• Clause 94 The method of claim 90, wherein the pharmaceutically acceptable ophthalmic composition is administered to the dominant eye of the patient.
• Clause 95 The method of claim 90, wherein the pharmaceutically acceptable ophthalmic composition is administered once daily.
• Clause 96 The method of claim 90, wherein the pharmaceutically acceptable ophthalmic composition is administered twice daily.
• Clause 97 The method of claim 90, wherein the pharmaceutically acceptable ophthalmic composition has a duration of effect of at least six hours.
• Clause 98 The method of claim 90, wherein administration of the pharmaceutically acceptable ophthalmic composition results in a lower incidence of at least one of ocular blurring, ocular discomfort, eye pain, brow ache, blurry vision, light sensitivity, stinging, and itching, compared to administration of a second ophthalmic composition comprising pilocarpine and a polymer.
• Clause 99 The method of claim 90, wherein the composition does not comprise any viscosity-enhancing polymers.
• Clause 100 The method of claim 90, wherein pilocarpine hydrochloride is the sole active ingredient in the pharmaceutically acceptable ophthalmic composition.
• Clause 101 The method of claim 90, wherein the composition comprises 1.25% w/v pilocarpine hydrochloride, boric acid, sodium citrate dihydrate, sodium chloride, hydrochloric acid and/or sodium hydroxide, and water.
• Clause 102 The method of claim 101, wherein the composition comprises about 1.25% w/v pilocarpine hydrochloride, about 1.0% w/v boric acid, about 0.015% w/v sodium citrate dihydrate, about 0.08% w/v sodium chloride, and about 0.0075% w/v benzalkonium chloride.
• Clause 103 The method of claim 90, wherein the ocular condition is presbyopia, and wherein the composition consists essentially of 1.25% w/v pilocarpine hydrochloride, 1.0% w/v boric acid, 0.015% w/v sodium citrate dihydrate, 0.08% w/v sodium chloride, and 0.0075% w/v benzalkonium chloride, with a pH of 3.0-5.5.
• Clause 104 A method for improvement of near vision in a patient with presbyopia in need thereof, comprising administering to an eye of the patient a pharmaceutically acceptable composition comprising pilocarpine hydrochloride as the sole active agent at a concentration from 1.0 to 1.5% w/v.
• Clause 105 The method of claim 104, where the pharmaceutically acceptable composition is administered once daily.
• Clause 106 The method of claim 104, wherein the pharmaceutically acceptable composition is administered twice daily.
• Clause 107 The method of claim 104, wherein the pharmaceutically acceptable composition comprises 1.25% w/v pilocarpine hydrochloride.
• Clause 108 The method of claim 104, wherein the pharmaceutically acceptable composition does not contain any viscosity-enhancing polymers.
• Clause 109 The method of claim 104, wherein the wherein the composition comprises about 1.25% w/v pilocarpine hydrochloride, about 1.0% w/v boric acid, about 0.015% w/v sodium citrate dihydrate, about 0.08% w/v sodium chloride, and about 0.0075% w/v benzalkonium chloride.
• Clause 110 The method of claim 104, wherein the administration of the
• compositions to the patient results in a lower incidence of at least one adverse event compared to the administration of a second composition comprising pilocarpine hydrochloride and a viscosity-enhancing polymer, and wherein the adverse events are selected from the group consisting of ocular blurring, ocular discomfort, eye pain, brow ache, blurry vision, light sensitivity, ocular stinging, and ocular itching.
• Clause 111 A composition substantially as described herein.
• Clause 112 A method of treatment substantially as described herein.

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