An 8-week, Phase II, Single-center, Randomized, Double-masked, Vehicle-controlled, Parallel-group Study With 4 Weeks of Follow-up to Evaluate Safety and Efficacy of rhNGF Eye Drops Solution vs Vehicle in Patients With Dry Eye
Phase: PHASE2
Conditions: Dry Eye
Sponsor: Dompé Farmaceutici S.p.A

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Study protocol  
 Final Version 2.0, 27Oct2016  
Page 1 of 66 
 
Study code NGF0216  
 
 
 
An 8-week, Phase II, single-center, randomized, double-masked, 
vehicle-controlled, parallel-group study with 4 weeks of follow-up 
to evaluate safety and efficacy of recombinant human nerve 
growth factor (rhNGF) eye drops solution versus vehicle in 
patients with dry eye 
 
 
Test Formulation: 
Recombinant human nerve growth factor (rhNGF) 20 μg/ml 
ophthalmic sterile buffered aqueous solution, Dompé 
farmaceutici S.p.A., Italy 
 
 
Sponsor: 
Dompé farmaceutici S.p.A., Via S. Martino 12, 20122 Milan, 
Italy 
Phone: 
+39.02.583831  
Fax:  
+39.02.58383324 
Contact: Valentina Vaja 
Email: valentina.vaja@dompe.com 
 
 
Principal Investigator  
Giacomina Massaro Giordano , MD 
Co-Director, Penn Dry Eye and Ocular Surface Center, 
University of Pennsylvania 
Scheie Eye Institute 
 51 North 39th Street 
Philadelphia, PA 19104 
 
IMP Manufacturer Contact: Dompé farmaceutici S.p.A., Via San Martino 12, 20122 Milan, 
Italy 
Phone: 
+39.02.583831  
Fax:  
+39.02.58383324 
 
 
 
 
 
Version and Date: 
 Final Version 2.0, 27Oct2016  
 
 
This study will be conducted in accordance with Good Clinical Practice (GCP), ICH topic E6 
Property of the Sponsor 
May not be used, divulged, published or otherwise disclosed without the consent of the Sponsor 

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Study protocol  
 Final Version 2.0, 27Oct2016  
Page 2 of 66 
PROTOCOL APPROVAL 
 
SPONSOR 
Dompé farmaceutici S.p.A. Italy  
 
 
Clinical Development Specialist 
Valentina Vaja, PhD 
 
 
 
 
Date 
 
Signature 
 
 
Medical Expert 
Flavio Mantelli, MD, PhD  
 
 
 
 
Date 
 
Signature 

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Study protocol  
 Final Version 2.0, 27Oct2016  
Page 3 of 66 
INVESTIGATORS 
 
Principal Investigator 
 
Investigator Agreement: 
I have read the clinical study described herein, recognize its 
confidentiality, and agree to conduct the described trial in compliance with Good Clinical 
Practice (GCP), the ethical principles contained within the Declaration of Helsinki, this 
protocol, and all applicable regulatory requirements. 
 
 
 
Giacomina Massaro Giordano , MD 
Co-Director, Penn Dry Eye and Ocular Surface Center, University of Pennsylvania 
Scheie Eye Institute 
51 North 39th Street 
Philadelphia, PA 19104 
 
 
 
 
Date 
 
Signature 
 
 
 

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Study protocol  
 Final Version 2.0, 27Oct2016  
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CONTACTS 
Dompé Drug Safety  
Laura Boga, Senior Safety Manager  
Email to:  farmacovigilanza@dompe.com 
or Fax:  +39.02.36026913 
 
Dompé Medical Expert 
Flavio Mantelli – Chief Medical Officer Ophthalmology,  
Email to:  flavio.mantelli@dompe.com 
or Fax:  +39.02.58383324 
 
Dompé Clinical Development 
Valentina Vaja – Clinical Development Specialist 
Email to: valentina.vaja@dompe.com  
or Fax:  +39.02.58383575 
 
CRO:  
CROMSOURCE 
Clinical Research Operations 
Mauro d’Apolito – Clinical Research Senior Director 
Email to: mauro.dapolito@cromsource.com 
Or Fax: +39.045.8222811 
 
Heidy Munguia – Project Manager 
Email to: heidy.munguia@cromsource.com 
 
Akila Chandrasekar – Medical Monitor 
Email to: akila.chandrasekar@cromsource.com 
 
 
 

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Study protocol  
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STUDY SYNOPSIS 
Title of Study: 
An 8-week, Phase II, single-center, randomized, double-masked, vehicle-controlled, parallel-
group study with 4 weeks of follow-up to evaluate safety and efficacy of recombinant human 
nerve growth factor (rhNGF) eye drops solution versus vehicle in patients with dry eye 
Study Number: NGF0216 
Principal Investigators: Dr Giacomina Massaro Giordano 
Study Center: Scheie Eye Institute, Philadelphia, PA, US 
Phase of Development: II  Safety, Efficacy 
Investigational product(s): 
Test Product: Recombinant human nerve growth factor (rhNGF) ophthalmic sterile buffered 
aqueous solution, Dompé farmaceutici S.p.A, Italy, 20 μg/mL vials (Group 1) 
Background information: 
NGF is a polypeptide discovered in the early 1950s by R. Levi Montalcini. NGF acts through 
specific receptors: high-affinity tropomyosin receptor kinase A (TrkA) and low-affinity p75 
neurotrophin receptor (p75NTR), which are expressed not only on nerve fibers but also on 
anterior segment of the eye (iris, ciliary body, lens, cornea and conjunctiva) and by the lacrimal 
gland, providing the rationale for use of NGF in the treatment of diseases of the anterior segment 
of the eye. Murine NGF (mNGF), extracted and purified from the male mouse submaxillary 
gland, was administered to over 100 patients (45 published) with stage 2 and stage 3 
neurotrophic keratitis (NK) in form of eye drops at a concentration of 200 µg/mL in balanced 
salt solution in two uncontrolled, unmasked, open-label studies. Compelling results were 
observed, with all affected eyes healed from persistent epithelial defects. Tolerability was good, 
with only mild, local, and transient side effects. As for dry eye disease, administration of NGF 
to dogs with surgically induced dry eye resulted in enhanced production and functional 
characteristics of tear film, with an associated improvement of ocular surface signs.  
Based on these data, the Company has developed a recombinant human NGF (rhNGF) 
expressed in E. coli for the treatment of NK. 
A phase I, double-masked, placebo-controlled clinical study in 74 healthy volunteers, using 
single and multiple doses of different concentrations of rhNGF eye drops, showed a safety 
profile rhNGF eye drops (Study NGF0112). A Phase I/II multicenter, double-masked, vehicle-
controlled study evaluated the safety and efficacy of rhNGF at 10 and 20 μg/mL six times daily 
in 174 patients with stage 2 and 3 NK (study NGF0212) has been completed in 2015, 
demonstrating that rhNGF also was very well tolerated in patients with NK. 
rhNGF, in the same formulation (containing L-methionine) proposed for the present study, has 
been evaluated in a Phase I/II study in retinitis pigmentosa (RP) patients at the doses of 60 and 
180 μg/mL (Study NGF0113), and in a phase II study in NK patients at the same concentration 
of the present study, 20 μg/mL (6 times daily) (Study NGF0214). 
An open-label, uncontrolled study showed that 4-week treatment with rhNGF eye drops (at 20 
μg/mL and 4 μg/mL concentrations) was safe and effective in improving symptoms, corneal 
staining, and tear function in patients with dry eye as compared to baseline (NGF0213). 

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Safety and tolerability of rhNGF at 20 μg/mL six times daily has been demonstrated in both 
NGF0212 and NGF0214 studies. 
Study Design and Methodology:  
The proposed phase II study is a single-center, randomized, double-masked, parallel-arm, 
vehicle-controlled trial, designed to evaluate the safety and efficacy of rhNGF eye drops at 20 
µg/ml concentration administered six times daily for 8 weeks in patients with dry eye.  
 
After confirmation of inclusion and exclusion criteria  all eligible patients will be randomized 
at 2:1 ratio to rhNGF or vehicle control treatment with 8 weeks of study treatments 
administration with 4 weeks Follow-up :  
 
 
 
  
 
 
Treatment: either rhNGF eye drops 20 µg/ml or vehicle six times daily for 8 weeks.  
 
Follow-up: 4 weeks with no further treatment except preservative-free artificial tears (use 
recorded in drops/day). 
 
After baseline (day 0), enrolled patients will be evaluated for safety and efficacy at week 4 (day 
282), week 8 (day 564) or early exit and at 4 weeks after the end of study treatment (284 
days). 
 
Treatment Groups: 
Before randomization study eye will determined for primary efficacy and safety analysis as the 
“worse eye” (i.e. the eye with more severe dry eye – if both eyes are equally worse, the right 
eye will be the study eye). In all patients, both eyes will be treated as specified below: 
 
Group 1: rhNGF 20 µg/mL: One drop (40 µL) corresponding to 0.80 µg of rhNGF will be 
instilled into each eye six times a day (every 2h), for a total daily dose of 9.6 µg (both eyes, if 
applicable), for 56 consecutive days. 
 
Group 2: Vehicle: One drop (40 µL) will be instilled into each eye six times a day (every 2h). 
 
In the 4week follow up no further treatment except preservative-free artificial tears, whose use 
will be recorded (drops/day). 
 
Administration of rhNGF six times daily will maintain and improve lubrication of the ocular 
surface since the use of preservative-free artificial tears will be not allowed during treatment 
period. 
 
Follow-up 
4 weeks 
Treatment 
8 weeks 
Randomization 

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Number of Subjects:  In total 150 patients with dry eye will be enrolled in the study with 100 
patients to be treated with rhNGF and 50 patients with vehicle. 
Study Duration:  
Treatment duration: 8 weeks 
Follow-up period: 4 weeks  
Maximum total study duration: 12 weeks 
Main Criteria for Inclusion: 
1. 
Patients (male or female) must be ≥ 18 years of age. 
2. 
Patients must be diagnosed with any type of dry eye (e.g. Meibomian Gland 
Dysfunction, Blepharitis, Keratoconjunctivitis sicca etc) at least 3 months before 
enrollment. 
3. 
Patients must present dry eye pathology characterized by the following clinical features: 
a) Corneal and/or conjunctival staining with fluorescein and lissamine green using 
National Eye Institute (NEI) grading system > 3 
b) Mean Symptom Assessment in Dry Eye (SANDE) questionnaire ≥30 
c) Schirmer test without anesthesia < 10 mm/5 minutes and/or tear film break-up time 
(TFBUT) < 10 seconds in the study eye 
4. 
The same eye (study eye) must fulfill all the above criteria. 
5. 
Patients must have best corrected distance visual acuity (BCDVA) score of ≥ 0.1 
decimal units in both eyes at the time of study enrollment. 
6. 
Female patients must have negative pregnancy test if at childbirth potential. 
7. 
Only patients who satisfy all requirements for informed consent may be included in the 
study. Written Informed Consent must be obtained before the initiation of any study-
specific procedures. 
8. 
Patients must have the ability and willingness to comply with study procedures. 
Main Exclusion Criteria: 
1. 
Best corrected distance visual acuity (BCDVA) score of < 0.1 decimal units in either 
eye. 
2. 
Evidence of an active ocular infection in either eye. 
3. 
Presence or history of any ocular disorder or condition, including ocular surgery, trauma, 
or disease that could possibly interfere with the interpretation of study results in the 
opinion of the Investigator. 
4. 
Intraocular inflammation defined as Tyndall score >0. 
5. 
Active or recent diagnosis of malignancy (i.e., currently under chemo/radiotherapy). 
6. 
Systemic disease not stabilized within 1 month before baseline visit (e.g., uncontrolled 
diabetes; thyroid malfunction) or judged by the Investigator to be incompatible with the 
study (e.g., current systemic infections) or with a condition incompatible with the 
frequent assessment required by the study. 
7. 
Patients who have had a serious adverse reaction or significant hypersensitivity to any 
drug or chemically related compounds, or had a clinically significant allergy to drugs, 
foods, amide local anesthetics, or other materials, including commercial artificial tears 
containing carboxymethylcellulose (CMC) (in the opinion of the Investigator). 
8. 
Use of topical cyclosporine, topical corticosteroids, or any other topical medication for 
the treatment of dry eye in either eye until the day of study enrollment. 
9. 
Contact lenses or punctal plug use during the study (previous use not an exclusion 
criteria, but must be discontinued at the baseline visit. 

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10. An anticipated need of additional systemic treatments for dry eye during the study (all 
prior treatment must be continued for the entire duration of the study). 
11. Females of childbearing potential (those who are not surgically sterilized or post-
menopausal for at least 1 year) are excluded from participation in the study if they meet 
any one of the following conditions:  
a) are currently pregnant or,  
b) have a positive result at the urine pregnancy test (Baseline/Day 0) or,  
c) intend to become pregnant during the study treatment period or,  
d) are breast-feeding or, 
e) are not willing to use highly effective birth control measures, such as: hormonal 
contraceptives - oral, implanted, transdermal, or injected - and/or mechanical 
barrier methods - spermicide in conjunction with a barrier such as a condom or 
diaphragm or IUD - during the entire course of and 30 days after the study treatment 
periods.  
12. History of drug addiction or alcohol abuse. 
13. Any prior ocular surgery (including refractive palpebral and cataract surgery) if within 
90 days before the screening visit. 
14. Participation in a clinical trial with a new active substance during the past 30 days. 
15. Participation in another clinical trial study at the same time as the present study. 
Primary objectives: 
Clinical efficacy and safety parameters will be evaluated at each time point: 
Primary endpoint: 
 Change from baseline in SANDE scores for severity and frequency assessed at 8 weeks of 
treatment(with LOCF imputation at earlier end of trial assessment)  
Secondary endpoints: 
 Change from baseline in SANDE scores for severity and frequency assessed at 4 and 8 
weeks of treatment (without imputation) 
 Changes in Cornea and conjunctival vital staining with fluorescein, National Eye Institute 
(NEI) scales 
 Changes in Tear film break-up time (TFBUT) and Schirmer test I 
Exploratory endpoint: 
 Changes in levels of the inflammatory biomarker matrix metallopeptidase 9 (MMP-9) in 
tears, measured by the RPS InflammaDry detector 
Safety endpoints 
 Incidence and frequency of Treatment-emergent adverse events (TEAEs), assessed 
throughout the study 
 
Analyses of endpoints will be performed based on evaluations obtained on days 0, 282, 564 
and 28±4 days after discontinuation of study treatment. Details of analyses will be presented in 
the Statistical Analysis Plan finalized before Database Lock. 
Sample size calculation 
Sample size was calculated by assuming both for severity and frequency a mean difference from 
baseline SANDE scores of -30±20 in the rhNGF groups versus -20±20 in vehicle group (80% 
power, alpha =0.05; 2-sided test), considering that the active compound has already proven safe 

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and effective in dry eye patients.  The sample size has been calculated based on a 2:1 
randomization scheme by the following formula:  
n1 = (0. 5) × n × (1 + k) 
n2 = (0.5) × n × (1 + (1/k)) 
With n1 = active treatment, n2 = vehicle, n = 63, and k = n1/n2 = 2/1=2. Therefore, n1= 94.5 
and n2=47.25. Assuming a 5% dropout rate, a total of 100 patients will be enrolled in the active 
arm, and 50 in the vehicle arm.  
 

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a.) Visit window of ± 2 days; b.) Visit window of ± 4 days; c.) SANDE - Symptom Assessment In Dry Eye 
 
Study procedures 
 
Study procedures 
Baseline 
Visit Day 
0  
Week 4 a 
Week 8 b 
Follow-up Visit 
Week 12 or early 
termination b 
Informed Consent 
X 
 
 
 
Inclusion/Exclusion Criteria 
X 
 
 
 
Urine Pregnancy Test 
X 
 
X 
 
Randomization 
X 
 
 
 
Demographics 
X 
 
 
 
Ocular and General Medical 
History 
X 
 
 
 
Previous and Concomitant 
Ocular And Systemic 
Medications 
 
X 
 
X 
X 
X 
Frequency of Artificial Tear Use 
X 
 
 
X 
Record Adverse Events (AEs) 
X 
X 
X 
X 
Verify Patient Study Medication 
Dosing Compliance 
 
X 
X 
 
 SANDEc questionnaire 
X 
X 
X 
X 
Best Corrected Distance  Visual 
Acuity (BCDVA) 
X 
X 
X 
X 
Schirmer test I (without 
anesthesia) 
X 
 
X 
 
External Ocular Examination 
X 
X 
X 
X 
Slit-lamp Examination (SLE) 
X 
X 
X 
X 
Fluorescein and lissamine green 
staining (NEI scale) 
X 
X 
X 
X 
Tear Film Break-up Time 
(TFBUT) 
X 
X 
X 
X 
InflammaDry (MMP-9) 
X 
 
X 
 
Study Drug Dispensation 
X 
X 
 
 

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TABLE OF CONTENTS 
 Page 
1 
INTRODUCTION 
16 
1.1 
Background Information 
16 
1.1.1 
Nerve growth factor - overview 
16 
1.1.2 
Chemical and formulation data 
16 
1.1.3 
Rationale for rhNGF therapy in patients with dry eye 
16 
1.1.4 
Previous experience in humans with rhNGF 
17 
1.2 
Study Rationale 
18 
1.2.1 
Dose and Schedule Rationale 
18 
1.3 
Risks and benefits 
19 
2 
STUDY OBJECTIVES 
20 
2.1 
Primary endpoint 
20 
2.2 
Secondary endpoints 
20 
2.3 
Exploratory endpoint 
20 
2.4 
Safety endpoint 
20 
3 
CLINICAL SUPPLIES 
21 
3.1 
Treatment 
21 
3.1.1 
Description of products 
21 
3.1.2 
Dose regimen 
21 
3.1.3 
Route and method of administration 
21 
3.2 
Packaging, labeling, distribution and storage 
22 
3.2.1 
Formulation and packaging 
22 
3.2.2 
Labeling, Storage, and Handling 
23 
3.3 
Drug accountability 
24 
4 
INVESTIGATIONAL PLAN 
26 
4.1 
Overall study design 
26 
4.2 
Discussion of design 
26 
5 
STUDY POPULATION 
28 
5.1 
Target population 
28 
5.2 
Inclusion criteria 
28 
5.3 
Exclusion criteria 
28 
5.3.1 
Concomitant Medication 
29 
6 
STUDY SCHEDULE 
30 
6.1 
Study visits and procedures 
30 
7 
DESCRIPTION OF SPECIFIC PROCEDURES 
34 
7.1 
Ophthalmological Evaluations 
34 
7.1.1 
External Ocular Examination 
34 
7.1.2 
Symptom Assessment in Dry Eye (SANDE): 
34 
7.1.3 
Best corrected distance visual acuity (BCDVA): 
34 
7.1.4 
Slit-lamp examination (SLE) 
36 
7.1.5 
Tear Film Break-up Time (TFBUT) 
38 
7.1.6 
Schirmer test I (without anesthesia) 
39 
7.1.7 
Ocular surface staining (NEI score - Lissamine green and fluorescein) 
39 
7.1.8 
InflammaDry: 
39 
8 
ASSIGNMENT OF STUDY TREATMENT 
40 
8.1 
Randomization 
40 
8.2 
Treatment allocation 
40 
8.3 
Masking 
40 
9 
EVALUATION PARAMETERS 
41 
9.1 
Study variables 
41 
9.1.1 
Primary endpoint 
41 
9.1.2 
Secondary endpoints 
41 

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9.1.3 
Exploratory endpoint 
41 
9.1.4 
Safety endpoints 
41 
10 
STATISTICAL METHODS 
42 
10.1 
Analysis Sets 
42 
10.1.1 
Definitions 
42 
10.1.2 
Reasons for exclusion from the Full Analysis Set 
42 
10.1.3 
Reasons for exclusion from the Per Protocol set 
43 
10.2 
Sample size and power considerations 
43 
10.3 
Compliance with IMP administration 
43 
10.4 
Demographic, baseline and background characteristics 
44 
10.5 
Analysis of ophthalmological evaluations 
44 
10.6 
Safety and tolerability evaluation 
44 
11 
DEFINITION AND HANDLING OF AES AND SAES 
45 
11.1 
Applicable SOPs 
45 
11.2 
Definitions 
45 
11.2.1 
Adverse Events 
45 
11.2.2 
Adverse Drug Reaction 
45 
11.2.3 
Serious Adverse Event (SAE) 
45 
11.2.4 
Unexpected Adverse Event/Reaction 
46 
11.2.5 
Suspected Unexpected Serious Adverse Reaction 
47 
11.2.6 
Adverse Events (AEs) of Special Interest (Sight-threatening Events) 
47 
11.3 
Adverse Event (AE) Monitoring 
47 
11.4 
Recording 
48 
11.5 
Relationship of AEs to the Investigational Product 
48 
11.6 
Severity of AEs 
49 
11.7 
Serious Adverse Event Reporting Procedure (from Investigator to Dompé/CRO) 
49 
11.7.1 
Reporting Procedure from Investigator to Dompé and CRO 
49 
11.7.2 
Conditions that should not be reported as serious adverse events 
50 
11.7.3 
Reporting Procedure to IEC and to Regulatory Authorities 
51 
11.7.4 
Periodical Reporting to Regulatory Authorities 
52 
11.8 
Unmasking of the Study Treatment 
52 
11.9 
Follow-up of patients with adverse events (AEs) 
52 
11.10 
Pregnancy in the clinical trial 
53 
11.11 
Adverse Events Causing Treatment Discontinuation 
53 
11.12 
Overdose 
53 
12 
DATA MANAGEMENT PROCEDURES 
55 
12.1 
Data collection – case report forms (eCRFs) 
55 
12.2 
Unique subject identifier 
55 
12.3 
Database management 
55 
12.3.1 
Coding dictionaries 
55 
12.4 
Monitoring 
56 
12.5 
Quality Control and Quality Assurance 
56 
12.6 
Applicable SOPs 
56 
12.7 
Data access 
56 
12.8 
Audits and inspections 
56 
13 
ETHICAL CONSIDERATIONS 
58 
13.1 
Ethics and Good Clinical Practice (GCP) 
58 
13.2 
Informed consent 
58 
13.3 
Insurance policy 
59 
13.4 
Withdrawal of patients 
59 
13.4.1 
Primary reason for discontinuation 
59 
13.4.2 
Discontinuation procedures 
59 
13.4.3 
Replacement 
60 
13.5 
Study termination 
60 
14 
ADMINISTRATIVE PROCEDURES 
61 

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14.1 
Protocol amendments 
61 
14.2 
Study documentation and record keeping 
61 
14.3 
Study patients’ recruitment 
61 
14.4 
Confidentiality and data protection 
62 
14.5 
Publication policy 
62 
14.6 
Liability Statement 
62 
14.7 
Financing of the Study 
63 
14.8 
Responsibilities of the Investigator 
63 
14.9 
Confidentiality and data protection 
63 
14.10 
Final study report 
63 
15 
STUDY RESPONSIBLE PERSONS 
64 
15.1 
Sponsor 
64 
15.2 
Institutes performing the study 
64 
15.2.1 
Clinical centre 
64 
16 
REFERENCES 
65 
 
TABLES 
 Page 
Table 3.1.2.1 
Doses for dose Groups ................................................................................................... 21 
Table 3.2.1.1 
Investigational Medicinal Product (IMP) Delivery Plan ................................................ 22 
Table 11.5.1 
Relationship of the Adverse Event to the IMP ............................................................... 48 
Table 11.6.1 
Intensity (Severity) of the Adverse Event ...................................................................... 49 
 
FIGURES 
 Page 
Figure 4.1.1 
Study flow chart ............................................................................................................. 26 
 

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LIST OF ABBREVIATIONS 
ADR 
Adverse Drug Reaction 
AE 
Adverse Event 
ANOVA 
Analysis Of Variance 
BCDVA 
Best Corrected Distance Visual Acuity 
CDISC 
Clinical Data Interchange Standards Consortium 
CFR 
Code of Federal Regulations 
CMC 
Carboxymethylcellulose 
eCRF 
electronic Case Report Form 
CRO 
Contract Research Organization 
DSUR 
Development Safety Update Report 
ETDRS 
Early Treatment Diabetic Retinopathy Study 
ETV 
Early Termination Visit 
FAS 
Full Analysis Set 
FDA 
Food and Drug Administration  
FPI 
First Patient In 
FSFV 
First Subject (Patient), First Visit 
FU 
Follow-Up 
GCP 
Good Clinical Practice 
GLP 
Good Laboratory Practice 
IB 
Investigator’s Brochure 
ICH 
International Conference On Harmonisation 
IEC 
Independent Ethics Committee 
IRB 
Institutional Review Board 
IMP 
Investigational Medicinal Product 
IND 
Investigational New Drug 
LPO 
Last Patient Out 
LSLV 
Last Subject (Patient), Last Visit 
MedDRA 
Medical Dictionary For Regulatory Activities 
mL 
milliLitres  
mmHg 
millimetres of mercury 
MMP-9 
Matrix Metallopeptidase 9 
MVPVU 
Materiovigilance And Pharmacovigilance Unit 
mNGF 
Murine Nerve Growth Factor 
Μg 
Micrograms 
NA 
Not Applicable 
NEI 
National Eye Institute 
NGF 
Nerve Growth Factor 
NK 
Neurotrophic Keratitis  
NSAE 
Non-Serious Adverse Event 
NSAIDs 
Nonsteroidal Anti-Inflammatory Drugs 
NT 
Neurotrophin 
OTC 
Over-The-Counter 
PP 
Per Protocol Set 
PT 
Preferred Term 
rhNGF 
Recombinant Human Nerve Growth Factor 
RP 
Retinitis Pigmentosa 
SAE 
Serious Adverse Event 
SAF 
Safety Analysis Set 
SANDE 
Symptom Assessment In Dry Eye 
SAP 
Statistical Analysis Plan 
SLE 
Slit-Lamp Examination 
SOC 
System Organ Class 
SOP 
Standard Operating Procedure 
SDTM 
Study Data Tabulation Model 
SUSAR 
Suspected Unexpected Serious Adverse Reaction 
TEAE 
Treatment-Emergent Adverse Event 

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TFBUT 
Tear Film Break-Up Time 
TrkA 
Tropomyosin receptor kinase A (a.k.a. neurotrophic tyrosine kinase receptor type 1; high-
affinity nerve growth factor receptor) 
VA 
Visual Acuity 
VAS 
Visual Analog Scale 
VHP 
Voluntary Harmonisation Procedure 
WHODDE 
World Health Organization Drug Dictionary Enhanced 
 

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1 
INTRODUCTION 
1.1 
Background Information 
1.1.1 
Nerve growth factor - overview 
Nerve growth factor (NGF) is a polypeptide essential for the survival and growth of sympathetic 
and sensory neurons, and for differentiation of neurons in the central nervous system. It binds 
with at least two classes of receptors: high-affinity tropomyosin receptor kinase A (TrkA), a 
transmembrane tyrosine kinase, and low-affinity NGF receptor (LNGFR), also known as p75 
neurotrophin receptor (p75NTR). 
NGF and TrkA are expressed in the anterior segment of the eye (iris, ciliary body, lens, cornea 
and conjunctiva), and NGF is released in the aqueous humor. Several pieces of experimental 
evidence suggest that NGF affects all tissues of the anterior ocular segments, playing a crucial 
role in the physiopathology of several anterior ocular segment diseases. 
1.1.2 
Chemical and formulation data 
As recombinant human NGF (rhNGF) production in mammalian cells does not achieve 
adequate yields, a manufacturing process based on the use of recombinant Escherichia coli (E. 
coli) has been developed. However, because the biological activity of NGF relies on the 
formation of three disulfide bonds, and because disulfide bonds cannot occur in the reducing 
cytosol, the purification and renaturation of NGF produced in E. coli is problematic. Based on 
the knowledge that the prosequence increases the yield and rate of refolding of NGF, we have 
developed a manufacturing process starting from proNGF. After expression of proNGF in E. 
coli, the insoluble protein is isolated in the form of insoluble inactive aggregates (inclusion 
bodies), solubilized in a strong denaturing agent and subsequently converted into the natural 
conformation, which is determined by the disulfide bridges present in the natural NGF. 
Biologically active rhNGF is finally obtained by splitting off the prosequence by enzymatic 
cleavage. The DNA sequence of human proNGF has been optimized for E coli expression 
(codon adjustment) and two changes in the furin cleavage site, R101V and K103A, have been 
introduced. These two changes are important to ensure a homogeneous rhNGF preparation 
during the process with the mature protein starting with serine 105. 
The investigational medicinal product (IMP) consists of a sterile isotonic solution for ocular 
administration (containing L-methionine as excipient), containing rhNGF 20 µg/mL (i.e. 0.020 
mg/mL) as drug substance.  
1.1.3 
Rationale for rhNGF therapy in patients with dry eye 
Dry eye is a chronic inflammatory condition of the ocular surface with severe symptoms and 
visual impairment, leading to worse efficiency to perform duties for an average of 184 work 
days and resulting in an average loss of productivity estimated in 5,000USD per year per patient 
(13).  

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Dry eye results from systemic diseases (Sjögren's syndrome, rheumatoid arthritis, systemic 
lupus erythematosus, Stevens-Johnson syndrome, thyroid disease, Bell's palsy), ocular 
conditions (Meibomian gland dysfunction, blepharitis, ocular rosacea, corneal dystrophies), 
elective surgeries (refractive surgery, blepharoplasty), eyelid conditions (lagophthalmos, 
entropion/ectropion), cranial surgeries, side effects of drugs (antihistamines, diuretics, beta-
blockers), ocular injuries and burns, chemotherapy and radiation, aging, menopause, etc. (2).  
Dry eye pathogenesis is multifactorial; however, a number of common mechanisms can be 
identified: (i) chronic inflammation of the conjunctiva; (ii) decrease of ocular surface 
sensitivity; (iii) impairment of quantity of tears and/or quality of the tear film, including tear 
film hyperosmolarity; (iv) changes of conjunctival epithelium with squamous metaplasia and 
decrease of goblet cells density; (v) corneal epithelium damage.  
Until now, treatment has been limited to the use of artificial tears to temporarily improve 
lubrication of the ocular surface, or the use of steroids to decrease the inflammatory reaction. 
However, chronic use of steroids is associated with severe complications such as cataract and 
glaucoma (2). Cyclosporine eye drop therapy for dry eye patients has been approved in the 
United States but not in Europe. This drug seems to affect only inflammation and tear film 
production, without any effect on ocular surface sensitivity or the corneal epithelium. On the 
other hand, experimental and clinical evidence suggests that NGF may affect all the pathogenic 
mechanisms of dry eye, potentially restoring ocular surface homeostasis (11). 
Indeed, several studies have shown that NGF is involved in the regulation of tear film 
production. In fact, NGF, TrkA and p75, as well as other neurotrophins (NTs) and related 
receptors, are expressed by the rat lacrimal gland tissue; moreover, NGF has been quantified in 
human tears, indicating that NGF is basally released by the lacrimal gland (12, 6, 17). These 
data suggest that NGF may play a role in the maintenance of the tear film and in its alterations 
in drying ocular surface diseases. Specifically, considering that NGF potentially affects all the 
components of the ocular surface (cornea, conjunctiva, lacrimal gland, and sensory 
innervation), it might play an important role during dry eye disease. In line with this hypothesis: 
1) NGF eye drop administration in a dog experimental model of dry eye increases tear 
production, conjunctival goblet cell density and corneal transparency (4, 2) an increased tear 
concentration of NGF has been reported in patients affected by dry eye (9; 3) NGF stimulates 
glycoconjugate secretion by conjunctival goblet cells, without affecting cell proliferation (14). 
1.1.4 
Previous experience in humans with rhNGF  
NGF is a polypeptide discovered in the early 1950s by R. Levi Montalcini. NGF acts through 
specific receptors: high-affinity tropomyosin receptor kinase A (TrkA) and low-affinity p75 
neurotrophin receptor (p75NTR), which are expressed not only on nerve fibers but also on 
anterior segment of the eye (iris, ciliary body, lens, cornea and conjunctiva) and by the lacrimal 
gland, providing the rationale for use of NGF in the treatment of diseases of the anterior segment 
of the eye. Murine NGF (mNGF), extracted and purified from the male mouse submaxillary 
gland, was administered to over 100 patients (45 published) with stage 2 and stage 3 
neurotrophic keratitis (NK) in form of eye drops at a concentration of 200 µg/mL in balanced 
salt solution in two uncontrolled, unmasked, open-label studies. Compelling results were 
observed, with all affected eyes healed from persistent epithelial defects. Tolerability was good, 
with only mild, local, and transient side effects. As for dry eye disease, administration of NGF 

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to dogs with surgically induced dry eye resulted in enhanced production and functional 
characteristics of tear film, with an associated improvement of ocular surface signs.  
Based on these data, the Company has developed a recombinant human NGF (rhNGF) 
expressed in E. coli for the treatment of NK. 
A phase I, double-masked, placebo-controlled clinical study in 74 healthy volunteers, using 
single and multiple doses of different concentrations of rhNGF eye drops, showed a safety 
profile rhNGF eye drops (Study NGF0112). A Phase I/II multicenter, double-masked, vehicle-
controlled study evaluated the safety and efficacy of rhNGF at 10 and 20 μg/mL six times daily 
in 174 patients with stage 2 and 3 NK (study NGF0212) ; this study was has been completed in 
2015, demonstrating that rhNGF also was very well tolerated in patients with NK. 
rhNGF, in the same formulation (containing L-methionine) proposed for the present study, has 
been evaluated in a Phase I/II study in retinitis pigmentosa (RP) patients at the doses of 60 and 
180 μg/mL (Study NGF0113), and in a phase II study in NK patients at the same concentration 
of the present study, 20 μg/mL (6 times daily) (Study NGF0214). 
An open-label, uncontrolled study showed that 4-week treatment with rhNGF eye drops (at 20 
μg/mL and 4 μg/mL concentrations) was safe and effective in improving symptoms, corneal 
staining, and tear function in patients with dry eye as compared to baseline (NGF0213). 
1.2 
Study Rationale 
The data reported above, together with the evidence of rhNGF eye drop effectiveness in the 
treatment of patients affected by corneal ulcers, make rhNGF a strong candidate for the 
treatment of dry eye disease (7, 8, 3). 
As part of the development plan to evaluate the potential efficacy of the rhNGF solution, the 
present exploratory study was designed in order to preliminary evaluate the potential efficacy 
and safety of the IMP. 
For additional information regarding the development of rhNGF, please consult the current IB 
(1)]. 
1.2.1 
Dose and Schedule Rationale 
The dose proposed for this trial is 20 µg/mL (1 drop to both eyes, six times daily for 8 weeks). 
In previous studies with Dompé rhNGF in human volunteers, the compound has been 
administered in a wide range of doses after single and multiple administrations up to 180 µg/mL 
(three times daily for five days, one eye).  
In the Phase I/II of the NK studies (NGF0212 and NGF0214), rhNGF administered at 20 µg/mL 
(six times daily for 8 weeks, one eye) demonstrated to be safe and well tolerated at this dose 
regime.  
Dose regime at six times daily will also ensure the lubrication of the ocular surface in the present 
study where the use of artificial tears will be not allowed during the treatment period. 

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1.3 
Risks and benefits 
In the present study, potential risks of multiple rhNGF applications to patients with dry eye are 
not expected to surpass the frequency of adverse reactions and untoward effects previously 
reported in the Phase I/II studies. 
The patients with dry eye participating in this study may potentially benefit from the application 
of rhNGF for 56 days.  

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2 
STUDY OBJECTIVES 
The primary objective of this study is to assess the efficacy and safety of rhNGF when 
administered as eye drops to patients with dry eye. 
Evaluation of the clinical efficacy and safety during and at the end of treatment with rhNGF, 
on the basis of the following assessments at each time point: 
2.1 
Primary endpoint 
 Change from baseline in SANDE scores for severity and frequency assessed at 8 weeks of 
treatment (with LOCF imputation at earlier end of trial assessment)  
2.2 
Secondary endpoints 
 Change from baseline in SANDE scores for severity and frequency assessed at 4 and 8 
weeks of treatment (without imputation) 
 Changes in Cornea and conjunctival vital staining with fluorescein, National Eye Institute 
(NEI) scales 
 Changes in Tear film break-up time (TFBUT) and Schirmer test I 
2.3 
Exploratory endpoint 
 Changes in Levels of the inflammatory biomarker matrix metallopeptidase 9 (MMP-9) in 
tears, measured by the RPS InflammaDry detector 
2.4 
Safety endpoint 
 
Incidence and frequency of Treatment-emergent adverse events (TEAEs), assessed 
throughout the study  
 
Evaluations will be performed on days 0, 28±2, 56±4 and 28±4 days after discontinuation of 
treatment.  

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3 
CLINICAL SUPPLIES 
3.1 
Treatment 
3.1.1 
Description of products 
The analytical certificates will be enclosed with the IMP.  
Test product 
TEST PRODUCT 
 
IMP 
Recombinant human nerve growth factor (rhNGF), 
containing L-methionine as excipient 
- 
20 μg/mL vials (Group 1), 
- 
Vehicle vials (Group 2) 
Manufacturer active 
substance 
Dompé Farmaceutici S.p.A., Italy 
Manufacturer 
finished product 
Bulk drug product is manufactured by Patheon Italia S.p.A-
Italy. 
Packaging and labelling is performed by PCI Inc. USA 
Pharmaceutical form 
Sterile buffered aqueous solution 
Dose 
6 times daily for 8 weeks 
Administration route 
Ophthalmic  
3.1.2 
Dose regimen 
The dosing scheme of the different study groups is summarized in the following table: 
Table 3.1.2.1 
Doses for dose Groups  
Group 
Doses to be 
tested 
Dose (µg / day / eye)  
Total daily dose (µg)/ 
both eyes 
Total dose (µg) 
in 56 days 
Group 1 
20 µg/mL 
4.80 µg 
9.60 µg 
537.6 µg 
Group 2 
vehicle 
Not Applicable 
Not Applicable 
Not Applicable 
3.1.3 
Route and method of administration 
Administration route and dose regimen for Groups 1 and 2 will be:  
Group 1: rhNGF 20 µg/mL: One drop (40 µL) corresponding to 0.80 µg of rhNGF will be 
instilled into each eye six times daily, for a total daily dose of 9.60 µg (both eyes), for 56 
consecutive days. Total dose will be 537.6 µg/56 days.  
 

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Group 2: vehicle: One drop of vehicle (40 µL) will be instilled into each eye six times daily, 
for 56 consecutive days. 
 
For both groups 1 and 2, the patients will self-administer the drops at home. In all patients, both 
eyes will be treated as specified above, whereas only the “worse eye” (i.e. the eye with the more 
severe dry eye) will be the study eye. The Investigator will check that all patients take the IMP 
appropriately verifying the diary and the used medication returned. 
3.2 
Packaging, labeling, distribution and storage 
3.2.1 
Formulation and packaging 
The Investigator will be provided with frozen IMP solutions (-20 ± 5°C) containing rhNGF at 
concentrations of 20 µg/mL (for the dosing Group 1) and vehicle (for group 2) in a monthly 
box containing 4 weekly boxes. 
The monthly boxes containing the treatments for each day will be delivered to the patient at 
each study visit according to the following scheme: 
Table 3.2.1.1 
Investigational Medicinal Product (IMP) Delivery Plan 
Box delivery  
Boxes to be provided 
Day 0 
4 Weeks (Day 0 - Day 28) – 1 Box rhNGF/Vehicle 
Day 28 ±2 
4 Weeks (Day 28 - Day 56) – 1 Box rhNGF/Vehicle 
 
Each monthly box will contain a total of 28 vials of rhNGF (Group 1) or Vehicle (Group 2). 
Together with the IMP monthly box, the patients will be provided with a sufficient number of 
syringes and adaptors to be used for the administration of the IMP for the following 4 weeks. 
Syringes and adaptors will be provided separately in single sterile polyethylene packages and 
may be kept at room temperature. 
The syringe is used with an adaptor consisting of a connecting device with dual connections: 
one end for the syringe and one end for the vial. Patients will need to: 
1) Put the adaptor on the top of the vial (after removing the plastic seal) by piercing the 
septum 
2) Put the syringe on adaptor inlet 
3) Draw the solution contained in the vial with the syringe until this reaches its 
predetermined capacity 
4) Remove the syringe and use it as a dropper to administer one drop of IMP into each 
eye 

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3.2.2 
Labeling, Storage, and Handling 
Labeling 
The monthly boxes containing the vials of drug will be labeled in accordance with the relevant 
labeling standards (according to the Annex 13). 
The medication labeling will report all the information requested according to the Annex 13 to 
the good manufacturing practices (published by the European Commission in “The rules 
governing medicinal products in the European Union,” Volume 4) as follows: 
a. 
Name, address and telephone number of the Sponsor, contract research organization (CRO) 
or Investigator (the main contact for information on the product, clinical study) 
b. Pharmaceutical dosage form, route of administration, quantity of dosage units (and in the 
case of open studies, the name and strength) 
c. 
The batch code number to identify the contents and packaging operation 
d. A study reference code allowing identification of the study, site, Investigator, and Sponsor 
if not given elsewhere 
e. 
The study patient identification study number and where relevant, the treatment period  
f. 
Directions for use (reference may be made to a leaflet or other explanatory document 
intended for the study patient or person administering the product) 
g. “For clinical study use only” or similar wording 
h. The storage conditions 
i. 
Period of use (use-by date, expiry date, or re-test date as applicable), in month/year format 
and in a manner that avoids any ambiguity 
j. 
“Keep out of reach of children”  
 
Labels will be in local language. 
Storage and handling 
The Pharmacist and/or Investigator will be responsible for receipt, proper storage, and usage of 
study drug, as well as for the IMP distribution, collection of used and unused vials and final 
disposal of the remaining IMP.  
The investigational product must be stored at -20 ± 5 °C at the investigational sites, in an 
appropriate locked room accessible only to the pharmacist, the Investigator, or a duly 
designated person.  
A temperature probe and data logger will accompany the drug on shipment. It is essential that 
the investigational sites will verify the temperature excursion during shipment vs. the 
acceptable storage conditions, in order to identify potential stability concerns during shipment. 
These must be immediately communicated to the Sponsor that will decide upon appropriate 
actions to be taken. The IMP will be stored in a locked place, sheltered from light. The vials 
will be not shaken since agitation of vials may cause foaming and/or particle formation.  

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On Day 0 and at Week 4 visits, the study personnel will give the patient monthly boxes 
containing the study medications in a refrigerated bag. The refrigerated bag will be used to 
ensure that the medications will maintain refrigeration temperatures during transport to the 
patient’s home.  
Patient should bring the study medication, one box containing 4 weekly kits, at home as soon 
as possible and immediately store it in a freezer at -20 ± 5 °C. 
The weekly kit must be kept at 2-8°C for 7 days, the daily vial can be kept at room temperature 
before the patient will use the single vial for each instillation (both eyes) as far as 12 hours are 
not exceeded.  
Together with the IMP monthly box, the patient will also receive a separate kit of vial adapters 
(one per vial), pipettes (6 per vial) and disinfectant wipes (6 per vial). 
IMP eye drops solution instruction will be provided to patients.  
Patients will use one vial to instill one drop in both eyes six times daily between 8 AM and 6 
PM for 8 weeks (six times daily every 2 hours). 
The IMP contains L-methionine as an excipient. The contents of each vial are for the daily 
administration to both eyes only (1 drop of 40 µL per eye 6 times per day). After the last 
administration the used vial should be returned to the original medication box and is not to be 
reused. 
Any deviations from the recommended storage conditions should be immediately reported by 
the pharmacist to the Sponsor and Investigator, and the use of the drug should be suspended 
until they have given authorization for its continued use. The IMP supplies are to be used only 
in accordance with this protocol. The Investigator will not use any drug samples for other 
purposes (e.g., treating patients or deviating from the protocol with regard to dose regimen, 
duration of treatment, etc.). Under no circumstances will the Investigator give any drug samples 
to a third party. 
3.3 
Drug accountability 
The Pharmacist and/or Investigator will confirm the receipt of the IMP supply in writing by 
signing and dating standard drug accountability forms. 
At the week 4 and 8 visits the patients will return the used or unused study boxes to the 
Investigator.  
The Pharmacist and/or Investigator will keep a cumulative inventory and dispensing records, 
and will maintain all supplies under adequate security.  
An accurate drug disposition record will be kept, specifying the date and amount dispensed to 
each patient.  
Adequate record of receipt and use or loss of drug will be retained. This inventory record must 
be available for inspection by the Sponsor and regulatory inspection at any time. Copies of this 
record will be provided to the Sponsor by the CRO throughout the duration of the study. 
At each scheduled visit, the diary should be reviewed by the Investigator with the patient for 
completeness. Missing information should not be provided during the diary check but reported 
as missing. 

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Partially used or unused study drug boxes will be verified and returned by the Investigator/ 
Institution to the IMP manufacturer, at the end of the study.  
At the conclusion of the study, and if appropriate during the course of the study, the Investigator 
will complete the drug accountability forms. Within one month after completion of the trial the 
unused study medication will be shipped to the Sponsor or will be destroyed after authorization 
by the Sponsor by an authorized company according to GCP regulations. 

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4 
INVESTIGATIONAL PLAN 
4.1 
Overall study design 
This is a Phase II, single-center, randomized, double-masked, parallel-arm, vehicle-controlled 
trial, designed to evaluate the safety and efficacy of rhNGF eye drops at 20 µg/ml concentration 
administered six times daily for 8 weeks in patients with dry eye.  
Patients will be evaluated at baseline (day 0), week 4 (28±2 days), week 8 (day 56±4) or early 
exit and 4 weeks  after the end of study treatment (284 days). 
Eligible patients will be randomized 2:1 to either rhNGF eye drops 20 µg/ml or vehicle six 
times daily and treated for 8 weeks.  
In the 4 weeks following the end of the study treatment, no further treatment will be allowed, 
except preservative-free artificial tears (use recorded in drops/day). 
The study flow chart is given below: 
Figure 4.1.1 
Study flow chart 
 
 
  
 
 
4.2 
Discussion of design 
The study is designed in order to investigate the clinical efficacy and safety of rhNGF in patients 
with dry eye.  
In the previous studies with Dompé rhNGF in human volunteers the compound has been 
administered in a wide range of doses after single and multiple administrations up to 180 µg/mL 
(three times daily for five days, one eye).  
In the Phase I/II of the NK studies, rhNGF was administered up to 20 µg/mL (six times daily 
for 8 weeks, one eye).  
In the Phase I/II of the NK studies (NGF0212 and NGF0214), rhNGF administered at 20 µg/mL 
(six times daily for 8 weeks, one eye) demonstrated to be safe and well tolerated at this dose 
regime.  
Dose regime at six times daily will also ensure the lubrication of the ocular surface in the present 
study where the use of artificial tears will be not allowed during the treatment period. 
Treatment 
8 weeks 
Follow-up 
4 weeks 
Randomization 

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In the present study, the dose planned (Group 1) is 20 µg/mL (1 drop, 40µL, six times daily, 
both eyes, for 56 days) corresponding to a daily dose of 9.60 µg and a total dose in 56 days of  
537.6 µg.  

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5 
STUDY POPULATION 
5.1 
Target population 
Male and female patients ≥ 18 years old, affected by dry eye syndrome.  
5.2 
Inclusion criteria 
To be enrolled in this study, patients must fulfill all these criteria: 
 
1. Patients (male or female) must be ≥ 18 years of age. 
2. Patients must be diagnosed with any type of dry eye (e.g. Meibomian Gland Dysfunction, 
Blepharitis, Keratoconjunctivitis sicca etc) at least 3 months before enrollment. 
3. Patients must present dry eye pathology characterized by the following clinical features: 
a. Corneal and/or conjunctival staining with fluorescein and lissamine green using 
National Eye Institute (NEI) grading system > 3 
b. Mean Symptom Assessment in Dry Eye (SANDE) questionnaire ≥30 
c. Schirmer test without anesthesia < 10 mm/5 minutes and/or tear film break-up time 
TFBUT < 10 seconds in the study eye 
4. The same eye (study eye) must fulfill all the above criteria. 
5. Patients must have BCDVA score of ≥ 0.1 decimal units in both eyes at the time of study 
enrollment. 
6. Female patients must have negative pregnancy test if at childbirth potential 
7. Only patients who satisfy all requirements for informed consent may be included in the 
study. Written Informed Consent must be obtained before the initiation of any study-
specific procedures. 
8. Patients must have the ability and willingness to comply with study procedures. 
5.3 
Exclusion criteria 
Patients meeting any of these criteria will not be enrolled in the study: 
 
1. Best corrected distance visual acuity (BCDVA) score of < 0.1 decimal units in either eye. 
2. Evidence of an active ocular infection in either eye. 
3. Presence or history of any ocular disorder or condition, including ocular surgery, trauma, 
or disease that could possibly interfere with the interpretation of study results in the opinion 
of the Investigator. 
4. Intraocular inflammation defined as Tyndall score >0. 
5. Active or recent diagnosis of malignancy (i.e., currently under chemo/radiotherapy). 
6. Systemic disease not stabilized within 1 month before baseline visit (e.g., uncontrolled 
diabetes; thyroid malfunction) or judged by the Investigator to be incompatible with the 
study (e.g., current systemic infections) or with a condition incompatible with the frequent 
assessment required by the study. 
7. Patients who have had a serious adverse reaction or significant hypersensitivity to any drug 
or chemically related compounds, or had a clinically significant allergy to drugs, foods, 

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amide local anesthetics, or other materials, including commercial artificial tears containing 
carboxymethylcellulose (CMC) (in the opinion of the Investigator). 
8. Use of topical cyclosporine, topical corticosteroids, or any other topical medication for the 
treatment of dry eye in either eye until the day of study enrollment. 
9. Contact lenses or punctal plug use during the study (previous use not an exclusion criteria, 
but must be discontinued at the baseline visit. 
10. An anticipated need of additional systemic treatments for dry eye during the study (all prior 
treatment must be continued for the entire duration of the study). 
11. Females of childbearing potential (those who are not surgically sterilized or post-
menopausal for at least 1 year) are excluded from participation in the study if they meet any 
one of the following conditions:  
a. are currently pregnant or,  
b. have a positive result at the urine pregnancy test (Baseline/Day 0) or,  
c. intend to become pregnant during the study treatment period or,  
d. are breast-feeding or, 
e. are not willing to use highly effective birth control measures, such as: hormonal 
contraceptives - oral, implanted, transdermal, or injected - and/or mechanical barrier 
methods - spermicide in conjunction with a barrier such as a condom or diaphragm or 
IUD - during the entire course of and 30 days after the study treatment periods.  
12. History of drug addiction or alcohol abuse. 
13. Any prior ocular surgery (including refractive palpebral and cataract surgery) if within 90 
days before the screening visit. 
14. Participation in a clinical trial with a new active substance during the past 30 days. 
15. Participation in another clinical trial study at the same time as the present study. 
5.3.1 
Concomitant Medication 
All medications (including over-the-counter drugs, herbal products, vitamins, and antacids) 
taken within 4 weeks prior to the start of and throughout the study must be recorded on the case 
report form. Medication entries should be specific to product name (if a combination drug 
product) and spelled correctly. The dose, unit, frequency, route of administration, start date, 
discontinuation date, and indication should also be recorded. For medications administered only 
one time, the frequency column may reflect "once." 

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6 
STUDY SCHEDULE 
The schedule of the study is summarized at the end of the synopsis (page 10). 
6.1 
Study visits and procedures 
Each study patient will undergo 4 visits. 
Maximum study duration will be 84 days. A written informed consent will be obtained before 
any study assessment or procedure. 
The first patient first visit (FSFV) is defined as the 1st visit performed at the clinical center by 
the 1st screened patient. The “last patient, last visit” (LSLV) is defined as the last visit performed 
at the clinical center (or the telephone follow-up, if applicable) by the last patient (i.e., the last 
visit foreseen by the study protocol), independently of whether the patient completed or 
withdrew from the study. 
The following phases, visits and procedures will be performed: 
 
 Interventional phase 
 Baseline Visit - Day 0  
 Week 4 Visit - Day 28  ± 2 
 Week 8 Visit - Day 56 ± 4 
 
 Follow-up phase 
 Week 12 Follow-up Visit - Day 84 ± 4 / Early Termination Visit (ETV): In case of early 
discontinuation, discontinued patients will undergo an early termination visit (ETV) 
 

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Day 
Procedures/Assessments 
Baseline Visit 
Day 0 
The following procedures will be performed (the below order is not mandatory): 
 Explanation to the patient of study aims, procedures and possible risks 
 Informed consent signature 
 Screening number allocation (as S001, S002, etc.) 
 Demographic data 
 Medical and surgical history/current medical conditions 
 Prior/concomitant medications 
 AE collection 
 Ocular examination of both eyes: 
1. Assessment by SANDE questionnaire 
2. Assessment of best corrected distance visual acuity (BCDVA) 
3. Slit-lamp examination (SLE) to assess the eyelid (Meibomian glands), 
eyelid (erythema), eyelid (edema), lashes, conjunctiva erythema, lens, iris, 
anterior chamber 
4. External Ocular Examination 
5. TFBUT 
6. Schirmer test  I (without anesthesia)  
7. Ocular surface staining (NEI score - fluorescein and lissamine green) 
8. InflammaDry (MMP-9) 
 Frequency of patient’s own artificial tear use (to be reported in eCRF) 
 Pregnancy test for female patients if childbirth potential. 
 Patient eligibility: Inclusion/exclusion criteria evaluation 
 Assignment of the study eye 
 Randomization 
 Study Drug Dispensation 
 
The Investigator will dispense to the patients their monthly box containing the 
study drug for the following 4 weeks together with an adequate number of 
adapters and pipettes After completing baseline evaluation patients will start the 
study treatment as per instructions and will self-administer at home the 
subsequent doses till the evening of Day 28 (±2). Patients will return to the 
clinical site on Day28 (Week 4 Visit). 
The patients will be instructed to enter time of self-administration, AE occurrence, 
and concomitant medication intake into the diary, and to return the refrigerated 
box on the Week 4 visit.  
At home 
Days 0-28 
±2 
 Self-administration at home of the IMP, six times daily every 2 h for both eyes 
(diary) 
 Recording any new or changes in concomitant medications (diary) 
 Recording any unusual medical conditions  - AE monitoring (diary) 
Data will be recorded by the patient in the patient’s diary. 

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Day 
Procedures/Assessments 
Week 4 Visit  
Day 28±2 
The following procedures will be performed (order below is not mandatory): 
 
 Assessment of compliance to treatment (from patient diary and IMP 
reconciliation from returned weekly boxes) 
 Current medical conditions 
 Concomitant medications 
 AE monitoring 
 Ocular examination of both eyes: 
1. Assessment by SANDE questionnaire 
2. Assessment of best corrected distance visual acuity (BCDVA) 
3. Slit-lamp examination (SLE) to assess the Eyelid - Meibomian glands, 
Eyelid – Erythema, Eyelid - Edema Lashes, Conjunctiva Erythema, Lens, 
Iris, Anterior Chamber 
4. External Ocular Examination 
5. Tear Film Break-up Time (TFBUT) 
6. Ocular surface staining (NEI score - Fluorescein and Lissamine green) 
 Study Drug Dispensation 
 
The Investigator will deliver to the patients their monthly box containing the study 
drug for the following 4 weeks together with an adequate number of adapter and 
pipettes. 
After discharge the patients will continue the therapy as per instructions and will 
self-administer at home the subsequent doses from the evening of Day 28±2 to 
the evening of Day 56±4. Patients will return to the clinical site on Day56 ± 4 
(Week 8 Visit). 
The patients will be instructed to enter time of self-administration, AE 
occurrence, and concomitant medication intake into the diary, and to return the 
refrigerated box on the Week 8 visit. 
At home  
Days 28±2 
– 56±4 
 Self-administration at home of the IMP, six times daily for every 2 h (diary)  
 Recording any new or changes inconcomitant medications (diary) 
 Recording any unusual medical conditions  - AE monitoring (diary) 
Data will be recorded by the patient on the patient’s diary. 

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Day 
Procedures/Assessments 
Week 8 Visit  
Day 56±4  
  
The following procedures will be performed (the below order is not mandatory): 
 Compliance to treatment (from patient diary and control of returned weekly 
box) 
 current medical conditions 
 Concomitant medications 
 AE monitoring 
 Ocular examination in both eyes: 
1. Assessment by SANDE questionnaire 
2. Assessment of best corrected distance visual acuity (BCDVA) 
3. Slit-lamp examination (SLE) to assess the eyelid (Meibomian glands), 
eyelid (erythema), eyelid (edema), lashes, conjunctiva erythema, lens, 
iris, anterior chamber 
4. External Ocular Examination 
5. TFBUT 
6. Schirmer test  I (without anesthesia)  
7. Ocular surface staining (NEI score - Fluorescein and Lissamine green) 
8. InflammaDry (MMP-9) 
 Pregnancy test for female patients (urine). 
 
At completion of the test the patient will be discharged and will be asked to return 
for the follow-up visit on day 84±4 (Week 12 Visit). 
The patients will be instructed to enter time of self-administration, AE 
occurrence, and concomitant medication intake into the diary, and to return the 
refrigerated box. 
At home  
Days 56 
±4– 84 ± 4 
 Recording any new or changes in concomitant medications (diary) 
 Recording any unusual medical conditions  - AE monitoring (diary) 
 Artificial tears use during 4 weeks of FU 
Data will be recorded by the patient on the patient’s diary. 
Week 12 Visit  
Final visit or early termination visit (ETV) 
Day 84 ± 4 
 
The final visit is defined as the visit performed 28 ± 2 days after the last IMP 
administration (i.e., at day 84 ± 4). In case of premature study discontinuation, 
patients will undergo an early termination visit (ETV). 
 
The following procedures will be performed (the below order is not mandatory): 
 
 Medical and surgical history/current medical conditions 
 Prior/concomitant medications 
 AE monitoring 
 Ocular examination of both eyes: 
1. Assessment by SANDE questionnaire 
2. Assessment of best corrected distance visual acuity (BCDVA) 
3. Slit-lamp examination (SLE) to assess the Eyelid - Meibomian glands, 
Eyelid – Erythema, Eyelid - Edema Lashes, Conjunctiva Erythema, Lens, 
Iris, Anterior Chamber 
4. External Ocular Examination 
5. Tear Film Break-up Time (TFBUT) 
6. Ocular surface staining (NEI score - Fluorescein and Lissamine green) 
 Frequency of patient’s own artificial tear use during 4 weeks of FU (to be 
reported in eCRF) 

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7 
DESCRIPTION OF SPECIFIC PROCEDURES 
7.1 
Ophthalmological Evaluations 
Ocular evaluations will be performed on both eyes. The assessment will be performed at Day 0 
Baseline Visit, Week 4 Visit, Week 8 Visit and Week 12 Visit. The study eye will be the worse 
eye determined at Day 0 Baseline Visit (the right eye if both eyes are equally worse). The 
ophthalmological assessment will include: 
7.1.1 
External Ocular Examination 
External Ocular Examination assesses the motility of the extraocular muscles and the 
appearance and function of the eyelids before the instillation of any dilating or anesthetic eye 
drops. 
7.1.2 
Symptom Assessment in Dry Eye (SANDE): 
The Symptom Assessment in Dry Eye (SANDE) questionnaire is a short questionnaire to 
evaluate both dry eye intensity and frequency by using a 100 mm VAS. The patient symptoms 
of ocular dryness and/or irritation will be quantified on the scale based on two questions that 
assess both severity and frequency of symptoms. A VAS is a measurement instrument that tries 
to measure a characteristic or attitude that is believed to range across a continuum of values and 
cannot easily be directly measured. For example, the amount of irritation that a patient feels 
ranges across a continuum from none to an extreme amount of irritation. From the patient's 
perspective this spectrum appears continuous (i.e. their irritation does not take discrete jumps, 
as a categorization of none, mild, moderate and severe would suggest). It was to capture this 
idea of an underlying continuum that the VAS was devised.  
For the assessment, the patients mark on the 100 mm VAS line the point that they feel represents 
their perception of their current state. The VAS score is determined by measuring in millimeters 
from the left hand end of the line to the point that the patient marks. The SANDE scores will 
be then evaluated for the 2 questions severity (0-100) and frequency (0-100).  
7.1.3 
Best corrected distance visual acuity (BCDVA):  
Refraction and visual acuity measurements will be performed for all patients by trained vision 
examiners only. The name and certification number of the vision examiner should be 
documented in the patient’s visual acuity (VA) worksheet (provided by the Sponsor) at each 
visit. Refraction should be conducted prior to visual acuity testing to obtain best-corrected 
vision as described below. Best-corrected visual acuity is measured at all trial visits using 
standard charts, lighting, and procedures. Best correction is determined by careful refraction at 
that visit according to the standard protocol for refraction as described below. 

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Equipment 
Refraction equipment required includes:  
 Retroilluminated Light box and ETDRS 4 meter distance acuity chart set  
 Trial lens frames 
 Trial lens set with plus or minus cylinder lenses  
 Jackson cross-cylinders of 0.25, 0.50, and 1.00 diopters  
 Pinhole occluder 
 Tissues or eye pads and tape  
 A 1 meter rigid measuring stick 
Visual acuity charts: Chart 1 is used for testing the visual acuity of the RIGHT eye; Chart 2 for 
testing the LEFT eye; and Chart R (or 3) for refraction only. Patients should not be allowed to 
see any of the charts before the examination.  
A distance of 4 meters is required between the patient’s eyes and the visual acuity chart. With 
the box light off, not more than 15 foot-candles of light (161.4 Lux) should fall on the center of 
the chart. To measure the amount of light, the room is set up for visual acuity testing, but with 
the box light off. The light meter is placed at the fourth line from the top of the chart, with its 
back against the chart and the reading is taken. If more than one line available for testing visual 
acuity, the visual acuity of an individual patient should be measured in the same line at each 
visit, if possible. If different lines are used to test visual acuity, they must each meet the same 
standards.  
Retroilluminated ETDRS charts are used in this trial. The illuminator box will be either wall-
mounted or mounted on a stand. The light box should be mounted at a height such that the top 
of the third row letter is 49 + 2 inches from the floor.  
The visual acuity light box is equipped with two General Electric 20-watt fluorescent tubes and 
ballast. Each tube is partly covered by a 14-inch fenestrated sleeve, which is centered on the 
tube and open in the back. This serves as a “baffle” to produce even illumination over the testing 
chart. Because the illumination of fluorescent tubes diminishes by 5 percent during the first 100 
hours and by another 5 percent during the next 2000 hours, new tubes should be kept on for 4 
days (96 hours) continuously, and should be replaced once a year. 
A sticker should be placed on the back of the light box, indicating the date when the present 
tubes were installed. A spare set of burned in bulbs should be available on site.  
Detailed instructions for VA assessment 
As a reminder, Charts 1, 2 and R (or 3) are used for testing the right eye, left eye, and refraction, 
respectively. Patients should not see the charts until the test begins. The lens correction from 
the patient’s refraction should be in the trial frame worn by the patient.  
All eyes must be tested at 4 meters first, even if the refraction was performed at 1 meter.  
The patient should be seated comfortably directly in front of the chart so that the eyes remain 
at the 4 meter distance. Testing always begins with the right eye. The fellow eye should be 
occluded with a folded tissue or eye pad lightly taped over the eye behind the trial frame serves 
as an effective occluder that allows eccentric fixation without inadvertent use of the covered 
eye. After testing the right eye, occlusion of the right eye should be done BEFORE Chart 2 is 
put up for testing the left eye.  

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The patient is asked to read the letters slowly, approximately one letter per second. The patient 
should be told that only one chance is given to read each letter, but may change their mind 
before moving to the next letter. If the patient is unsure about the identity of the letter, then the 
patient should be encouraged to guess.  
The patient should begin by reading the top line of the chart and continue reading every letter 
on each smaller line, from left to right on each line. The patient should be encouraged to 
continue reading even if making mistakes. Each letter read is counted. The examiner circles 
every correct letter read and totals each line and the whole column (0 if no letters are correct) 
on the provided VA worksheet. An X is put through letters read incorrectly. Letters, for which 
no guess was attempted, are not marked. When a patient reaches a level where he/she cannot 
guess, the examiner may stop the test, provided that the patient has made errors on previous 
guesses, which is a clear indication that the best visual acuity has been obtained.  
When a patient cannot read at least 20 letters on the chart at 4 meters, the patient is tested at 1 
meter. The distance from the patient to the chart should be measured again using the rigid one 
meter stick. The distance is measured from the outer canthus to the center of the fourth letter 
(right eye) or the second letter (left eye) of the third line of the chart. The spherical correction 
in the trial frame should be changed by adding +0.75 to correct for the closer test distance. The 
patient may fixate eccentrically or turn or shake his/her head to improve visual acuity. Particular 
care should be taken to make sure the patient does not move forward when testing at 1 meter. 
The patient should be reminded to blink. 
The examiner should not tell the patient if a letter was identified correctly. The patient may be 
encouraged by neutral comments, such as “good,” “next,” and “OK.”  
The examiner should not stand close to the chart during testing. Attention should be focused on 
the patient and the VA worksheet. If the patient has difficulty locating the next line to read, the 
examiner may go up to the chart and point briefly to the next line to be read, but then must 
move away from the chart.  
When 20 or more letters are read at 4 meters the visual acuity score for that eye is recorded as 
the number of letters correct at 4 meters plus 30 (refer to the VA worksheet). The patient gets 
credit for the 30 letters at 1 meter even though they did not have to read them. Otherwise, the 
visual acuity score is the number of letters read correctly at 1 meter plus the number, if any, 
read at 4 meters. If no letters are read correctly at either 4.0 meters or 1 meter, then the visual 
acuity score is recorded as “0.” 
7.1.4 
Slit-lamp examination (SLE) 
The Slit-lamp examination (SLE) must be performed before the instillation of any dilating or 
anesthetic eye drops or the fluorescein agent. 
The patient will be seated at the slit-lamp while being examined. Grading of the eyelids, lashes, 
conjunctiva, cornea, lens, iris and anterior chamber will be done according to the following 
scales:  

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Eyelid - Meibomian glands  
Evaluation of the central ten Meibomian gland openings in the mid-portion of the upper eyelid: 
0 = None (none are plugged).  
1 = Mild (1 to 2 glands are plugged).  
2 = Moderate (3 to 4 glands are plugged).  
3 = Severe (All glands are plugged).  
Eyelid - Erythema  
0 = None (normal).  
1 = Mild (redness localized to a small region of the lid(s) margin OR skin).  
2 = Moderate (redness of most or all lid margin OR skin).  
3 = Severe (redness of most or all lid margin AND skin).  
4 = Very severe (marked diffuse redness of both lid margin AND skin).  
Eyelid - Edema  
0 = None (normal).  
1 = Mild (localized to a small region of the lid).  
2 = Moderate (diffuse, most or all lid but not prominent/protruding).  
3 = Severe (diffuse, most or all lid AND prominent/protruding).  
4 = Very severe (diffuse AND prominent/protruding AND reversion of the lid).  
Lashes  
0 = Normal  
1 = Abnormal (specify)  
Conjunctiva – Erythema  
0 = None (normal).  
1 = Mild (a flush reddish color predominantly confined to the palpebral or bulbar conjunctiva).  
2 = Moderate (more prominent red color of the palpebral or bulbar conjunctiva).  
3 = Severe (definite redness of palpebral or bulbar conjunctiva).  
Conjunctiva - Edema  
0 = None (normal).  
1 = Mild (slight localized swelling).  
2 = Moderate (moderate/medium localized swelling or mild diffuse swelling).  
3 = Severe (severe diffuse swelling).  
4 = Very severe (very prominent/protruding diffuse swelling). 
 

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Lens  
0 = No opacification (normal lens).  
1 = Mild lens opacification.  
2 = Moderate lens opacification.  
3 = Severe lens opacification. 
N/A = Patient with artificial lens 
Iris  
0 = Normal  
1 = Abnormal. 
Anterior Chamber Inflammation (Slit beam = 0.3 mm wide, 1.0 mm long)  
0 = None (no Tyndall effect).  
1 = Mild (Tyndall effect barely discernible).  
2 = Moderate (Tyndall beam in the anterior chamber is moderately intense).  
3 = Severe (Tyndall beam in the anterior chamber is severely intense).  
Corneal findings of interest on the SLE include the horizontal diameter of the cornea (measured 
in mm at the time of the SLE using a ruler).  
Relevant findings of the SLE will be entered in the eCRF.  
7.1.5 
Tear Film Break-up Time (TFBUT) 
Patients with a Tear Film Break-up Time TFBUT test ≤ 10 in the study eye (study eye) at the 
screening visit are eligible for enrollment. 
TFBUT will be measured by determining the time to tear break-up. The TFBUT will be 
performed after instillation of 5 l of 2% preservative-free sodium fluorescein solution into the 
inferior conjunctival cul-de-sac of each eye. The patient will be instructed to blink several times 
to thoroughly mix the fluorescein with the tear film. In order to achieve maximum fluorescence, 
the examiner should wait approximately 30 seconds after instillation before evaluating TFBUT. 
With the aid of a slit lamp at 10X magnification using cobalt blue illumination, the examiner 
will monitor the integrity of the tear film, noting the time it takes to form lacunae (clear spaces 
in the tear film) from the time that the eye is opened after the last blink. This measurement will 
be performed within 10 seconds maximum. The TFBUT will be measured twice during the first 
minute after the instillation of the fluorescein. If the 2 readings differ by more than 2 seconds a 
third reading is taken.  
The TFBUT value will be the average of the 2 or 3 measurements. 
Relevant TFBUT findings will be entered in the eCRF. 

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7.1.6 
Schirmer test I (without anesthesia) 
Patients with a Schirmer test without anesthesia ≤ 10 mm/5 minutes in the worse eye (study 
eye) at the screening visit are eligible for enrollment. 
This test will be performed to measure aqueous tear secretion prior to the instillation of any 
dilating or eye drops. Both eyes may be tested at the same time.  
This test will be conducted in a dimly lit room. While the patient looks upwards, the lower lid 
will be drawn gently downwards and temporally. The rounded bent end of a sterile strip will be 
inserted into the lower conjunctival sac over the temporal one-third of the lower eyelid margin. 
The test should be done without touching directly the Schirmer test strip with the fingers to 
avoid contamination of skin oils. The patients will be instructed to close their eyes gently. 
After 5 minutes have elapsed, the Schirmer test strip will be removed and the length of the tear 
absorption on the strip will be measured (millimeters/5 minutes).  
The wetting distance at 5 minutes for each eye will be recorded in the eCRF. 
7.1.7 
Ocular surface staining (NEI score - Lissamine green and fluorescein)   
As grading scale of the corneal and conjunctiva damage, the NEI/Industry Workshop guidelines 
will be used (10). The cornea is divided into five sectors (central, superior, inferior, nasal and 
temporal), each of which is scored on a scale of 0–3, with a maximal score of 15. Both nasally 
and temporally, the conjunctiva is divided into a superior paralimbal area, an inferior paralimbal 
area and a peripheral area with a grading scale of 0–3 and with a maximal score of 9 for the 
nasal and temporal conjunctiva.  
For a better reading it is also essential not to use an intense illumination beam, which may 
reduce the contrast and lead to an underestimation of grading (5). 
7.1.8 
InflammaDry: 
InflammaDry is a rapid, in-office test that detects MMP-9, an inflammatory marker that is 
consistently elevated in the tears of patients with dry eye disease. Using direct sampling 
microfiltration technology, InflammaDry accurately identifies elevated levels of MMP-9 
protein in tear fluid samples taken from the inside lining of the lower eyelid, the palpebral 
conjunctiva. 
 

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8 
ASSIGNMENT OF STUDY TREATMENT 
After obtaining informed consent a consecutive screening number will be assigned to each 
patient according to the sequence of study entry, from 001 to 150.  
8.1 
Randomization 
Eligible patients will be randomized 2:1 to either rhNGF eye drops 20 µg/ml (100 patients) or 
vehicle solution (50 patients). 
Each randomized patient will be allocated with randomization number to a consecutive list of 
starting with 1001 onwards. 
Drop outs after randomization will not be replaced. 
8.2 
Treatment allocation 
Each randomized patient will receive masked study treatment (either rhNGF eye drops 20 µg/ml 
or vehicle solution) according to the randomization code and determined by the allocated 
randomization number. 
 
8.3 
Masking 
The identity of the treatments will remain unknown to the patient, Investigator, site staff and 
Sponsor’s clinical research personnel until the study is unmasked for the final statistical analysis 
(after data base lock) except in case of specific events that will require unmasking of the patient. 
The vials containing rhNGF (20 µg/ml) or vehicle will be identical in appearance, and the 
contents of the vials will be indistinguishable. All staff directly involved in the analysis of study 
results will remain masked to treatment assignments while the study is in progress. 
A list of sequential kit numbers will be generated by a member of the CRO SAS programming 
group not involved in the conduct of the study. Each kit number will be randomly associated 
with a treatment group. Patients will be assigned to treatment in numerical order. A tear-off 
label from the kit box, with the kit number, will be attached to the investigational product 
dispensing log. 
If the Investigator becomes unmasked for any reason, this information will be recorded on 
source data and in the eCRF of the study, specifying the date and the reason.  
In the event of a medical emergency where the knowledge of patient treatment is required to 
provide the patient with appropriate care, Investigators will have the possibility to unmask the 
treatment assignment for a specific patient. . The Investigators are encouraged to contact the 
CRO staff before becoming unmasked if there is sufficient time. 

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9 
EVALUATION PARAMETERS 
9.1 
Study variables 
Clinical efficacy and safety parameters will be evaluated at each time point: 
9.1.1 
Primary endpoint 
 Change from baseline in Symptom Assessment in Dry Eye (SANDE) scores for severity 
and frequency assessed at 8 weeks of treatment (with LOCF imputation at earlier end of 
trial assessment)  
9.1.2 
Secondary endpoints 
 Change from baseline in SANDE scores for severity and frequency assessed at 4 and 8 
weeks of treatment (without imputation) 
 Changes in Cornea and conjunctival vital staining with fluorescein, National Eye Institute 
(NEI) scales 
 Changes in Tear film break-up time (TFBUT) and Schirmer test I 
9.1.3 
Exploratory endpoint 
 Changes in levels of the inflammatory biomarker matrix metallopeptidase 9 (MMP-9) in 
tears, measured by the RPS InflammaDry detector 
9.1.4 
Safety endpoints 
 Incidence and frequency of Treatment-emergent adverse events (TEAEs), assessed 
throughout the study 
Analyses of endpoints will be performed based on evaluations obtained on days 0, 282, 564 
and 28±4 days after discontinuation of study treatment. Details of analyses will be presented in 
the Statistical Analysis Plan finalized before Database Lock. 
Details on the assessments are given in § 7.1. 

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10 
STATISTICAL METHODS 
The data documented in this study will be summarized using descriptive summary statistics, 
i.e., arithmetic mean, standard deviation (SD), (%), minimum, median, and maximum values 
for quantitative variables, and frequencies for qualitative variables. 
A statistical analysis plan (SAP) will be developed and finalized before database lock and de-
masking. Final statistical analysis on the study variables will be presented in detail in the SAP.  
10.1 
Analysis Sets 
10.1.1 
Definitions 
A patient will be defined as screened after the signature of the informed consent, regardless of 
the completion of all the screening procedures. 
A patient will be defined as eligible if he/she respects all the inclusion/exclusion criteria. 
Otherwise he/she will be defined as a screen failure.  
A patient will be defined as enrolled in the study if he/she is randomized.  
 Enrolled Set: all enrolled patients. This analysis set will be used for demographic, baseline 
and background characteristics 
 Safety Set (SAF): all enrolled patients who receive at least one dose of the investigational 
medicinal product at the study eye. This analysis set will be used for the safety analysis 
 Full Analysis Set (FAS): all patients in the FAS who have at least one post-baseline 
efficacy measurement. This analysis set will be used for the primary efficacy analysis 
 Per Protocol Set (PP): all patients in the FAS who fulfil the study protocol requirements in 
terms of investigational medicinal product intake and collection of primary efficacy data 
and with no major deviations that may affect study results. This analysis set will be used 
for supportive efficacy analysis 
Each patient will be coded by the CRO Biometry Unit as valid or not valid for the Enrolled Set, 
FAS, FAS and PP. Patients will be evaluated according to the treatment dose they will actually 
receive. 
10.1.2 
Reasons for exclusion from the Full Analysis Set 
Reasons for the exclusion from the Full Analysis Set are the following: 
 
failure to take at least one dose of the IMP at the study eye 
 
lack of any efficacy data post enrollment 

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10.1.3 
Reasons for exclusion from the Per Protocol set 
Reasons for the exclusion from the Per Protocol set will be determined in the Blind Data Review 
Meeting and can be the following: 
 
lack of compliance with IMP administration (see § 10.3) 
 
exposure to an IMP dose different from the one assigned to the patient 
 
missing primary efficacy data 
 
failure to satisfy any inclusion/exclusion criteria (eligibility violations) 
 
intake of prohibited medications 
10.2 
Sample size and power considerations 
Sample size was calculated by assuming both for severity and frequency a mean difference 
from baseline SANDE score of -30±20 in the rhNGF groups versus -20±20 in vehicle group 
(80% power, alpha =0.05; 2-sided t-test), considering that the active comparator has already 
proven safe and effective in dry eye patients. Therefore, the sample size has been calculated 
based on a 2:1 randomization scheme by the following formula:  
n1 = (0.5) × n × (1 + k) 
n2 = (0.5) × n × (1 + (1/k)) 
With n1 = active treatment, n2 = vehicle, n = 63, and k = n1/n2 = 2/1=2. Therefore, n1= 94.5 
and n2=47.25. Assuming a 5% dropout rate, a total of 100 patients will be enrolled in the active 
arm, and 50 in the vehicle arm. 
Since this is an exploratory study, no adjustment has been made for multiplicity of SANDE 
parameters, neither has it been taken into account that the actual analysis will be descriptive 
only. 
10.3 
Compliance with IMP administration 
The assessment of patients’ compliance to the IMP will be made by determining the number of 
study medication vials dispensed to the patient at Day 0 baseline Visit, Week 4 Visit and the 
number of unused study medication vials returned at Week 4 Visit and Week 8 Visit, 
respectively. Compliance will be evaluated according to the following formula: 
 
Compliance= Number of vials dispensed – Number of unused vials returned 
Number of expected days on treatment 
 
Gross non compliance will be defined as compliance lower than 80% or greater than 120% and 
in case of gross non compliance the patient will be excluded from the Per Protocol Set (see § 
10.1.3). Since this definition does not warrant that the study eye treatment is compliant, if 
indicated the SAP will contain further definitions based upon the diary card information. 

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10.4 
Demographic, baseline and background characteristics 
Demographic and baseline characteristics will be examined per treatment group according to 
qualitative or quantitative data. Qualitative data will be listed and summarized in contingency 
tables. Quantitative data will be listed and summarized using descriptive statistics. 
10.5 
Analysis of ophthalmological evaluations  
All efficacy variables will be summarized for their study eye, using descriptive statistics (i.e., 
arithmetic mean, SD, (%), minimum, median and maximum values for quantitative variables, 
and frequencies for qualitative variables) by dose and evaluation time point. Changes from 
baseline (Day 0 Baseline Visit assessment) will be presented as well, if applicable. 
Additional details on the analyses will be provided in the statistical analysis plan. 
10.6 
Safety and tolerability evaluation 
AEs 
Adverse events (AEs) will be coded by System Organ Class (SOC) and Preferred Term (PT), 
using the Medical Dictionary for Regulatory Activities (MedDRA). 
AEs are all events occurring or worsening after the first dose of the IMP. 
Individual AEs will be listed in patient data listings.  AEs will be summarized by treatment 
group. The number and percentage of patients with any AE and the number of TEAEs will be 
tabulated by SOC and PT, seriousness, relationship to treatment and severity.  

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11 
DEFINITION AND HANDLING OF AES AND SAES 
11.1 
Applicable SOPs 
AE definition, classification and management will follow the Sponsor and CRO SOPs, based 
upon applicable local and international regulations. A brief summary of AE definition, 
classification and management is reported below. 
11.2 
Definitions 
11.2.1 
Adverse Events 
Adverse event (AE) means any untoward medical occurrence associated with the use of a drug 
in humans, whether or not considered drug related. (CFR - Code of Federal Regulations Title 
21 Sec. 312.32). An AE can therefore be any unfavorable and unintended sign (including an 
abnormal laboratory finding), symptom, or disease temporally associated with the use of a 
medicinal (investigational) product, whether or not related to the medicinal (investigational) 
product. 
11.2.2 
Adverse Drug Reaction  
 
Any noxious and unintended response to a medicinal product related to any dose should be 
considered an Adverse Drug Reaction (ADR). Any responses to a medicinal product means that 
a causal relationship between a medicinal product and an adverse event is at least a reasonable 
possibility, i.e., the relationship cannot be ruled out. 
 
The definition covers also medication errors and uses outside what is foreseen in the protocol, 
including misuse and abuse of the product.   For the purposes of IND safety reporting, 
“reasonable possibility” means there are facts (evidence) or arguments to suggest a causal 
relationship between the drug and the adverse event. 
11.2.3 
Serious Adverse Event (SAE)  
A serious adverse event (SAE) is defined in line with (CFR - Code of Federal Regulations Title 
21 Sec. 312.32) as any adverse experience that, in the view of either the Investigator or sponsor, 
meets any of the following criteria: 
 Results in death 
 Is life-threatening  
(NOTE: Life-threatening means that the patient was at immediate risk of death from the 
reaction as it occurred, i.e., it does not include a reaction which hypothetically might 
have caused death had it occurred in a more severe) 
 Requires inpatient hospitalization or prolongation of existing hospitalization 

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NOTE: In general, hospitalization means that the individual remained at the hospital or 
emergency ward for observation and/or treatment (usually involving an overnight stay) 
that would not have been appropriate in the physician's office or an outpatient setting. 
Complications that occur during hospitalization are AEs. If a complication prolongs 
hospitalization or fulfills any other serious criteria, the event is serious. When in doubt 
as to whether “hospitalization” occurred, the event should be considered serious. 
 Results in persistent or significant disability/incapacity 
(NOTE: The term disability means a substantial disruption of a person’s ability to 
conduct normal life functions. This definition is not intended to include experiences of 
relatively minor medical significance such as uncomplicated headache, nausea, 
vomiting,  diarrhea, influenza, or accidental trauma (e.g., sprained ankle) which may 
interfere or prevent everyday life functions but do not constitute a substantial 
disruption). 
 Results in a congenital anomaly/birth defect 
 Is an important medical event 
(NOTE: An important medical event is an event that may not result in death, be life-
threatening, or require hospitalization but may be considered a SAE when, based upon 
appropriate medical judgment, it may jeopardize the patient’s wellbeing and may 
require medical or surgical intervention to prevent one of the outcomes listed in the 
definitions for SAEs. Examples of such medical events include allergic bronchospasm 
requiring intensive treatment in an emergency room or at home, blood dyscrasias or 
convulsions that do not result in patient hospitalization or the development of drug 
dependency or drug abuse). 
 
Pre-planned hospitalization or hospitalization for routine treatment or monitoring of the studied 
indication, not associated with any deterioration in condition are not considered to be SAEs 
(see Par. 11.7.2).These events must be recorded in the AE page of the eCRF where a variable 
will be ticked to indicate that they are not SAEs.  
If a SAE results in death, cause of death shall always be specified when known. In case cause 
of death is not initially available, adequate follow up to seek information shall be made by the 
Investigator. 
11.2.4 
Unexpected Adverse Event/Reaction  
An AE or ADR is considered unexpected if it is not listed in the Investigator Brochure or is not 
listed at the specificity or severity that has been observed and listed in the Investigator Brochure. 
Events that are mentioned in the Investigator Brochure as occurring with a class of drugs or as 
anticipated from the pharmacological properties of the drug, but are not specifically mentioned 
as occurring with the particular drug under investigation are considered unexpected (21 
CFR312.32(a)). 

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11.2.5 
 Suspected Unexpected Serious Adverse Reaction 
A Suspected Unexpected Serious Adverse Reaction (SUSAR) is defined as an adverse reaction 
that is both unexpected (not consistent with the applicable product information) and meets the 
definition of a Serious Adverse Reaction.  
The determination of expectedness should be made on the basis of the IB.  
11.2.6 
Adverse Events (AEs) of Special Interest (Sight-threatening Events) 
The following adverse events are considered to be of special interest and by default shall be 
reported as SAEs (medically important criteria): 
 AEs that caused a decrease in visual acuity of >30 ETDRS letters or > +0.6 LogMAR 
(compared with the last assessment of visual acuity at the last visit) lasting >1 hour 
 AEs that caused a decrease in visual acuity to the level of Light Perception or worse lasting 
>1 hour 
 AEs that required surgical intervention (e.g., conventional surgery, vitreous tap or biopsy 
with intravitreal injection of anti-infectives, or laser or retinal cryopexy with gas) to prevent 
permanent loss of sight 
 AEs associated with severe intraocular inflammation (i.e., 4+ anterior chamber cell/flare or 
4+ vitritis) 
 AEs that, in the opinion of the Investigator, may require medical intervention to prevent 
permanent loss of sight. 
11.3 
Adverse Event (AE) Monitoring 
At each post-baseline visit, after the patient has had the opportunity to spontaneously mention 
any problems, the Investigator or appropriate designee should inquire about AEs by asking the 
standard questions:  
 “Have you had any health problems since your last study visit?” 
 “Have there been any changes in the medicines you take since your last study visit?”  
AEs should be reported for any clinically relevant change in concomitant condition(s) that is 
the result of an untoward (unfavorable and unintended) change in patient's medical conditions. 
Changes in any protocol-specific ocular or systemic parameter evaluated during the study are 
to be reviewed by the Investigator. In addition, the patient’s responses to any questionnaire 
utilized during the study are to be reviewed by the Investigator. Any untoward (unfavorable 
and unintended) change in a protocol-specific parameter or questionnaire response that is 
clinically relevant is to be reported as an AE. These clinically relevant changes will be reported 
regardless of causality. 
In order to collect as complete as possible information in the clinical study database, all ADRs and 
SAEs ongoing at the time the subject’s study participation ends should be evaluated within 10 days 
after the final visit. After this period, all unresolved ADRs and SAEs will be reported as “ongoing” 
in the eCRF. 

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11.4 
Recording  
Adverse Events:  
All AEs (non-serious and serious) that occur during the course of the study will be recorded in 
the eCRF. Any pre-existing medical conditions or signs/symptoms present in a patient prior to 
the start of the study (i.e., before informed consent is signed) should be specified in the 
dedicated eCRF sections. Subsequent to signing an informed consent form, all untoward 
medical occurrences that occur during the course of the study must be documented on eCRF. 
When possible, signs and symptoms indicating a common underlying pathology should be 
documented as one comprehensive event. For each recorded event, the AE documentation must 
include the onset date, outcome, resolution date (if event is resolved), intensity (i.e., severity), 
any action with study treatment taken as a result of the event, and an assessment of the adverse 
event relationship to the study treatment.  
Serious Adverse Events:  
The Investigator must record all SAEs, including sight-threatening events, occurring at any time 
during the study regardless of presumed causal relationship, on the Serious Adverse Event form 
in the eCRF of the EDC system within 24 hours of learning of the event; information on the 
SAE must also be recorded on a specific Non-Carbon Repeat SAE form (included in the 
Investigator’s Site File).  
If the Investigator becomes aware of a related serious adverse event occurring to a subject after 
the treatment of that subject has ended, this event should be reported by the Investigator to 
Dompé. Such “post-study cases” should be regarded for expedited reporting purposes as though 
they were study reports. Therefore, a causality assessment (by the Investigator and by Dompé) 
and determination of expectedness (by Dompé) are needed for a decision on whether or not 
expedited reporting is required. 
11.5 
Relationship of AEs to the Investigational Product 
The Investigator will assess the relationship between the AE and the investigational medication, 
according to the criteria in Table below: 
Table 11.5.1 
Relationship of the Adverse Event to the IMP 
None 
(Intercurrent 
Event) 
An event that is not and cannot be related to the investigational product, 
e.g. patient is a passenger in a road traffic accident or surgical 
intervention performed during the study, but planned before patient 
enrolment into the study  
Unlikely (remote) 
Relationship is not likely e.g. a clinical event including laboratory test 
abnormality with temporal relationship to drug administration which 
makes a causal relationship improbable and in which other drugs, 
chemicals or underlying disease provide plausible explanations 
Possible 
Relationship may exist, but could have been produced by the patient’s 
condition or treatment or other cause 

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Probable 
Relationship is likely, the AE abates upon discontinuation of 
investigational product  and cannot be due to the patient’s condition 
Highly Probable 
Strong relationship, the event abates upon discontinuation of 
investigational product and, if applicable, re-appears upon repeat 
exposure 
 
An ADR is defined as an adverse experience which is reasonably likely to have been caused by 
the drug. Events considered “Possible”, “Probable” and “Highly Probable” related to the IMP 
treatment and implying a reasonable possibility, if considered unexpected, will be reported to 
appropriate regulatory authorities. 
11.6 
Severity of AEs  
The Investigator will grade the severity of any AE using the definitions in the Table below. For 
each episode, the highest severity grade attained should be reported. 
Specifically, the intensity of events should be classified as mild, moderate, or severe.  
Table 11.6.1 
Intensity (Severity) of the Adverse Event 
Mild 
Grade 1 - Does not interfere with patient’s usual function (awareness of symptoms 
or signs, but easily tolerated [acceptable]). 
Moderate 
Grade 2 - Interferes to some extent with patient’s usual function (enough discomfort 
to interfere with usual activity [disturbing]). 
Severe 
Grade 3 - Interferes significantly with patient’s usual function (incapacity to work 
or to do usual activities [unacceptable]) 
11.7 
Serious Adverse Event Reporting Procedure (from Investigator to 
Dompé/CRO) 
11.7.1 
Reporting Procedure from Investigator to Dompé and CRO 
As per Paragraph 11.4, the Investigator must record all SAEs, including sight-threatening 
events, occurring at any time during the study regardless of presumed causal relationship, on 
the Serious Adverse Event form in the eCRF of the EDC system within 24 hours of learning of 
the event and simultaneously the Investigator shall forward the filled in, signed and dated SAE 
form to Dompé Drug Safety and to Cromsource (MVPVU) to the following addresses:  
 
Dompé Contact information 
Dompé Drug Safety  
Laura Boga, Senior Safety Manager  
Email: 
 farmacovigilanza@dompe.com 
or Fax:  +39.02.36026913 
 
Dompé Medical Expert  
Flavio Mantelli – Chief Medical Officer Ophthalmology,  
Email: 
 flavio.mantelli@dompe.com 

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or Fax:  +39.02.58383324 
 
Dompé Clinical Development 
Email:valentina.vaja@dompe.com 
or Fax:  +39.02.58383324 
 
Cromsource Contact Information:  
 For Pharmacovigilance: DOMPE-NGF0216-PV@cromsource.com 
 
For Medical Monitor and Pharmacovigilance: DOMPE-NGF0216-MM@cromsource.com  
 
or by Fax to:  
 Study specific eFax +1.2013267710 (linked to Dompé and Cromsource addresses). 
 
Respective IRB must also be informed of all SAEs according to local specific requirements. 
If assistance is needed with the reporting of a SAE, the CRO/Sponsor may be contacted at the 
addressed provided above  
Serious adverse events will be managed directly by the Dompé Drug Safety department, with 
Cromsource MVPVU support for follow-up requests. 
Whenever more than one SAE is observed, the Investigator should identify which is the primary 
adverse event, i.e. the most relevant one. If other events are listed in the same report, the 
Investigator, along with their relatedness to the Investigational Product, should identify which 
adverse events are serious and which are non-serious. In any case, the Investigator is requested 
to record his/her opinion about the relationship of the observed event(s) with the investigational 
medication. 
An assessment of expectedness and causality of each serious adverse event will be performed 
case by case by Dompé/CRO. For SAE reported by the Investigator as not related that is 
subsequently assessed to be related by Dompé, the Investigator will receive a notification. 
Depending on the nature and seriousness of the AE, further information, including copies of 
appropriate medical records of the patient, as well as results of laboratory tests performed will 
need to be included in the patients chart. If the patient was hospitalized, a copy of the discharge 
summary should be available, if possible.  
 Follow-up reports (as many as required) should be completed and faxed/e-mailed 
following the same procedure above, marking the SAE form as “follow up Number XX”. 
11.7.2 
 Conditions that should not be reported as serious adverse events 
The conditions listed below, that may require hospitalization of a patient, are not considered to 
be SAE and shall not be reported as such, but only need to be recorded in the eCRF: 
 Hospitalizations planned before entry into the clinical study which is part of the normal 
treatment or monitoring of the studied indication and not associated with any deterioration 
in condition. 

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 Hospitalization for routine treatment or monitoring of the studied indication, not associated 
with any deterioration in condition. 
 Hospitalization for treatments, which was elective or pre-planned, for a pre-existing 
condition that is unrelated to the indication under study and did not worsen. 
 Hospitalization for general care not associated with any deterioration in condition. 
 Treatment on an emergency, outpatient basis for an event not fulfilling any of the 
definitions of SAEs given above and not resulting in hospital admission. 
In addition, the following situation shall not be considered SAE: 
 Trial end points 
 Abnormal lab values or test results that do not induce clinical signs and/or symptoms and 
require intervention/therapy, i.e. are not clinically significant. 
11.7.3 
Reporting Procedure to IEC and to Regulatory Authorities 
In addition to reporting the SAE to Dompé, the Investigator must also comply with the 
requirements related to the reporting of SAEs to the IRB which approved the study. The 
requirements of IRBs vary from one IRB to another; however, as a minimum requirement, the 
Investigators must promptly report all suspected unexpected serious adverse reaction (SUSAR) 
to their IRB. 
In line with provisions set forth in 21CFR312, Dompé shall notify all participating Investigators 
in an IND safety report of any suspected adverse reaction that is both serious and unexpected  
and of potential serious risks, from clinical trials or any other source, as soon as possible, but 
in no case later than:  
 seven calendar days after becoming aware of the information if the event is fatal or life 
threatening; to be followed by any relevant information within eight days. 
 fifteen calendar days after becoming aware of the information if the event is serious but 
neither fatal nor life threatening. 
The Investigators in turn shall notify their IRB.  
If the results of an investigation show that an ADR not initially determined to be reportable is 
reclassified as reportable, the Sponsor shall report such reaction in a written safety report as 
soon as possible, but in no event later than 7/15 calendar days after the determination is made. 
Treatment will be unblinded by Dompé Drug Safety Pharmacovigilance prior to submission of 
a SUSAR to Regulatory Authorities and only cases referred to active treatment will be 
considered expeditable for regulatory reporting, in line with law requirements. 
Copies of all correspondence relating to reporting of any SAEs to the IRB should be maintained 
in the Investigator’s Files. 
Dompé shall also notify FDA in an IND safety report of potential serious risks, from clinical 
trials or any other source, as soon as possible after Dompé determines that the information 
qualifies for reporting, in particular shall notify of: 

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 any suspected adverse reaction that is both serious and unexpected. Dompé must report an 
adverse event as a suspected adverse reaction only if there is evidence to suggest a causal 
relationship between the drug and the adverse event.  
 findings from other studies that suggest a significant risk in humans exposed to the drug. 
Such a finding would result in a safety-related change in the overall conduct of the clinical 
investigation.  
 findings from animal or in vitro testing that suggest a significant risk in humans exposed to 
the drug 
 increased rate of occurrence of serious suspected adverse reactions. 
11.7.4 
 Periodical Reporting to Regulatory Authorities 
Dompé shall be responsible to prepare and submit annual safety reports (Development Safety 
Update Report – DSUR) to relevant Regulatory Authorities.  
11.8 
Unmasking of the Study Treatment 
Masked information on the identity of the assigned investigational product will be provided for 
each patient. If the treatment code needs to be broken in the interest of patient safety, the Dompé 
must be informed in all cases in which the code was broken and of the circumstances involved. 
Additionally, Dompé Drug Safety may be need to unmask the patient’s treatment if the a 
reported SAE meets criteria of a Suspected Unexpected Serious Adverse Reaction (SUSAR) in 
order to fulfil expedited regulatory reporting requirements. Unmasked information shall not be 
disclosed to Investigators. 
The identity of the treatments will remain unknown to the patient, Investigator, site staff and 
Dompé’s clinical research personnel and CRO staff (apart from pharmacovigilance). 
11.9 
Follow-up of patients with adverse events (AEs) 
The Investigator is responsible for adequate and safe medical care of patients during the trial 
and for ensuring that appropriate medical care and relevant follow-up procedures are 
maintained after the trial. All AEs should be followed-up to determine outcome of the reaction 
or until 10 days after the final visit. The Investigator should follow-up the event until resolution 
or stabilization of the condition. It is the Investigator's responsibility to assure that the patients 
experiencing AEs receive definite treatment for any AE, if required. 
If patient was hospitalized due to a SAE, a copy of the discharge summary is to be forwarded 
to CRO/Dompé as soon as it becomes available. In addition, a letter from the Investigator that 
summarizes the events related to the case as well as results of any relevant laboratory tests also 
may be requested. Further, depending upon the nature of the SAE, Dompé may request copies 
of applicable segments of the patient’s medical records. 
For pharmacovigilance purposes, all SAEs should be followed-up in order to elucidate as 
completely and practically as possible their nature and/or causality until resolution of all queries, 
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or the subject is lost to follow-up. Follow-up may therefore continue until after the subject has left 
the study up to  10 days after his/her discontinuation from the study for unrelated SAEs, and without 
timelines for related SAEs. 
11.10 
Pregnancy in the clinical trial 
Women of childbearing potential are not excluded from the study as long as adequate birth 
control methods are being utilized. Women of childbearing potential are defined as all women 
physiologically capable of becoming pregnant. Adequate birth control methods are summarized 
in the protocol’s exclusion criteria. 
Prior to enrollment in the clinical trial, female patients of childbearing potential and their 
partners must be advised of the importance of avoiding pregnancy during the entire course of 
the study treatment and for the 30 days after the study treatment period ends and of the potential 
risks associated with an unintentional pregnancy. During the trial (during the study treatment 
period and during the follow up), female patients are to be instructed to contact the Investigator 
immediately if they suspect they might be pregnant; in the same way, male patients who become 
aware that the partner might be pregnant, are to be instructed to contact the Investigator 
immediately.  
The Investigator must report every pregnancy on a pregnancy report form as soon as possible 
(within 24 hours of learning of the pregnancy) to the CRO/Dompé Drug Safety contacts 
reported at Paragraph 11.7.1, even if no AE has occurred, and follow it to term.  
The pregnancy form will be utilized to capture all pregnancy-related information until the birth 
of the child for both the patient and the partner.  
If the pregnancy is associated with an SAE (eg, if the mother is hospitalized for dehydration), 
in addition to the pregnancy report form, a separate SAE report form must be filed as described 
in Section 11.7 with the appropriate serious criterion (eg, hospitalization) indicated on the SAE 
report form. Miscarriage, stillbirth and any malformation/disease must be reported as a SAE. 
Any pregnancy leads to the immediate cessation of the study treatment.  
11.11 
Adverse Events Causing Treatment Discontinuation 
If a patient is withdrawn from the study as a consequence of an AE, this must be recorded and 
reasoned in the eCRF, and the patient must be followed up until the resolution of the AE or as 
instructed by the medical monitor. 
11.12 
Overdose 
Cases of overdose (accidental or intentional) which result in serious adverse reactions are to be 
handled following emergency procedures, and reported within 24 hours from the Investigator’s 
knowledge of its occurrence. This includes reports related to drug intake through different 
routes (e.g. ingestion), or drug intake with suicidal intentions and consequent drug overdose. 
Since in the preclinical toxicology studies in animals and in the multiple ascending dose study 
performed in healthy volunteers none of the dose has caused an overdose as documented by 

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adverse reaction, for the purpose of this study we define that the administration of more than 3 
times the total daily dose on any given treatment day will be reported as an overdose, even if 
not associated with adverse reactions, and shall be reported to Dompé Drug Safety by e-mail or 
fax within 24 hours, in order to have information about symptoms, corrective treatment and 
outcome of overdose. 

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12 
DATA MANAGEMENT PROCEDURES 
12.1 
Data collection – case report forms (eCRFs) 
The Investigator must ensure that the clinical data required by the study protocol are carefully 
reported in the eCRFs. He must also check that the data reported in the eCRFs correspond to 
those in the patients’ source documents.  
An electronic case report form (eCRF) will be provided for each randomized patient.  
All protocol-required information collected during the study must be entered by the 
Investigator, or designated representative, in the eCRF. Details of eCRF completion and 
correction will be explained to the Investigator. If the Investigator authorizes other persons to 
make entries in the eCRF, the names, positions, signatures, and initials of these persons must 
be supplied to the Sponsor.  
The Investigator, or designated representative, should complete the eCRF pages as soon as 
possible after information is collected, preferably on the same day that a study subject is seen 
for an examination, treatment, or any other study procedure. Any outstanding entries must be 
completed immediately after the final examination. An explanation should be given for all 
missing data. 
12.2 
Unique subject identifier 
All the patients who sign the informed consent form for the present study will be coded with 
“unique subject identifiers” when data are extracted from the study database into the domains 
of the CDISC SDTM model. The unique subject identifier consists of the 4-digit screening 
number (e.g. S001, S002, etc.) and, if applicable, the 4-digit subject study number (e.g. 1001, 
1002, etc.).  
Screening number and subject study number are separated by slashes (e.g. “S001/1001”). 
12.3 
Database management 
Data management of all data captured within the eCRF will be performed by the CRO. CRO 
will update and verify the database and create the final SAS data sets. The tabulation datasets 
and analysis datasets created according to the standard CDISC (STDM and ADaM) will be 
provided to the Sponsor with all the other study documentation.  
12.3.1 
Coding dictionaries 
Medical/surgical history and underlying diseases, physical examination abnormalities and AEs 
will be coded using the Medical Dictionary for Regulatory Activities (MedDRA™). 
Prior and concomitant medications will be coded using the WHO Drug Dictionary Enhanced 
(WHODDE). Version of coding dictionaries will be stated in the SAP and the study 
report.Study Monitoring, Quality Control And Quality Assurance. 

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12.4 
Monitoring 
The monitoring visits will be conducted by a local monitor.  
Monitoring will comply with ICH-GCP chapter 5.18 requirements for what concerns 
monitoring purpose, selection and qualifications of monitors, extent and nature of monitoring, 
monitoring procedures, monitoring reports. 
Adequate time and availability for monitoring activities should be ensured by the Investigator 
and key study personnel. 
Data verification is required and will be done by direct comparison with source documents, 
always giving due consideration to data protection and medical confidentiality. In this respect 
the Investigator will assure support to the monitor at all times. 
The Investigator agrees, by written consent to this protocol, to fully co-operate with compliance 
checks by allowing authorized individuals to have access to all the study documentation. In 
addition to the monitoring activities performed by the study monitor, the Sponsor could perform 
some quality control activities to verify the compliance with the study procedures and the ICH-
GCP guidelines.  
12.5 
Quality Control and Quality Assurance  
The CRO has implemented and maintains a Quality System that includes quality controls and 
audits at different study steps with written SOPs to ensure that the study is conducted in 
compliance with the protocol and all effective amendments, ICH-GCP, and the applicable 
regulatory requirement(s) and that data have been reliably and correctly generated, recorded, 
processed and reported, in agreement with the ALCOA principles (Attributable-Legible-
Contemporaneous-Original-Accurate). 
12.6 
Applicable SOPs 
The Sponsor, the clinical center and the CRO will follow their respective SOPs in the conduct 
of the respective activities, unless otherwise stated in written agreements. SOPs will be made 
available for review, if required. 
12.7 
Data access 
The Investigator and the CRO will ensure that all raw data records, medical records, eCRFs and 
all other documentation that is relevant to this study will be made accessible to monitoring 
activities, audits, IEC review, and regulatory inspection. 
12.8 
Audits and inspections 
The Sponsors, independent bodies acting on behalf of the Sponsor and the CRO have the right 
to perform audits according to ICH-GCP responsibilities. 
The study may also be inspected by regulatory authorities.  

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The Investigators agrees, by written consent to this protocol, to fully co-operate and support 
audits and inspections compliance checks by allowing authorized individuals to have access to 
all the study documentation. 

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13 
ETHICAL CONSIDERATIONS 
13.1 
Ethics and Good Clinical Practice (GCP) 
The study will be performed in accordance with the relevant guidelines of the Declaration of 
Helsinki. 
The approval of the study protocol by the relevant Local (AKH) Research Ethics Committees 
Authorities will be obtained before the start of the study. 
Study notification to the Competent Authorities (BASG, Austria) will be performed according 
to the Austrian current regulations. 
The present clinical study will be carried out according to the general principles of “ICH Topic 
E6, CPMP/ICH/135/95,” July 1996 including post Step 4 errata, status September 1997 and 
post Step errata (linguistic corrections), July 2002. 
13.2 
Informed consent 
Before being enrolled into the clinical study, the patients must have expressed their consent to 
participate, after the Investigator has explained to them, clearly and in details, the scope, the 
procedures and the possible consequences of the clinical study. Information will be given in 
both oral and written form. The information sheet and informed consent form will be prepared 
in the local language by the CRO and must be approved by the EC and regulatory authorities. 
It will include all the elements required by law according to the ICH-GCP recommendations.  
In addition to the standard requirements that physicians are currently obliged to observe when 
providing information, the following points must also be covered: 
 a description of the aims of the study and how it will be organised 
 the type of treatment 
 any potential negative effects attributable to the study treatment 
 the freedom to ask for further information at any time 
 the patients’ right to withdraw from the clinical study at any time without giving reasons 
and without jeopardising their further course of medical treatment  
 the existence of patient insurance cover and obligations following from this cover 
Adequate time and opportunity to satisfy questions will be given to the patients and the time 
will be recorded. 
The Investigator will be supplied with an adequate number of blank informed consent forms to 
be used. The forms will be signed and dated by both the Investigator and the patients.  
A copy of the signed form will be given to the patient. 
To ensure medical confidentiality and data protection, the signed informed consent forms will 
be stored in the Investigator's study file according to the regulatory requirements (see § 14.2). 
The Investigator will allow inspection of the forms by authorized representatives of the 
Sponsor, EC members and regulatory authorities. He will confirm, by signing and dating the 
forms, that informed consent has been obtained. 

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13.3 
Insurance policy 
An insurance cover has been issued in favor of the patients participating in this clinical study. 
The insurance is in compliance with the local regulation and with the requirements of the Health 
Authorities. 
13.4 
Withdrawal of patients 
It will be documented whether or not each patient completed the clinical study. If, for a patient, 
study treatment or observations are discontinued, the primary reason for discontinuation will 
be recorded. 
13.4.1 
Primary reason for discontinuation 
 Adverse event (AE): Any significant AE that, in the opinion of the Investigator or 
concerned patient, is not compatible with study continuation. For the definition of AE, 
please refer to § 11.2. 
 Death: the absence of life or state of being dead 
 Lack of efficacy: the lack of expected or desired effect related to a therapy 
 Lost to follow-up: the loss or lack of continuation of a patient to follow-up 
 Non-compliance with study drug: an indication that a patient has not agreed with or 
followed the instructions related to the study medication 
 Physician decision: a position, opinion or judgment reached after consideration by a 
physician with reference to the patient 
 Pregnancy: pregnancy is the state or condition of having a developing embryo or fetus in 
the body (uterus), after union of an ovum and spermatozoon, during the period from 
conception to birth (please see § 11.10) 
 Protocol violation: an event or decision that stands in contrast to the guidelines set out by 
the protocol 
 Study terminated by the Sponsor: an indication that a clinical study was stopped by its 
Sponsor 
 withdrawal by patient: study discontinuation requested by a patient for whatever reason 
 other: different than the ones previously specified. 
13.4.2 
Discontinuation procedures 
For any patient discontinuing the study, the Investigator will:  
 ask the patient to undergo, as far as possible, a final medical visit (ETV) to examine the 
patient's health conditions This examination will verify that all values tested at screening 
have remained within a clinically acceptable range (i.e., not clinically significant changes 
compared to screening) 

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 arrange for alternative medical care of the withdrawn patient, if necessary 
 report in the eCRF date and time of the last dose administration, and date and primary reason 
of study discontinuation 
 record in the eCRF any follow-up, if the patient is withdrawn for an AE. 
13.4.3 
Replacement 
Discontinued patients will not be replaced.  
13.5 
Study termination 
The study will be considered terminated at the date of the last visit of the last patient or upon 
completion of any follow-up procedure described in the protocol. The Investigator and the 
Sponsor have the right to discontinue the study at any time for reasonable medical and/or 
administrative reasons. As far as possible, this should occur after mutual consultation. Reasons 
for discontinuation have to be documented appropriately. In this event, no further patients will 
receive doses of the study drugs, and patients already having received a dose of study drug will 
not receive any further doses of the study IMP but will undergo all safety assessments scheduled 
after the last dose of study drug, up to an including the end of study examination. 

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14 
ADMINISTRATIVE PROCEDURES 
14.1 
Protocol amendments 
In order to obtain interpretable results, neither the Investigator nor the Sponsor will alter the 
study conditions agreed upon and set out in this protocol. Amendments should be made by 
mutual agreement between the Investigator and the Sponsor. Any amendment must be set out 
in writing, giving the reasons, and being signed by all concerned parties. The amendment 
becomes then part of the protocol. 
All amendments will be sent to the EC and concerned Competent Authorities. 
14.2 
Study documentation and record keeping 
The Investigator should ensure the accuracy, completeness, legibility, and timeliness of the data 
reported in the eCRFs and in all required reports. 
The Investigator must keep source documents for each patient in the study. All information on 
the eCRFs must be traceable to these source documents, which are generally stored in the 
patient's medical file. The source documents should contain all demographic and medical 
information, including ophthalmic assessments, etc., and the original signed informed consent 
forms. 
Data reported on the eCRF, that are derived from source documents, should be consistent with 
the source documents or the discrepancies should be explained. 
The Investigator and the Sponsor should maintain the study documents as specified in the 
“Essential Documents for the Conduct of a Clinical Trial” chapter 8 of ICH-GCP and as 
required by the applicable regulatory requirement(s).  
These are documents which individually and collectively permit evaluation of a study and the 
quality of the data produced and include groups of documents, generated before the study 
commences, during the clinical study, and after termination of the study and include but are not 
limited to, study protocol, amendments, submission and approval of EC, raw data of patients 
including ophthalmic assessments, insurance contracts, certificate of analysis of the IMP(s), 
drug accountability records, signed informed consent forms, confidential subjects identification 
code, eCRFs, curricula vitae of the Investigator and other participants in the study, study staff 
lists and responsibilities, monitoring reports and final study report. 
The Investigator and the Sponsor should take measures to prevent accidental or premature 
destruction of these documents. 
Study documents must be retained by the Investigator and the Sponsor as long as needed to 
comply with ICH-GCP, national and international regulations. By signing the protocol, the 
Investigator and the Sponsor agree to adhere to these requirements. 
14.3 
Study patients’ recruitment 
The clinical site have detailed SOPs on recruitment process. 

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14.4 
Confidentiality and data protection 
By signing this protocol, the Investigator and the CRO agree to keep all the information 
provided by the Sponsor in strict confidentiality and to request similar confidentiality from 
his/her staff. Study documents provided by the Sponsor (protocols, IB, eCRFs and other 
materials) will be stored appropriately to ensure confidentiality. The information provided by 
the Sponsor to the Investigator and to the CRO cannot be disclosed to others without direct 
written authorisation from the Sponsor, except for the extent necessary to obtain the informed 
consent from the patients wishing to participate in the study. 
Data on patients collected on the e CRFs during the study will be documented in an anonymous 
way (see § 12.2). If, as an exception, it becomes necessary to identify a patient for safety or 
regulatory reasons, the monitor, the Sponsor and the Investigator will be bound to keep this 
information confidential. 
14.5 
Publication policy 
The Sponsor agrees that the study results (including negative and inconclusive as well as 
positive results) can be made publicly available by the Investigator publishing in peer reviewed 
journals; presenting results at scientific congresses; and posting information and results on 
internet-based public registers and databases. 
In any case, study results will be communicated in full to the competent Health Authorities by 
the submission of a complete Clinical Study Report. 
As the Sponsor agrees that the study results can be published by the Investigator(s), the 
Investigator agrees to submit any manuscript (abstract, publication, paper etc.) to the Sponsor 
before any public disclosure. 
This will be done in order to ensure that clinical trial results are reported in an objective, 
accurate and balanced manner. The Sponsor reviews proposed manuscripts prior to submission 
within a reasonable period of time (30-90 business days in relation with the complexity of the 
work). 
The Investigator(s) will also be provided by the Sponsor with the clinical study report and the 
results of any additional analysis, tables, figures etc undertaken for the purposes of the article, 
in order to take responsibility for the content of the publication(s). 
On an exceptional basis, the Sponsor may temporarily delay registration of certain data 
elements (e.g. compound, name, outcome, measures etc.) to seek necessary intellectual property 
protection. This is because early disclosure of such a data could, in some circumstances, prevent 
or negatively impact patentability. 
14.6 
Liability Statement  
On behalf of the Sponsor, the investigational sites will take out reasonable third-party liability 
insurance cover in accordance with all local legal requirements. The civil liability of the 
Investigators, the persons instructed by them and the hospital, practice or institute in which they 
are employed and the liability of the Sponsor in respect of financial loss due to personal injury 

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and other damage which may arise as a result of the carrying out of this study are governed by 
the applicable local laws. 
As a precautionary measure, the Investigators, the persons instructed by them and the hospital, 
practice or institute are included in such cover in respect of work done by them in carrying out 
this study to the extent that the claims are not covered by their own professional indemnity 
insurance. 
14.7 
Financing of the Study 
The financial aspects of this study are described in detail in the contract between Sponsor and 
CRO and between CRO and clinical site involved in this study.  
14.8 
Responsibilities of the Investigator 
The Investigator is aware of his/her responsibility towards the Sponsor for all the actions 
delegated by him/her to other members of his/her staff assigned to the conduct of the study. 
Except where specifically required, the wording "Investigator" used in this protocol and in the 
eCRF, refers to the Investigator or the qualified person designated by him/her, who may carry 
out activities relevant to the clinical trial and sign the study documents on his/her behalf. 
The Investigator is obliged to conduct the study in compliance with the study protocol and in 
adherence to GCP (ICH E6) and with the principles of the Declaration of Helsinki (1964) and 
subsequent revisions as well as in respect of applicable legislation. 
14.9 
Confidentiality and data protection 
By signing this protocol, the Investigator(s) and the CRO agree to keep all the information 
provided by the Sponsor in strict confidentiality and to request similar confidentiality from 
his/her staff. Trial documents provided by the Sponsor (protocols, IBs, eCRFs and other 
materials) will be stored appropriately to ensure their confidentiality. The information provided 
by the Sponsor to the Investigator and to the CRO cannot be disclosed to others without direct 
written authorisation from the Sponsor, except for the extent necessary to obtain the informed 
consent from the patients wishing to participate in the trial. 
14.10 
Final study report 
The final Clinical Study Report will be written by the CRO and then approved by Dompé 
Farmaceutici S.p.A., and the Principal Investigator. It will be written in compliance with the 
ICH E3 guideline for both content and format. 

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15 
STUDY RESPONSIBLE PERSONS 
15.1 
Sponsor 
Dompé  farmaceutici S.p.A. Via S. Martino 12, 20122 Milan, Italy 
Phone: 
+39.02.583831 
Fax: 
+39.02.58383324 
 
Sponsor representatives 
 
Pharmacovigilance 
Dompé Drug Safety,  
Dompé farmaceutici S.p.A. - Milan  
Phone: 
+39.02.58383462 
Mobile: +39.335219580 
Fax: 
+39.02.36026913 
Email:  
farmacovigilanza@dompe.com 
eFax number: +1.2013267710 
 
Dompé Medical Expert 
Flavio Mantelli, MD, PhD  
Dompé farmaceutici  S.p.A., Milan  
Email: 
flavio.mantelli@dompe.com 
Fax: +39.02.58383324 
 
Clinical Development Manager 
Valentina Vaja, PhD 
Dompé farmaceutici  S.p.A., Milan  
Phone: 
+39.02.58383 575  
Email: 
valentina.vaja@dompe.com 
 
15.2 
Institutes performing the study 
15.2.1 
Clinical centre  
Scheie Eye Institute 
 51 North 39th Street 
Philadelphia, PA 19104 
 
Principal Investigator  
Giacomina Massaro Giordano , MD 
Email: 
Giacomina.Massaro-Giordano@uphs.upenn.edu 
 

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16 
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