Efficacy of the Nanodropper Device on Pupillary Dilation
Phase: NA
Conditions: Dilation
Sponsor: University of California, San Francisco

 
 
 
 
 
 
 
 
 
 
 
 
Efficacy of the Nanodropper Device on Pupillary Dilation 
 
NCT05274321 
 
March 31, 2022 

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Clinical Research Protocol 
RANDOMIZED TRIAL TO EVALUATE THE EFFICACY OF A SMALL VOLUME 
EYE DROP ADAPTER FOR PUPILLARY DILATION AND CYCLOPLEGIA IN 
CHILDREN 
 
Protocol Number: 
20-32530 
Version Date: 
1.0 
Intervention: 
Nanodropper Device (Nanodropper, Inc., Rochester MN) 
IND Number: 
N/A 
Development Phase: 
N/A 
Sponsor: 
N/A 
Funding Organization: 
Partial funding from the NIH-NEI EY002162 Core Grant for 
Vision Research. Three eye drop bottle adaptors were 
provided by Nanodropper, Inc. 
Principal Investigator: 
Name: Julius Oatts, MD 
 
Telephone: (415) 353-2800 
Fax: N/A 
 
E-mail: Julius.Oatts@ucsf.edu 
 
Medical Monitor: 
N/A 
 
Coordinating Center: 
N/A 
 
Approval: 
 
 
 
PI or Sponsor Signature (Name and Title)  
 
Date 
This confidential information about an investigational product is provided for the exclusive use of 
investigators of this product and is subject to recall at any time.  The information in this document 
may not be disclosed unless federal or state law or regulations require such disclosure.  Subject to the 
foregoing, this information may be disclosed only to those persons involved in the study who have a 
need to know, with the obligation not to further disseminate this information.   

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PROTOCOL AGREEMENT 
 
I have read the protocol specified below. In my formal capacity as Investigator, my duties 
include ensuring the safety of the study subjects enrolled under my supervision.  It is 
understood that all information pertaining to the study will be held strictly confidential and 
that this confidentiality requirement applies to all study staff at this site. Furthermore, on 
behalf of the study staff and myself, I agree to maintain the procedures required to carry out 
the study in accordance with accepted GCP principles and to abide by the terms of this 
protocol. 
 
Protocol Number: #20-32530 
 
Protocol Title:  Randomized Trial to Evaluate the Efficacy of a Small Volume Eye Drop 
Adapter for Pupillary Dilation and Cycloplegia in Children 
 
Protocol Date: 21 March 2022 
 
 
 
 
Investigator Signature  
 
Date 
 
Print Name and Title 
Site # 
N/A 
 
Site Name 
University of California, San Francisco 
Address 
490 Illinois St 
 
San Francisco, CA 94158 
 
 
 
 
Phone Number 
(415) 353-2800 

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TABLE OF CONTENTS 
 
1 
BACKGROUND………………………………………………………………………………10 
1.1 
Overview of Non-Clinical Studies……………………………………………………….10 
1.2 
Overview of Clinical Studies…………………………………………………………….10 
2 
STUDY RATIONALE………………………………………………………………………...10 
2.1 
Risk / Benefit Assessment……………………………………………………………….10 
3 
STUDY OBJECTIVES……………………………………………………………………….10 
3.1 
Primary Objective………………………………………………………………………..10 
3.2 
Secondary Objectives…………………………………………………………………….10 
4 
STUDY DESIGN……………………………………………………………………………...11 
4.1 
Study Overview…………………..……………………………………………………...11 
4.2 
Primary Efficacy Outcome………………………………………………………………11 
4.3 
Secondary Efficacy Outcome……………………………………………………………11 
4.4 
Safety Evaluations……………………………………………………………………… 11 
5 
SUBJECT SELECTION……………………………………………………………………...11 
5.1 
Study Population…………………………………………………………………………11 
5.2 
Inclusion Criteria………………………………………………………………………...11 
5.3 
Exclusion criteria………………………………………………………………………...11 
6 
CONCURRENT MEDICATIONS…………………………………………………………...12 
6.1 
Allowed Medications and Treatments…………………………………………………...12 
7 
STUDY TREATMENTS……………………………………………………………………...12 
7.1 
Method of Assigning Subjects to Treatment Groups…………………………………….12 
7.2 
Blinding………………………………………………………………………………….12 
7.3 
Formulation of Test and Control Products……………………………………………….12 
7.4 
Supply of Adaptors at the Site. ………………………………………………………….12 
8 
STUDY PROCEDURES AND GUIDELINES……………………………………………...13 
8.1 
Clinical Assessments…………………………………………………………………….13 
9 
EVALUATIONS BY VISIT…………………………………………………………………..13 
9.1 
Visit 1…………………………………………………………………………………….13 
9.2 
Early Withdrawal………………………………………………………………………...14 
10 ADVERSE EXPERIENCE REPORTING AND DOCUMENTATION…………………..14 
10.1 Adverse Events…………………………………………………………………………..14 
10.2 Serious Adverse Experiences (SAE) ……………………………………………………15 
11 DISCONTINUATION AND REPLACEMENT OF SUBJECTS………………………….16 
11.1 Early Discontinuation of Study Drug……………………………………………………16 
12 PROTOCOL VIOLATIONS…………………………………………………………………16 
13 STATISTICAL METHODS AND CONSIDERATIONS…………………………………..17 
13.1 Data Sets Analyzed………………………………………………………………………17 
13.2 Demographic and Baseline Characteristics……………………………………………...17 
13.3 Analysis of Primary Endpoint……………………………………………………………17 

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13.4 Analysis of Secondary Endpoints………………………………………………………..17 
13.5 Interim Analysis………………………………………………………………………….17 
13.6 Sample Size and Randomization………………………………………………………...17 
14 DATA COLLECTION, RETENTION AND MONITORING…………………………….18 
14.1 Data Collection Instruments……………………………………………………………..18 
14.2 Data Management Procedures…………………………………………………………...18 
14.3 Data Quality Control and Reporting……………………………………………………..18 
14.4 Archival of Data………………………………………………………………………….18 
14.5 Availability and Retention of Investigational Records…………………………………..19 
14.6 Monitoring……………………………………………………………………………….19 
14.7 Subject Confidentiality…………………………………………………………………..19 
15 ADMINISTRATIVE, ETHICAL, REGULATORY CONSIDERATIONS……………….19 
15.1 Protocol Amendments……………………………………………………………………19 
15.2 Institutional Review Boards and Independent Ethics Committees………………………20 
15.3 Informed Consent Form………………………………………………………………….20 
15.4 Publications………………………………………………………………………………21 
15.5 Investigator Responsibilities……………………………………………………………..21 
 

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LIST OF ABBREVIATIONS 
 
μL 
microliter 
AE 
adverse event 
CFR 
Code of Federal Regulations 
CRF 
case report form 
D 
diopter 
DMC 
Data Monitoring Committee 
DSMB 
Data Safety Monitoring Board 
FDA 
Food and Drug Administration 
GCP 
Good Clinical Practice 
HIPAA 
Health Insurance Portability and Accountability Act of 1996 
ICF 
informed consent form 
ICH 
International Conference on Harmonisation 
IEC 
Independent Ethics Committee 
IRB 
Institutional Review Board 
PI 
Principal Investigator 
SAE 
serious adverse experience 
SE 
spherical equivalent 
SOC 
standard of care 

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PROTOCOL SYNOPSIS 
TITLE 
Randomized Trial to Evaluate the Efficacy of a Small Volume Eye 
Drop Adapter for Pupillary Dilation and Cycloplegia in Children 
SPONSOR 
N/A 
FUNDING 
ORGANIZATION 
Partial funding from the NIH-NEI EY002162 Core Grant for Vision 
Research 
NUMBER OF SITES 
1 
RATIONALE 
Topical ophthalmic medications in the form of eye drops are widely 
used in pediatric ophthalmology clinics to achieve pupillary dilation 
and cycloplegia. The human eye can only absorb 7-10 μL of fluid, yet 
conventional eye drops are 50 μL. The extra medication contributes to 
waste, potential added systemic toxicity, and problems with 
medication durability, where patients run out of medication and are 
unable to obtain refills due to premature eye drop bottle exhaustion.  
This study aimed to directly compare the effect of small volume eye 
drops with standard of care eye drops on pupillary dilation and 
cycloplegia among pediatric patients. 
STUDY DESIGN 
This is a randomized, unblinded, non-inferiority study. 
PRIMARY 
OBJECTIVE 
To interpret a non-inferiority analysis of using the Nanodropper 
device for pupillary dilation and cycloplegia in pediatric patients. 
SECONDARY 
OBJECTIVES 
To interpret a non-inferiority analysis of using the Nanodropper 
device for intraocular pressure measurement in pediatric patients. 
NUMBER OF 
SUBJECTS 
50 
SUBJECT 
SELECTION 
CRITERIA 
Inclusion Criteria:  
Children ≤18 years of age who were having pupillary dilation 
performed as part of their routine eye examinations at the UCSF 
Pediatric Ophthalmology Clinic. 
 
Exclusion Criteria: 
Inability to cooperate with study interventions (eye drop 
administration, pupillometry, autorefraction); medication allergy to 
tropicamide, cyclopentolate, or phenylephrine; congenital or 
iatrogenic anterior segment abnormalities; anisocoria; not attending 
the scheduled appointment; or use of pupil altering topical or systemic 
medications. 
TEST PRODUCT, 
DOSE, AND ROUTE 
1% cyclopentolate at 10.4 μL dose 
1% tropicamide at 10.4 μL dose  

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OF 
ADMINISTRATION 
2.5% phenylephrine at 10.4 μL dose 
Product will be administered once with one drop of each of the above, 
topically through standard-sized eyedrop bottles with the 
Nanodropper adaptor affixed. 
CONTROL 
PRODUCT, DOSE 
AND ROUTE OF 
ADMINISTRATION 
1% cyclopentolate at standard -sized (approximately 50 μL) dose 
1% tropicamide at (approximately 50 μL) dose  
2.5% phenylephrine at (approximately 50 μL) μL dose 
Product will be administered once with one drop of each of the above, 
topically through standard-sized eyedrop bottles without any adaptor 
(standard of care). 
DURATION OF 
SUBJECT 
PARTICIPATION 
AND DURATION OF 
STUDY 
Participants will be on study for one clinic visit, approximately 40 
minutes – 90 minutes. The total duration of the study is expected to be 
6 months. 
CONCOMMITANT 
MEDICATIONS 
N/A 
EFFICACY 
EVALUATIONS 
N/A 
PRIMARY 
OUTCOME(S) 
• 
Intra-eye change in spherical equivalent from before and after 
dilation 
• 
Maximum pupil diameter after dilation 
• 
Change in pupil constriction percentage 
SECONDARY 
ENDPOINTS 
• 
Intraocular pressure after dilation 
OTHER 
EVALUATIONS 
N/A 
SAFETY 
EVALUATIONS 
N/A 
PLANNED INTERIM 
ANALYSES  
An interim analysis is planned after the enrollment of 20 participants 
for data collection quality and possible presentation of preliminary 
data at an academic conference. 
STATISTICS 
Primary Analysis Plan 
A non-inferiority analysis was done on the primary outcomes with 
pre-dilation measurements and treatment arm used as predictor 
variable and participants treated as random effect variable. A 10% 
margin on the SOC group was used to determine non-inferiority. 

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Rationale for Number 
of Subjects 
Sample size was determined based on a power calculation to reach 
significance for one outcome at a p-value=0.05. 
 

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1 
BACKGROUND 
Instillation of a smaller volume eye drop has numerous advantages, including prolonging 
the use of medication bottles, reducing waste, and minimizing systemic absorption and 
local toxicity. Here, we evaluated the effectiveness of a novel small volume eye drop 
adapter, Nanodropper, which administers 10.4 μL eye drops when used for pediatric 
pupillary dilation and cycloplegia. 
1.1 
Overview of Non-Clinical Studies 
There are two factors that coalesce to create the problem of premature bottle exhaustion. 
The first is patients regularly miss their eye when attempting to administer eye drops. One 
study determined that for every drop that makes it into a glaucoma patient’s eye, seven 
drops are wasted during the instillation attempt.9 Second, prescription eye drop bottles 
elute drops that exceed the capacity of the human eye by five times.10 Therefore, every 
time a patient administers an eye drop, they lose approximately 80% of their medication to 
wasted overflow and/or systematic absorption. 
1.2 
Overview of Clinical Studies 
Previous studies demonstrate that smaller eye drops used in the treatment of glaucoma are 
just as efficacious as their larger counterparts. Research on this topic dates back to 1980, 
beginning with a study conducted by File & Patton.20 The authors determined that 20 μL 
drops and 50 μL drops of 0.5% pilocarpine hydrochloride produced an equivalent miotic 
response in healthy volunteers. Additionally, it was noted that the 20 μL drops of the 0.5% 
drug solution produced fewer local symptoms (i.e., transient blurring of vision, some 
stinging upon administration, watering eyes, and mild redness) than the larger 50 μL drops. 
2 
STUDY RATIONALE 
There has not yet been a study done to evaluate the efficacy of the Nanodropper device or 
the effect of small volume eye drops in pediatric patients. 
2.1 
Risk / Benefit Assessment 
N/A 
3 
STUDY OBJECTIVES 
3.1 
Primary Objective 
The primary objective is to conduct an interpret a non-inferiority analysis of using the 
Nanodropper device for pupillary dilation and cycloplegia in a cohort of pediatric patients. 
3.2 
Secondary Objectives 
The secondary objective is to conduct and interpret a non-inferiority analysis of using the 
Nanodropper device for intraocular pressure measurement in pediatric patients. 

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4 
STUDY DESIGN 
4.1 
Study Overview 
This is a single center, unblinded, randomized, simple, 1:1 trial. 100 eyes of 50 patients are 
planned. Each participant will have baseline autorefraction, pupillometry, and intraocular 
pressure measured at baseline. Each participant will be administered a single drop of 1% 
cyclopentolate, 1% tropicamide, and 2.5% phenylephrine in each eye for pupillary dilation 
and cycloplegia. One eye will receive the drops using standard-sized eye drop bottles and 
the other eye will receive drops using the same eye drop bottles, and with the Nanodropper 
adapter attached. 30 minutes after drop administration, each participant will have 
refraction, pupillometry, and intraocular pressure measured again. 
Participants who meet all inclusion criteria and none of the exclusion criteria will be 
entered into the study. 
Total duration of participation will be 40 minutes – 90 minutes. Total duration of the study 
is expected to be 6 months. 
4.2 
Primary Efficacy Outcome 
The primary outcomes are 1) intra-eye change in spherical equivalent from before and after 
dilation, 2) maximum pupil diameter after dilation, 3) change in pupil constriction 
percentage. 
4.3 
Secondary Efficacy Outcome 
The secondary outcome is intraocular pressure after dilation. 
4.4 
Safety Evaluations 
We do not expect there to be additional safety evaluations related to this trial. 
5 
SUBJECT SELECTION 
5.1 
Study Population 
Pediatric patients who were scheduled for routine pupillary dilation at the University of 
California, San Francisco Pediatric Ophthalmology clinic were eligible. 
5.2 
Inclusion Criteria 
1. Male or female ≤18 years of age 
2. Scheduled for routine pupillary dilation 
3. Written informed consent (and assent when applicable) obtained from subject or 
subject’s legal representative and ability for subject to comply with the requirements of 
the study. 
5.3 
Exclusion criteria 
1. Inability to cooperate with study interventions (eye drop administration, pupillometry, 
autorefraction) 

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2. Medication allergy to tropicamide, cyclopentolate, or phenylephrine 
3. Congenital or iatrogenic anterior segment abnormalities 
4. Anisocoria 
5. Not attending the scheduled appointment 
6. Use of pupil altering topical or systemic medications 
7. Presence of a condition or abnormality that in the opinion of the Investigator would 
compromise the safety of the patient or the quality of the data. 
6 
CONCURRENT MEDICATIONS 
N/A 
6.1 
Allowed Medications and Treatments 
N/A 
7 
STUDY TREATMENTS 
7.1 
Method of Assigning Subjects to Treatment Groups 
Example text: Up to 60 eligible patients will be randomly assigned receive eyedrops using 
the Nanodropper device in either the right or left eye, and standard of care drops in the 
other eye. Treatment groups (standard of care or Nanodropper) will be randomized in a 1:1 
ratio using a web-based computer-generated randomization. 
7.2 
Blinding 
Due to the nature of the study, investigators, research staff, and patients will be unblinded 
to the intervention. 
7.3 
Formulation of Test and Control Products 
The intervention product is the Nanodropper adaptor (Nanodropper, Inc., Rochester, MN). 
The Nanodropper adaptor (right, Nanodropper, Rochester, MN) is comprised of three parts: 
the tip, base, and cap. The silicone tip tapers to a small diameter opening in order to reduce 
drop volume and is secured to the existing bottle with the base, which screws onto the eye 
dropper over the original cap. A plastic cap is kept in place to protect the tip in between 
drop administrations. The Nanodropper can be used for multiple uses but should not be 
removed from a bottle once attached. 
7.4 
Supply of Adaptors at the Site 
Three Nanodropper adaptors have been provided by the manufacturer to the site for use in 
this study. The dedicated study eye drop bottles are located in the locked clinic office in the 
locked materials cabinet. Study staff will transport study eye drop bottles to and from clinic 
rooms for use. 

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7.4.1 
Administration Instructions  
Nanodropper adaptors will already be attached to eye drop bottles prior to use in the study. 
Administer the drops by gently squeezing eye drop bottles to elute one drop of medication 
into the patient’s open eye. Repeat for all three topical ophthalmic medications denoted in 
this protocol. 
7.4.2 
Storage 
Study adaptors should be stored by the study site at controlled room temperature.  
8 
STUDY PROCEDURES AND GUIDELINES 
A Schedule of Events representing the required testing procedures to be performed for the 
duration of the study is diagrammed in Appendix 1. 
Prior to conducting any study-related activities, written informed consent and the Health 
Insurance Portability and Accountability Act (HIPAA) authorization must be signed and 
dated by the subject or subject’s legal representative.  If appropriate, assent must also be 
obtained prior to conducting any study-related activities. 
8.1 
Clinical Assessments 
8.1.1 Demographics  
Demographic information (date of birth, gender, eye color) will be recorded at Visit 1. 
8.1.2 Baseline measurements 
Baseline spherical power, cylindrical power, axis; maximum pupil diameter, minimum 
pupil diameter, pupil constriction percentage, pupil construction latency, and intraocular 
pressure will be recorded at Visit 1. 
8.1.3 
Adverse Events 
Information regarding occurrence of adverse events will be captured throughout the study. 
Duration (start and stop and times), outcome, treatment and relation to study intervention 
will be recorded in the notes section of the electronic data collection form. 
9 
EVALUATIONS BY VISIT 
9.1 
Visit 1 
1. 
Review the study with the subject (subject’s legal representative) and obtain 
electronic informed consent and HIPAA authorization and assent, if appropriate. 
2. 
Assign the subject a unique screening number. 
3. 
Record demographics data. 
4. 
Record non-cycloplegic autorefraction, pupillometry, and tonometry. 
5. 
Randomize Nanodropper to be given to right or left eye. 
6. 
Administer dilating eye drops. 
7. 
Record cycloplegic autorefraction, pupillometry, and tonometry. 

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9.2 
Early Withdrawal 
1. 
Record any Adverse Experiences and record reason for withdrawal. 
10 ADVERSE EXPERIENCE REPORTING AND DOCUMENTATION 
10.1 Adverse Events 
An adverse event (AE) is any untoward medical occurrence in a clinical investigation of a 
patient administered a pharmaceutical product and that does not necessarily have a causal 
relationship with the treatment.  An AE is therefore any unfavorable and unintended sign, 
symptom or disease temporally associated with the administration of an investigational 
product, whether or not related to that investigational product.  An unexpected AE is one of 
a type not identified in nature, severity, or frequency in the current Investigator’s Brochure 
or of greater severity or frequency than expected based on the information in the 
Investigator’s Brochure. 
The Investigator will probe, via discussion with the subject, for the occurrence of AEs 
during each subject visit and record the information in the site’s source documents.  
Adverse events will be recorded in the patient CRF.  Adverse events will be described by 
duration (start and stop dates and times), severity, outcome, treatment and relation to study 
drug, or if unrelated, the cause. 
AE Severity 
The National Cancer Institute’s Common Terminology Criteria for Adverse Events 
(CTCAE) Version 3.0 should be used to assess and grade AE severity, including laboratory 
abnormalities judged to be clinically significant. The modified criteria can be found in the 
study manual.  If the experience is not covered in the modified criteria, the guidelines 
shown in Table 1 below should be used to grade severity.  It should be pointed out that the 
term “severe” is a measure of intensity and that a severe AE is not necessarily serious. 
Table 1.  AE Severity Grading 
Severity (Toxicity Grade) 
Description 
Mild (1) 
Transient or mild discomfort; no limitation in activity; no medical 
intervention or therapy required. The subject may be aware of the sign 
or symptom but tolerates it reasonably well. 
Moderate (2) 
Mild to moderate limitation in activity, no or minimal medical 
intervention/therapy required. 
Severe (3) 
Marked limitation in activity, medical intervention/therapy required, 
hospitalizations possible. 
Life-threatening (4) 
The subject is at risk of death due to the adverse experience as it 
occurred. This does not refer to an experience that hypothetically 
might have caused death if it were more severe. 
 
AE Relationship to Study Drug 
The relationship of an AE to the study drug should be assessed using the following the 
guidelines in Table 2. 

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Table 2.  AE Relationship to Study Drug 
Relationship 
to Drug 
Comment 
Definitely 
Previously known toxicity of agent; or an event that follows a reasonable temporal 
sequence from administration of the drug; that follows a known or expected response 
pattern to the suspected drug; that is confirmed by stopping or reducing the dosage of 
the drug; and that is not explained by any other reasonable hypothesis. 
Probably 
An event that follows a reasonable temporal sequence from administration of the 
drug; that follows a known or expected response pattern to the suspected drug; that is 
confirmed by stopping or reducing the dosage of the drug; and that is unlikely to be 
explained by the known characteristics of the subject’s clinical state or by other 
interventions. 
Possibly 
An event that follows a reasonable temporal sequence from administration of the 
drug; that follows a known or expected response pattern to that suspected drug; but 
that could readily have been produced by a number of other factors. 
Unrelated 
An event that can be determined with certainty to have no relationship to the study 
drug. 
10.2 Serious Adverse Experiences (SAE) 
An SAE is defined as any AE occurring at any dose that results in any of the following 
outcomes: 
• 
death 
• 
a life-threatening adverse experience 
• 
inpatient hospitalization or prolongation of existing hospitalization 
• 
a persistent or significant disability/incapacity 
• 
a congenital anomaly/birth defect  
Other important medical events may also be considered an SAE when, based on 
appropriate medical judgment, they jeopardize the subject or require intervention to prevent 
one of the outcomes listed.  
 
10.2.1 Serious Adverse Experience Reporting 
Study sites will document all SAEs that occur (whether or not related to study drug) per 
UCSF CHR Guidelines.  The collection period for all SAEs will begin after informed 
consent is obtained and end after procedures for the final study visit have been completed. 
In accordance with the standard operating procedures and policies of the local Institutional 
Review Board (IRB), the site investigator will report SAEs to the IRB.   
   

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11 DISCONTINUATION AND REPLACEMENT OF SUBJECTS 
11.1 Early Discontinuation of Study Drug  
A subject may be discontinued from study treatment at any time if the subject, the 
investigator, or the Sponsor feels that it is not in the subject’s best interest to continue.  The 
following is a list of possible reasons for study treatment discontinuation:  
• 
Subject withdrawal of consent (or assent) 
• 
Subject is not compliant with study procedures 
• 
Adverse event that in the opinion of the investigator would be in the best interest of the 
subject to discontinue study treatment 
• 
Protocol violation requiring discontinuation of study treatment 
• 
Lost to follow-up 
• 
Sponsor request for early termination of study 
If a subject is withdrawn from treatment due to an adverse event, the subject will be 
followed and treated by the Investigator until the abnormal parameter or symptom has 
resolved or stabilized.   
All subjects who discontinue study treatment should come in for an early discontinuation 
visit as soon as possible and then should be encouraged to complete all remaining 
scheduled visits and procedures. 
All subjects are free to withdraw from participation  
12 PROTOCOL VIOLATIONS 
A protocol violation occurs when the subject, study staff, or investigator fails to adhere to 
significant protocol requirements affecting the inclusion, exclusion, subject safety and 
primary endpoint criteria.  Protocol violations for this study include, but are not limited to, 
the following: 
• 
Failure to meet inclusion/exclusion criteria 
• 
Inappropriate administration of medication (too many eye drops) 
• 
Failure to measure or record data 
Failure to comply with Good Clinical Practice (GCP) guidelines will also result in a 
protocol violation. The study investigator will determine if a protocol violation will result 
in withdrawal of a subject. 
When a protocol violation occurs, it will be discussed with the investigator and a Protocol 
Violation Form detailing the violation will be generated. This form will be signed by a 
Sponsor representative and the Investigator. A copy of the form will be filed in the site’s 
regulatory binder and in the Sponsor’s files. 

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13 STATISTICAL METHODS AND CONSIDERATIONS 
Prior to the analysis of the final study data, a detailed Statistical Analysis Plan (SAP) will 
be written describing all analyses that will be performed.  The SAP will contain any 
modifications to the analysis plan described below.   
13.1 Data Sets Analyzed 
All eligible patients who are randomized into the study and receive the intervention of 
small volume eye drops will be included in the analysis. Outcome data will be analyzed an 
a by-eye level, not a by-patient level. 
13.2 Demographic and Baseline Characteristics 
The following demographic variables at screening will be summarized by 
intervention/control group: gender, age, eye color, refractive error.   
13.3 Analysis of Primary Endpoint 
We plan a non-inferiority analysis of the primary endpoints: spherical equivalent, 
maximum pupil diameter, and pupil constriction percentage. Change scores for each 
outcome will be calculated by subtracting post-dilation values from pre-dilation values for 
both the intervention and control groups. Absolute differences for each outcome will be 
calculated by subtracting standard of care and intervention change score. Confidence 
interval will be set at 95%. Analysis of covariance (ANCOVA) will be performed on each 
post-dilation outcome with pre-dilation measurements and treatment arms will be used as 
predictor variables. Participants will be considered as a random effect variable. The 
noninferiority margin will be determined by taking ten percent of the standard of care 
change score. Non-inferiority will be determined if the non-inferiority margin does not 
overlap with the regression coefficient’s 95% confidence interval.  
We will also analyze statistical significant differences between means of both groups for 
each outcome. We plan to use the Shapiro-Wilk test to analyze if the data is normally 
distributed. We will then plan to do a paired t-test or a Wilcoxon signed rank test to 
examine within-subject differences in the outcomes between standard of care and 
intervention groups. We plan to perform Welch’s t-test and Mann Whitney U test to 
examine within-eye differences between standard of care and intervention eyes determined 
by the distribution results of Shapiro-Wilk test. 
13.4 Analysis of Secondary Endpoints 
Statistical analysis of the secondary endpoint, intraocular pressure, will be analyzed as 
above. 
13.5 Interim Analysis 
N/A 
13.6 Sample Size and Randomization 
Sample size was determined based on a power calculation to reach significance for one 
outcome at a p-value=0.05. A minimum of 100 eyes will be included. 

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DATA COLLECTION, RETENTION AND MONITORING 
13.7 Data Collection Instruments 
The Investigator will prepare and maintain adequate and accurate source documents 
designed to record all observations and other pertinent data for each subject treated with the 
study drug.   
Study personnel at each site will enter data from source documents corresponding to a 
subject’s visit into the protocol-specific electronic Case Report Form (eCRF) OR paper 
CRF when the information corresponding to that visit is available.  Subjects will not be 
identified by name in the study database, but will be identified by a site number, subject 
number, and birthdate. 
For eCRFs: If a correction is required for an eCRF, the time and date stamps track the 
person entering or updating eCRF data and creates an electronic audit trail.  For paper 
CRFs:  If a correction is made on a CRF, the study staff member will line through the 
incorrect data, write in the correct data and initial and date the change. 
The Investigator is responsible for all information collected on subjects enrolled in this 
study.  All data collected during the course of this study must be reviewed and verified for 
completeness and accuracy by the Investigator.  A copy of the CRF will remain at the 
Investigator’s site at the completion of the study. 
13.8 Data Management Procedures 
The data will be entered into a validated database.  The Data Management group will be 
responsible for data processing, in accordance with procedural documentation.  Database 
lock will occur once quality assurance procedures have been completed. 
All procedures for the handling and analysis of data will be conducted using good 
computing practices meeting FDA guidelines for the handling and analysis of data for 
clinical trials. 
13.9 Data Quality Control and Reporting 
After data have been entered into the study database, a system of computerized data 
validation checks will be implemented and applied to the database on a regular basis. 
Queries are entered, tracked, and resolved through the EDC system directly.  The study 
database will be updated in accordance with the resolved queries.  All changes to the study 
database will be documented. 
13.10 Archival of Data 
The database is safeguarded against unauthorized access by established security 
procedures; appropriate backup copies of the database and related software files will be 
maintained.  Databases are backed up by the database administrator in conjunction with 
any updates or changes to the database.   
At critical junctures of the protocol (e.g., production of interim reports and final reports), 
data for analysis is locked and cleaned per established procedures. 

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13.11 Availability and Retention of Investigational Records 
The Investigator must make study data accessible to the monitor, other authorized 
representatives of the Sponsor (or designee), IRB/IEC, and Regulatory Agency (e.g., FDA) 
inspectors upon request.  A file for each subject must be maintained that includes the 
signed Informed Consent, HIPAA Authorization and Assent Form and copies of all source 
documentation related to that subject.  The Investigator must ensure the reliability and 
availability of source documents from which the information on the CRF was derived. 
All study documents (patient files, signed informed consent forms, copies of CRFs, Study 
File Notebook, etc.) must be kept secured for a period of two years following marketing of 
the investigational product or for two years after centers have been notified that the IND 
has been discontinued.  There may be other circumstances for which the Sponsor is 
required to maintain study records and, therefore, the Sponsor should be contacted prior to 
removing study records for any reason. 
13.12 Monitoring 
Monitoring visits will be conducted by representatives of the Sponsor according to the U.S. 
CFR Title 21 Parts 50, 56, and 312 and ICH Guidelines for GCP (E6).    By signing this 
protocol, the Investigator grants permission to the Sponsor (or designee), and appropriate 
regulatory authorities to conduct on-site monitoring and/or auditing of all appropriate study 
documentation. 
13.13 Subject Confidentiality 
In order to maintain subject confidentiality, only a site number, subject number and subject 
birthdate will identify all study subjects on CRFs and other documentation submitted to the 
Sponsor.  Additional subject confidentiality issues (if applicable) are covered in the 
Clinical Study Agreement. 
14 ADMINISTRATIVE, ETHICAL, REGULATORY CONSIDERATIONS 
The study will be conducted according to the Declaration of Helsinki, Protection of Human 
Volunteers (21 CFR 50), Institutional Review Boards (21 CFR 56), and Obligations of 
Clinical Investigators (21 CFR 312). 
To maintain confidentiality, all laboratory specimens, evaluation forms, reports and other 
records will be identified by a coded number and initials only.  All study records will be 
kept in a locked file cabinet and code sheets linking a patient’s name to a patient 
identification number will be stored separately in another locked file cabinet.  Clinical 
information will not be released without written permission of the subject, except as 
necessary for monitoring by the FDA.  The Investigator must also comply with all 
applicable privacy regulations (e.g., Health Insurance Portability and Accountability Act of 
1996, EU Data Protection Directive 95/46/EC). 
14.1 Protocol Amendments 
Any amendment to the protocol will be written by the study investigator.  Protocol 
amendments cannot be implemented without prior written IRB/IEC approval except as 
necessary to eliminate immediate safety hazards to patients.  A protocol amendment 

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intended to eliminate an apparent immediate hazard to patients may be implemented 
immediately, provided the IRBs are notified within five working days. 
14.2 Institutional Review Boards and Independent Ethics Committees 
The protocol and consent form will be reviewed and approved by the IRB of the 
participating center prior to study initiation.  Serious adverse experiences regardless of 
causality will be reported to the IRB/IEC in accordance with the standard operating 
procedures and policies of the IRB/IEC, and the Investigator will keep the IRB/IEC 
informed as to the progress of the study.  The Investigator will obtain assurance of 
IRB/IEC compliance with regulations. 
Any documents that the IRB/IEC may need to fulfill its responsibilities (such as protocol, 
protocol amendments, Investigator’s Brochure, consent forms, information concerning 
patient recruitment, payment or compensation procedures, or other pertinent information) 
will be submitted to the IRB/IEC.  The IRB/IECs written unconditional approval of the 
study protocol and the informed consent form will be in the possession of the Investigator 
before the study is initiated. 
Protocol and/or informed consent modifications or changes may not be initiated without 
prior written IRB/IEC approval except when necessary to eliminate immediate hazards to 
the patients or when the change(s) involves only logistical or administrative aspects of the 
study.  Such modifications will be submitted to the IRB/IEC and written verification that 
the modification was submitted and subsequently approved should be obtained.   
The IRB/IEC must be informed of revisions to other documents originally submitted for 
review; serious and/or unexpected adverse experiences occurring during the study in 
accordance with the standard operating procedures and policies of the IRB; new 
information that may affect adversely the safety of the patients of the conduct of the study; 
an annual update and/or request for re-approval; and when the study has been completed. 
14.3 Informed Consent Form  
Informed consent will be obtained in accordance with the Declaration of Helsinki, ICH 
GCP, US Code of Federal Regulations for Protection of Human Subjects (21 CFR 
50.25[a,b], CFR 50.27, and CFR Part 56, Subpart A), the Health Insurance Portability and 
Accountability Act (HIPAA, if applicable), and local regulations. 
The Investigator will prepare the informed consent form, assent and HIPAA authorization 
and provide the documents to the Sponsor or designee for approval prior to submission to 
the IRB/IEC.  The consent form generated by the Investigator must be acceptable to the 
Sponsor and be approved by the IRB/IEC.  The written consent document will embody the 
elements of informed consent as described in the International Conference on 
Harmonisation and will also comply with local regulations. The Investigator will send an 
IRB/IEC-approved copy of the Informed Consent Form to the Sponsor (or designee) for the 
study file. 
A properly executed, written, informed consent will be obtained from each subject prior to 
entering the subject into the trial.  Information should be given in both oral and written 
form and subjects (or their legal representatives) must be given ample opportunity to 
inquire about details of the study.  If appropriate and required by the local IRB/IEC, assent 

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from the subject will also be obtained.  If a subject is unable to sign the informed consent 
form (ICF) and the HIPAA authorization, a legal representative may sign for the subject.   
A copy of the signed consent form (and assent) will be given to the subject or legal 
representative of the subject and the original will be maintained with the subject’s records. 
14.4 Publications  
The preparation and submittal for publication of manuscripts containing the study results 
shall be in accordance with a process determined by mutual written agreement among the 
study Sponsor and participating institutions.  The publication or presentation of any study 
results shall comply with all applicable privacy laws, including, but not limited to, the 
Health Insurance Portability and Accountability Act of 1996.  
14.5 Investigator Responsibilities 
By signing the Agreement of Investigator form, the Investigator agrees to: 
1. Conduct the study in accordance with the protocol and only make changes after 
notifying the Sponsor (or designee), except when to protect the safety, rights or 
welfare of subjects. 
2. Personally conduct or supervise the study (or investigation). 
3. Ensure that the requirements relating to obtaining informed consent and IRB review 
and approval meet federal guidelines, as stated in § 21 CFR, parts 50 and 56. 
4. Report to the Sponsor or designee any AEs that occur in the course of the study, in 
accordance with §21 CFR 312.64. 
5. Ensure that all associates, colleagues and employees assisting in the conduct of the 
study are informed about their obligations in meeting the above commitments. 
6. Maintain adequate and accurate records in accordance with §21 CFR 312.62 and to 
make those records available for inspection with the Sponsor (or designee). 
7. Ensure that an IRB that complies with the requirements of §21 CFR part 56 will be 
responsible for initial and continuing review and approval of the clinical study. 
8. Promptly report to the IRB and the Sponsor (or designee) all changes in the research 
activity and all unanticipated problems involving risks to subjects or others (to include 
amendments and IND safety reports). 
9. Seek IRB approval before any changes are made in the research study, except when 
necessary to eliminate hazards to the patients/subjects. 
10. Comply with all other requirements regarding the obligations of clinical investigators 
and all other pertinent requirements listed in § 21 CFR part 312. 

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APPENDIX 1.  STUDY VISIT SCHEDULE 
 
VISIT 1 
Informed Consent 
X 
Demographics 
X 
Non-cycloplegic autorefraction 
X 
Non-cycloplegic pupillometry 
X 
Non-cycloplegic tonometry 
X 
Eye dilation using standard of 
care drops  
X 
Eye dilation using Nanodropper 
X 
Cycloplegic autorefraction 
X 
Cycloplegic pupillometry 
X 
Cycloplegic tonometry 
X 
Adverse Experiences 
X