A Phase I/II Randomized, Placebo-controlled, Double-Blind, Single-Center, Tolerability and Preliminary Efficacy Clinical Trial of Intravenous Immunoglobulin (IVIG) Eye Drops in Patients With Dry Eye Disease
Phase: PHASE1
Conditions: Dry Eye
Sponsor: Sandeep Jain, MD

 
CONFIDENTIAL 
CLINICAL RESEARCH PROTOCOL 
 
 
 
  
 
 
 
 
 
A Phase I/II Randomized Placebo-Controlled, Double-Blind, Single-Center, 
Tolerability and Preliminary Efficacy Clinical Trial of Intravenous Immunoglobulin 
(IVIG) Eye Drops In Patients with Dry Eye Disease 
 
 
 
 
 
Regulatory Sponsor: 
 
Sandeep Jain, MD 
UIC Corneal Neurobiology Laboratory 
Room L239, LIERI 
1905 W Taylor St. 
Chicago, IL 60612 
Phone: 312-996-8936 
Fax: 312-996-7770 
 
Funding Sponsor: 
 
 
Study Product: 
Intravenous Immunoglobulin (IVIG) Eye Drops 
 
Protocol Number: 
2019-0263 
IND Number: 
18834 
 
  Initial version:  
3.0; 04/09/2019 

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Table of Contents 
ABBREVIATIONS .................................................................................................................................................... 7 
STUDY SUMMARY .................................................................................................................................................. 8 
1 
BACKGROUND & RATIONALE ....................................................................................................................... 10 
1.1 
INTRODUCTION ................................................................................................................................................ 10 
1.2 
DRY EYE DISEASE: DEFINITION AND PATHOGENESIS ................................................................................................. 10 
1.3 
DRY EYE DISEASE: PATHOGENESIS – AUTOIMMUNE INFLAMMATION .......................................................................... 11 
1.3.1 
Immunoglobulins are increased in tear fluid of Dry Eye Disease patients: .......................................... 11 
1.3.2 
Immunoglobulins are produced locally by ocular surface cells: ........................................................... 12 
1.3.3 
Autoantibodies are present in tear fluid in ocular surface disease: ..................................................... 13 
1.4 
DRY EYE DISEASE: CLINICAL SIGNS AND SYMPTOMS ................................................................................................ 15 
1.5 
DRY EYE DISEASE: DIAGNOSTIC TESTING ............................................................................................................... 17 
1.6 
DRY EYE DISEASE: CURRENT MANAGEMENT .......................................................................................................... 18 
1.7 
SCIENTIFIC RATIONALE FOR IVIG EYE DROPS IN DRY EYE DISEASE ............................................................................... 18 
1.8 
SPECIFIC AGENT IN THIS STUDY ............................................................................................................................ 22 
1.9 
SAFETY STUDIES ............................................................................................................................................... 23 
1.10 
TISSUE DISTRIBUTION STUDIES ............................................................................................................................ 24 
1.11 
IVIG ANIMAL EFFICACY AND CLINICAL DATA TO DATE ............................................................................................. 25 
1.11.1 
IVIG Animal Efficacy Data .................................................................................................................... 25 
1.11.2 
IVIG Clinical Data to Date .................................................................................................................... 26 
1.12 
DOSE RATIONALE AND RISK/BENEFITS .................................................................................................................. 28 
2 
STUDY OBJECTIVES ....................................................................................................................................... 29 
3 
STUDY DESIGN ............................................................................................................................................. 29 
3.1 
GENERAL DESIGN.............................................................................................................................................. 29 
3.2 
TOLERABILITY END POINT: TEST SUBSTANCE TOLERANCE (VISUAL ANALOGUE SCALE) .................................................... 30 
3.3 
SECONDARY STUDY ENDPOINT ............................................................................................................................ 30 
3.4 
EXPLORATORY STUDY ENDPOINTS ........................................................................................................................ 30 
3.4.1 
Exploratory Efficacy End Point: Ocular surface Lissamine Dye staining score ..................................... 31 
3.4.2 
Exploratory Efficacy End Point: Ocular Surface Disease Index (OSDI) .................................................. 31 
3.4.3 
Exploratory Efficacy End Point: Clinical Global Impression (CGI) ......................................................... 32 
3.4.4 
Exploratory Efficacy End Point: Subject Global Assessment (SGA) ....................................................... 33 
3.4.5 
Exploratory Efficacy End Point: Ocular surface redness score ............................................................. 33 
3.4.6 
Exploratory Efficacy End Point: Keratograph Oculus Redness Score .................................................... 34 
3.4.7 
Exploratory Efficacy End Point: InflammaDry for MMP-9 Protein ....................................................... 35 
3.4.8 
Exploratory Efficacy End Point: Symptom (Ocular Discomfort) Intensity ............................................. 35 
3.5 
SAFETY ENDPOINTS ........................................................................................................................................... 36 
3.5.1 
Vital Signs ............................................................................................................................................ 36 
3.5.2 
Ophthalmic Examination ..................................................................................................................... 36 
3.6 
OTHER STUDY PROCEDURES: OCULAR SURFACE WASHINGS ...................................................................................... 37 
4 
SUBJECT SELECTION AND WITHDRAWAL ...................................................................................................... 37 
4.1 
INCLUSION CRITERIA .......................................................................................................................................... 37 
4.2 
EXCLUSION CRITERIA ......................................................................................................................................... 38 
4.3 
SUBJECT RECRUITMENT AND SCREENING ............................................................................................................... 38 
4.4 
EARLY WITHDRAWAL OF SUBJECTS ....................................................................................................................... 39 
4.4.1 
When and How to Withdraw Subjects ................................................................................................. 39 

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4.4.2 
Data Collection and Follow-up for Withdrawn Subjects ...................................................................... 39 
5 
STUDY DRUG ................................................................................................................................................ 39 
5.1 
DESCRIPTION ................................................................................................................................................... 39 
5.2 
TREATMENT REGIMEN ....................................................................................................................................... 40 
5.3 
METHOD FOR ASSIGNING SUBJECTS TO TREATMENT GROUPS .................................................................................... 40 
5.4 
PREPARATION AND ADMINISTRATION OF STUDY DRUG ............................................................................................ 40 
INSTRUCTIONS FOR DRUG USE: ........................................................................................................................... 41 
5.5 
SUBJECT COMPLIANCE MONITORING .................................................................................................................... 41 
5.6 
PRIOR AND CONCOMITANT THERAPY .................................................................................................................... 41 
5.7 
RESCUE PLAN ................................................................................................................................................... 43 
5.8 
PACKAGING ..................................................................................................................................................... 43 
5.9 
RECEIVING, STORAGE, DISPENSING AND RETURN .................................................................................................... 43 
5.9.1 
Receipt of Drug Supplies ...................................................................................................................... 43 
5.9.2 
Storage ................................................................................................................................................. 43 
5.9.3 
Dispensing of Study Drug ..................................................................................................................... 44 
5.9.4 
Return or Destruction of Study Drug .................................................................................................... 44 
6 
STUDY PROCEDURES .................................................................................................................................... 44 
6.1 
SUBJECT RECRUITMENT AND SCREENING ............................................................................................................... 44 
6.2 
ASSIGNMENT OF SUBJECT IDENTIFICATION ............................................................................................................. 45 
6.3 
SCREEN FAILURE ............................................................................................................................................... 45 
6.4 
SUBJECT ENROLLMENT ....................................................................................................................................... 45 
6.5 
STUDY ASSESSMENTS ........................................................................................................................................ 45 
6.5.1 
Visit 1 Screening ................................................................................................................................... 45 
6.5.2 
Visit 2 Day 1 (Randomization and First treatment visit) ...................................................................... 46 
6.5.3 
Visit 3: Week 4 (± 4 days) ..................................................................................................................... 47 
6.5.4 
Visit 4: Week 8 (± 4 days) ..................................................................................................................... 47 
6.5.5 
Visit 5: Week 10 (± 4 days) ................................................................................................................... 47 
7 
STATISTICAL PLAN ........................................................................................................................................ 48 
7.1 
SAMPLE SIZE DETERMINATION ............................................................................................................................ 48 
7.2 
STATISTICAL METHODS ...................................................................................................................................... 48 
7.3 
SUBJECT POPULATION(S) FOR ANALYSIS ................................................................................................................ 48 
8 
SAFETY AND ADVERSE EVENTS ..................................................................................................................... 49 
8.1 
ADVERSE EVENT DEFINITIONS ............................................................................................................................. 49 
8.2 
CLASSIFICATION OF ADVERSE EVENTS BY SEVERITY .................................................................................................. 50 
8.3 
ACTION(S) TAKEN ............................................................................................................................................. 51 
8.4 
OUTCOME ....................................................................................................................................................... 51 
8.5 
ADVERSE EVENT REPORTING ............................................................................................................................... 51 
8.6 
SERIOUS ADVERSE EVENT REPORTING ................................................................................................................... 51 
8.7 
IN CASE OF AN EMERGENCY ................................................................................................................................ 52 
8.8 
DATA SAFETY MANAGEMENT PLAN ...................................................................................................................... 52 
8.9 
STUDY OVERSIGHT ............................................................................................................................................ 53 
9 
CONFIDENTIALITY ........................................................................................................................................ 53 
10 
SOURCE DOCUMENTS .............................................................................................................................. 53 
10.1 
RECORDS RETENTION ........................................................................................................................................ 54 
11 
ETHICAL CONSIDERATIONS ....................................................................................................................... 54 

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12 
STUDY FINANCES ...................................................................................................................................... 54 
12.1 
FUNDING SOURCE ............................................................................................................................................. 54 
12.2 
CONFLICT OF INTEREST ....................................................................................................................................... 54 
12.3 
SUBJECT STIPENDS OR PAYMENTS ........................................................................................................................ 54 
13 
REFERENCES: ............................................................................................................................................ 56 
 
 
 
 

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SCHEDULE OF VISITS AND PROCEDURES 
 
 
Screening 
Day 1   
(Pre-Dose) 
Day 1  
(Post-Dose) 
Week 4 
Week 8 
Week 10 
Informed consent 
X 
 
 
 
 
 
Demographic information 
X 
 
 
 
 
 
Medical history/ Con Meds 
X 
 
 
 
 
 
Ophthalmic/ Dry Eye history 
X 
 
 
 
 
 
Vital signs 
 
X 
 
X 
X 
X 
Visual Acuity (Snellen’s chart) with eye 
glasses (if applicable) 
 
X 
 
X 
X 
X 
Ocular Surface Disease Index (OSDI) 
X 
X 
 
X 
X 
X 
Clinical Global Impression (CGI) 
 
 
 
X 
X 
X 
Subject Global Assessment (SGA) 
 
 
 
X 
X 
X 
Test Substance Tolerance (VAS) 
 
 
X 
X 
X 
 
Ophthalmic examination (Slit lamp) 
X 
X 
 
X 
X 
X 
Schirmer I test  
X 
X 
 
 
X 
 
Lissamine Dye staining 
X 
X 
 
 
X 
 
Ocular surface Redness (OR) score 
X 
X 
 
X 
X 
X 
Ocular surface wash collection for 
analysis 
 
X 
 
 
X 
 
Keratograph Oculus Redness Score 
 
X 
 
 
X 
 
Non-invasive Keratography Tear Film 
Break-up Time (NIKBUT) 
 
X 
 
 
X 
 
Symptom Intensity Assesment 
 
X 
 
X 
X 
X 
InflammaDry for MMP-9 Protein  
 
X 
 
 
X 
 
Pregnancy test 
X 
 
 
 
 
 
Randomization visit 
 
X 
 
 
 
 
First study medication 
 
X 
 
 
 
 
Drug dispensation visits 
 
 
X 
X 
 
 

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Instruction on study medication self-
administration  
 
 
X 
 
 
 
Adverse Events/ Concomitant Medications 
 
X 
X++ 
X 
X 
X 
*If applicable    ++ AEs only 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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ABBREVIATIONS 
 
AE  
 
Adverse Event 
APC 
 
Antigen-presenting cell 
ACPA 
 
Anti-Citrullinated Protein Antibodies 
BAK 
 
Benzalkonium Chloride 
CNL   
Corneal Neurobiology Laboratory  
CRF   
Case Report Form 
CGI 
 
Clinical Global Impression 
CGA 
 
Clinical Global Assessment 
CONSORT 
Consolidated Standards of Reporting Trials 
DED 
 
Dry Eye Disease 
DREAM 
Dry Eye Evaluation and Management 
DTS 
 
Dysfunctional Tear Syndrome 
EC 
 
Ethics Committee 
EEI 
 
Eye and Ear Infirmary 
FDA   
Food and Drug Administration 
GCP   
Good Clinical Practice 
HIPAA  
Health Insurance Portability and Accountability Act 
ICH  
 
International Conference on Harmonization 
IB  
 
Investigator’s Brochure 
IOP  
 
Intraocular pressure 
IRB  
 
Institutional Review Board 
IgA 
 
Immunoglobulin A 
IgG 
 
Immunoglobulin G 
KCS   
Keratoconjunctivitis sicca 
LFU 
 
Lacrimal Functional Unit 
NET 
 
Neutrophil extracellular trap 
NIKBUT 
Non-invasive Keratograph Tear Film Break-Up Time 
oGVHD 
ocular Graft-vs-Host Disease 
OSD 
 
Ocular Surface Disease 
OSDI   
Ocular Surface Disease Index 
OTC 
 
Over the counter 
BID 
 
Two times per day 
IVIG 
  
Intravenous Immunoglobuline 
SAE   
Serious Adverse Event 
SANDE 
Symptom Assessment in Dry Eye 
SGA 
 
Subject Global Assessment 
SPEED 
Standardized Patient Evaluation of Eye Dryness 
SS 
 
Sjogren Syndrome 
UIC  
 
University of Illinois at Chicago 
VA  
 
Visual Acuity 
VAS 
 
Visual Analog Scale 
VBR 
 
Validated Bulbar Redness 
 
 
 
 
 
 

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CONFIDENTIAL 
Study Summary 
Title 
A Phase I/II Randomized Placebo-Controlled, Double-Blind Single-
Center, tolerability and preliminary efficacy clinical trial of Intravenous 
Immunoglobulin (IVIG) eye drops in patients with Dry Eye Disease 
Short Title 
IVIG-eye drops treatment for Dry Eye Disease 
Protocol Number 
 
Phase 
Phase I/II 
Methodology 
Double-blind 
Study Duration 
10 weeks 
Study Center(s) 
Single-center 
Objectives 
To evaluate the safety and preliminary efficacy of IVIG-eye drops in 
patients with Dry Eye Disease. 
Number of Subjects 
24 (study drug- 12, placebo- 12) 
Diagnosis and Main 
Inclusion Criteria 
Men and women ≥ 18 years of age with a diagnosis of Dry Eye 
Disease, with Schirmer’s test ≥ 0 to ≤ 9 mm/5min, Ocular surface 
staining ≥1 and OSDI mild (≥13), with high ACPA (> 4.4 units) in ocular 
surface wash 
Study Product, 
Dose, Route, 
Regimen 
Study drug: Intravenous Immunoglobulin (IVIG), 4 mg/ml (0.4%) eye 
drops two times a day for eight weeks.  
Control: Normal Saline Eye Drops (0.9% NaCl) 
Duration of 
administration 
8 weeks 
Reference therapy 
Normal Saline eye drops two times a day for eight weeks. 

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Statistical 
Methodology 
Based on the classification of reasons for conducting pilot studies by 
Thabane et al, in this pilot study we will assess (i) Process– recruitment 
rate, retention rate, (non)compliance or adherence rate; and (ii) 
Scientific– safety (adverse event/SAE rate), tolerability, and efficacy, 
including reduction in clinical signs and symptoms (OSDI, Corneal 
staining, Redness etc) and treatment effect size. We will calculate the 
observed rate with 95% confidence interval for each rate by treatment 
group. Other descriptive statistics, including median with interquartile or 
mean with standard deviation for continuous variables and frequency 
with percentage for categorical variables will be reported as well. To 
estimate the preliminary efficacy under the scientific category, one eye 
(target eye) will be selected at screening visit as follows: (i) if only 1 eye 
meets inclusion criteria, this eye is used; (ii) if both eyes meet inclusion 
criteria, the eye with the higher corneal stain score is used; (iii) if both 
eyes have the same corneal stain score, then the one with the lower 
Schirmer I score is used; (iv) if both eyes have same scores, the right 
eye is used. Secondary analyses will be performed for the non-target 
eye as well. Due to the nature of this feasibility study, any efficacy 
statistical tests and adjusted analyses will not be conducted.  Detailed 
data validation will examine completeness, existence and accuracy of 
collected data to assess data quality and identify missing and 
conflicting data. Statistical analysis will be performed on an intention-to-
treat basis i.e., inclusion of patients randomly assigned, regardless of 
adherence, actual treatment received, and subsequent withdrawal of 
treatment and/or deviation from the protocol and per-protocol (i.e., 
inclusion of those who completed the treatment as planned)1 and will 
be reported according to 2010 CONSORT guidelines.2 All statistical 
analyses will be completed using SPSS Statistics V.22.0.31  
 

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1 Background & Rationale 
1.1 Introduction 
 
The sponsor-investigator (Sandeep Jain, MD) is initiating clinical investigations using Intravenous 
Immune Globulin (IVIG) eye drops 0.4% for the treatment of Dry Eye Disease (DED) in patients who 
have demonstrated presence of anti-citrullinated protein antibodies (ACPAs > 4.4 units in ocular 
surface wash) over the ocular surface. IVIG-eye drop is a fractionated plasma product comprising 
Immunoglobulin G (IgG) that offers significant advantages over unlicensed blood-derived eye drops 
(unfractionated serum or plasma eye drops). IVIG is currently an FDA approved product that is 
available from Grifols USA, LLC as Flebogamma 5% DIF immune globulin intravenous (human), 
indicated for treatment of primary (inherited) immunodeficiency (PI) in adults and pediatric patients 2 
years of age and older. Flebogamma 5% DIF will be repurposed as IVIG-eye drops by diluting in 
normal saline to achieve 4mg/ml (0.4%) dose.  
 
We have discovered that citrullinated proteins are present on the ocular surface of patients with DED 
and further discovered that anti-citrullinated protein antibodies (ACPA) are also present in the tear fluid 
of these patients (Figure 3). We also discovered that receptors (Fc-gamma 1) for these IgG 
autoantibodies are expressed on the ocular surface of neutrophils and dendritic cells and found 
evidence of engagement of IgG with Fc-gamma 1 receptors (Figures 6 & 7). Based on these findings, 
we hypothesized that IgG autoantibodies in the tear fluid contribute to ocular surface inflammation via 
interaction with Fc-gamma 1 receptors. In a murine model, we demonstrated that topical application of 
ACPA causes ocular surface disease (Figure 12 A1, A2) and competition with topical IgG abrogates 
surface disease (Figure 12 A3, A4). We also found that a topical application of IVIG-eye drops 
(4mg/ml) to murine eye does not cause ocular surface toxicity (Figure 9). Given these findings, we 
propose a feasibility clinical trial using IVIG eye drops to treat ocular surface disease in patients 
with DED who have high ACPA in the tear fluid. 
 
This document is a protocol for a human research study. This study is to be conducted according to US 
and international standards of Good Clinical Practice (FDA Title 21 part 312 and International 
Conference on Harmonization guidelines), applicable government regulations and Institutional research 
policies and procedures.  
1.2 Dry Eye Disease: Definition and Pathogenesis 
 
Dry eye is a multifactorial disease of the ocular surface characterized by a loss of homeostasis of the 
tear film, and accompanied by ocular symptoms, in which tear film instability and hyperosmolarity, 
ocular surface inflammation and damage, and neurosensory abnormalities play etiological roles.3 DED 
is also recognized as keratoconjunctivitis sicca (KCS), sicca syndrome, keratitis sicca, xerophthalmia, 
dry eye syndrome (DES), dysfunctional tear syndrome (DTS), ocular surface disease (OSD) or dry eye. 
DED is caused by chronic instability of preocular tear film. Tear film instability can be triggered by 
insufficient tear production, or by poor tear film quality that results in increased tear evaporation4, 5. 
Furthermore, dry eye is typically categorized into two groups:  
 
1) Aqueous tear deficient dry eye disease  
2) Evaporative dry eye disease  
 
As DED progresses, lacrimal gland obstruction, meibomian gland orifice obstruction, thickened eyelid 
margins, cloudy, solid, or granular meibum secretion, eyelid telangiectasia, and meibomian gland 

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dysfunction become common clinical features. In advanced cases, dry eye can cause fibrotic thickening 
of the cornea and conjunctiva, filamentous keratitis, mucoid clumping, trichiasis, symblepharon, 
keratinization of the eyelids and meibomian glands, corneal and conjunctival erosion and thinning, 
corneal and conjunctival neovascularization, corneal and conjunctival scarring, corneal ulceration, and 
corneal perforation. In addition, prolonged ocular surface inflammation can lead to moderate or 
absolute loss/atrophy of the meibomian glands, lacrimal glands, and conjunctival goblet cells, and 
subsequently a dramatic reduction in tear film production and the onset of permanent DED6.  
 
DED prevalence increases with age. The most common causes of dry eye are contact lens usage, 
autoimmune disorders, systemic drug effects, and refractive surgeries, particularly in middle-aged and 
older adults. DED also occurs in a higher percentage of women than men, especially in women 
entering menopause or pregnancy; hormone imbalances during menopause or pregnancy can cause 
lacrimal gland and ocular surface inflammation and tear film abnormalities4. 
1.3 Dry Eye Disease: Pathogenesis – Autoimmune Inflammation 
 
DED is a result of changes to the lacrimal functional unit (LFU). The LFU is composed of the lacrimal 
glands, cornea, eyelids, meibomian glands, conjunctiva, goblet cells, and ocular nerves. The LFU is 
responsible for the sustained production of adequate tear film to consistently lubricate the ocular 
surface. Structural changes to the LFU can induce tear film instability and insufficiency, which in turn 
can lead to tear hyperosmolarity. Chronic osmotic stress from tear film can activate stress associated 
pathways in ocular surface epithelial cells, thereby triggering a pro-inflammatory response that involves 
a mix of chemokines, cytokines, and matrix metalloproteinases. The subsequent maturation of antigen-
presenting cells (APC’s) on the ocular surface leads to the migration, activation, and expansion of 
autoreactive T cell lymphocytes as well as other leukocytic classes in the LFU. The constant 
recruitment of pro-inflammatory leukocytes onto the ocular surface inflicts epithelium damage in the 
form of small abrasions and epithelium barrier defects7, 8. These abrasions can eventually progress to 
superficial punctuate keratitis, squamous metaplasia, extracellular matrix deposits, decreased goblet 
cell differentiation, increased epithelial cell turnover (epitheliopathy), and significant ocular surface 
nerve damage and neuropathy.  
1.3.1 Immunoglobulins are increased in tear fluid of Dry Eye Disease patients:  
 
Immunoglobulins are a principal tear proteins that are directly secreted by lacrimal glands along with 
lactotransferrin, epidermal growth factor (EGF) and tear lipocalin.9 Some tear proteins are derived from 
serum, such as albumin, transferrin, IgG and IgM probably as a result of leakage from the blood 
vessels. It is also known that cell infiltrating conjunctiva (plasma cells) secrete immunoglobulins and 
cytokines in various conditions. There is general agreement that IgA is the pre-dominant tear 
immunoglobulin.10 IgA concentration in tears varies between 0.14 mg/ml – 0.40 mg/ml. IgG 
concentration in tears collected from the ocular surface is much less than IgA, reported as 0.02 mg/ml 
or undetectable, 11 although tears extracted from Schirmer strips have higher IgG amounts (0.23 
mg/ml).12 Therefore the IgA/IgG ratio in normal tears is >1.0. Our clinical data shows that patients 
with DED have abundant amounts of immunoglobulins in the tear fluid and the predominant 
immunoglobulin is IgG (Figure 1). 
 
 

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Figure 1: Total immunoglobulin amount in tear fluid of DED patients. We determined whether 
immunoglobulins were increased in tear fluids of DED patients. We performed ocular surface washings 
in healthy subjects (n=36 eyes) and patients with DED due to Sjogren’s syndrome (n=41 eyes). Ocular 
surface washings were performed and analyzed for human immunoglobulin total amount and isotype 
distribution using Human Immunoglobulin Isotyping MILLIPLEX MAP kit (Cat. No. HGAMMAG-301K, 
EMD Millipore, Billerica, MA). A. The amount of immunoglobulins in Sjogren’s syndrome patients 
(26,389.2±8,090.4 ng/mL; p<0.05) was significantly higher as compared to healthy subjects 
(130.0±26.7 ng/mL), which represents more than 200 fold higher amount.  B. The immunoglobulin 
isotype distribution was different in Sjogren’s syndrome patients as compared to healthy subjects. In 
Sjogren’s syndrome IgG was the dominant immunoglobulin comprising 92% of immunoglobulins. In 
healthy subjects IgA (42%) and IgG (43%) were the dominant immunoglobulins. Taken together, 
these experiments showed that patients with DED due to Sjogren’s syndrome have abundant 
amounts of IgG in the tear fluid.  
1.3.2 Immunoglobulins are produced locally by ocular surface cells:  
 
The human conjunctiva and lacrimal drainage system have an associated lymphoid tissue that is 
capable of detecting antigens and inducing a complete immune response by the activation of lymphatic 
cells and the production of antibodies.13 Antibodies in tears are not just the filtration product from the 
blood vessels, but are secreted by the immune tissue of the lacrimal system itself. In fact, in a quest for 
a needle-free vaccine administration strategy, ocular conjunctiva has been evaluated as an alternative 
mucosal immunization route. Conjunctival immunization with tetanus toxoid (TTd) induced TTd-specific 
local and systemic immune responses.14 Topical conjunctival application of ovalbumin also produces 
IgG antibodies in the tears.15  Our clinical data shows the presence of T cells and B cells in close 
proximity amongst ocular surface cells (Figure 2A), suggesting active immune processing. Our data 
also shows the presence of IgG containing Plasma cells on the ocular surface (Figure 2B), suggesting 
antibody production and secretion by Plasma cells. Taken together, our data shows that all cellular 
players that are needed for inducing an immune response are present on the surface of the eye. 
 
 

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Figure 2: Immunofluorescence staining of Plasma cells and Immunoglobulins (IgG) in 
conjunctival impression cytology specimen obtained from patient with DED due to Sjogren’s 
Syndrome. Conjunctival impression cytology was performed on Sjogren’s Syndrome patients to 
determine whether the cellular components necessary for immune response are present on the ocular 
surface. These cells include antigen processing B cells (CD19 positive), T-helper cells (CD4 positive) 
and immunoglobulin secreting Plasma cells (CD138). Impression filter papers were processed for 
immunofluorescence staining with anti-CD4 antibody (mouse monoclonal anti CD4 antibody; R&D 
Systems, #MAB379, 1:50), anti-CD19 antibody (rabbit monoclonal anti CD19 antibody; Abcam, 
#ab134114, 1:20), anti-CD138 antibody (mouse monoclonal anti CD138 antibody; Bio-Rad, 
MCA2459GA, 1:500), and anti-IgG antibody (rabbit monoclonal anti human IgG antibody; Abcam, 
#ab109489, 1:500) and confocal immunofluorescence microscopy was performed to localize the 
proteins. Figure 2A2 shows the T-helper cells (red) and figure 2A3 shows the B cells (green). The T 
cells and B cells are in close proximity (inset box in 2A4), suggesting active immune 
processing. Figure 2B2 shows the presence of Plasma cells (red) and figure 2B3 shows the presence 
of IgG (green). Plasma cell and IgG co-localize (figure 2B4), suggesting that there may be 
antibody production and secretion by Plasma cells on the ocular surface of the patients with 
DED due to Sjogren’s Syndrome.   
1.3.3 Autoantibodies are present in tear fluid in ocular surface disease:  
 
Autoantibodies have been detected in tears of patients in the context of ocular diseases. Anti-HSV IgG 
is present in tear fluid of patients with HSV keratitis and the presence of anti-HSV IgG in tears is 
significantly associated with decreased corneal sensation, presence of stromal opacities, and with 
neurotrophic keratitis.16 In Chlamydia trachomatis, the leading global cause of preventable blindness, 
significantly higher anti-chlamydial protein IgG levels are found in the tear fluid of inflammatory 
trachoma cases as compared with levels in the controls.17 Several autoantibodies (anti-SS-A, anti-SS-
B, and anti-DNase I) are present in tear fluid of Sjogren syndrome (SS) patients. These autoantibodies 
(anti-SS-A and anti-SS-B) are present in tears even though they are not detectable in the serum of 
Sjögren’s syndrome patients, suggesting that anti-SS-A or anti-SS-B IgG synthesis may occur within 
lacrimal glands/ocular surface tissues.18 Our clinical data shows the presence of citrullinated 
proteins over the ocular surface and the presence of anti-citrullinated protein antibodies 

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(ACPAs) in the tear fluid of several DED subtypes (Figure 3). We are the first to discover the 
presence of ACPAs in tear fluid of DED patients.  
 
 
 
Figure 3:  Presence of anti-citrullinated protein autoantibodies (ACPAs) in tear fluid of patients 
with DED. We determined the amount of ACPAs in the tear fluid of patients with DED and healthy 
subjects. Ocular surface washings were performed and analyzed for the presence and amount of 
ACPA using a semi-quantitative enzyme-linked immunosorbent assay (Quanta Lite CCP 3.1, Inova 
Diagnostics, San Diego, CA). Based on a 98th percentile value of ACPA amount in healthy subjects, 
we determined 4.4 units of ACPA to be the cutoff threshold above which values were considered 
positive for the presence of ACPA in tear fluid. We calculated the ACPA amount (units, median) in tear 
fluid of eyes that were positive for ACPA (i.e. ACPA > 4.4 units) and further calculated the percent of 
eyes that were ACPA positive (i.e. ACPA > 4.4 units) for each DED subtype. ACPAs were present in 
the tear fluid of many DED subtypes such as: (i) Sjogren’s syndrome (13.8 units median in 40.9% of 54 
eyes); (ii) tear deficient non-Sjogren’s DED (13.0 units median in 47.8% of 54 eyes); (iii) meibomian 
gland dysfunction (MGD) (13.1 units median in 31.1% of 33 eyes); (iv) ocular rosacea (9.2 units median 

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in 39.3% of 11 eyes); (v) symptom sign disconnect (27.5 units median in 50.0% of 20 eyes); (vi) mixed 
mechanism (26.7 units median in 31.3% of 15 eyes); (vii) Superior limbic keratoconjunctivitis (SLK) 
(12.4 units median in 43.3% of 29 eyes); (viii) neurotrophic cornea (35.7 units median in 50% of 14 
eyes); (ix) ocular cicatricial pemphigoid (OCP) (10.4 units median in 55.6% of 10 eyes); (x) Steven 
Johnson syndrome (50.6 units median in 27.3% of 3 eyes); (xi) none oGVHD (10.8 units median in 16% 
of 20 eyes) and (xii) definite oGVHD (13.7 units median in 15.3% of 21 eyes). Taken together, these 
data show that several DED subtypes have presence of ACPA in the tear fluid.  
 
 
Figure 4: Presence of non-ACPA autoantibodies in DED due to Sjogren’s syndrome. We 
determined whether autoantibodies other than ACPAs were also present in tear fluid of patients with 
Sjogren’s syndrome. We performed ocular surface washings in healthy subjects (n=14 eyes) and 
patients with DED due to Sjogren’s syndrome (n=27 eyes). Ocular surface washings were analyzed for 
the presence of non-ACPA autoantibodies using Human Autoimmune Autoantibody MILLIPLEX MAP 
kit (Cat. No. HAIAB-10K, EMD Millipore, Billerica, MA). Several autoantibodies were detected: (i) 
SSA/RO60 (260 folds higher amount than healthy); (ii) SSA/RO52 (178 folds higher amount than 
healthy); (iii) SSB/LA (54 folds higher amount than healthy); (iv) CENP-A (147 folds higher amount than 
healthy) and (v) CENP-B (173 folds higher amount than healthy). This data shows that several 
autoantibodies were present in the tear fluid of Sjogren’s syndrome patients. 
1.4 Dry Eye Disease: Clinical Signs and Symptoms  
 
Common signs and symptoms of DED include: eye redness, ocular pain, burning and stinging 
sensation, foreign body sensation, pruritus, itchy or scratchy eye sensation, tired eyes, enhanced eye 
pressure, photophobia, painful mucous discharge, and in some cases epiphora. DED typically affects 
eyes bilaterally. Dry eye can heavily impact visual function especially during visually intensive activities 
and can overall decrease quality of life.4, 6 Our clinical data shows that patients who have ACPAs in 
the tear fluid have more severe signs of DED (Table 1). 

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Table 1: Comparison of clinical signs and symptoms of DED in patients who have presence of 
anti-citrullinated antibodies in tear fluid (ACPA+) or serum (CCP+) with those who do not have 
these antibodies in tear fluid (ACPA-) or serum (CCP-). It is known that rheumatoid arthritis patients 
who have ACPA antibodies in serum have more severe joint disease, therefore we determined whether 
patients who have presence of ACPA in tear fluid similarly have more severe ocular surface disease. 
The presence of ACPA in tear fluid of DED patients (n=322 eyes) was determined using a semi-
quantitative enzyme-linked immunosorbent assay (Quanta Lite CCP 3.1, Inova Diagnostics, San Diego, 
CA). Patients who had tear fluid ACPA>4.4 units were considered positive (ACPA+). The presence of 
ACPA in serum was determined by processing performed in clinical laboratory. Patients who had serum 
ACPA>20 units were considered positive (CCP+). Based on whether patients were ACPA+, ACPA-, 
CCP+ and CCP- patients were divided into 3 groups:  (i) ACPA+/CCP+ (n=28 eyes). These patients 
had ACPAs in tear fluid as well as serum; (ii) ACPA+/CCP- (n=145 eyes). These patients had ACPAs in 
tear fluid but not in serum; and (iii) ACPA-/CCP- (n=149 eyes). These patients did not have ACPA in 
tear fluid as well as in serum. Patients with ACPA+/CCP+ had the highest levels of ACPA in tear fluid 
as well as in serum compared to other groups. Eyes in ACPA+/CCP+ group had more severe signs and 
symptoms of DED as compared to other groups. These eyes had more severe tear deficiency 
(Schirmer I) and more severe ocular surface disease (corneal staining and conjunctival staining). These 
eyes also had more corneal complications (ulcers, melts or scars). Taken together, these data show 
that patients who have ACPAs in the tear fluid have more severe signs of DED.  
 
-- 

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Figure 5. Photographs of eyes of Sjogrens syndrome patients with DED and high ACPA levels in 
tear fluid showing severe corneal disease. (A) 76 year old female with Sjogrens syndrome showing 
a corneal perforation. Serum ACPA level was high (137 units) and tear ACPA levels were also very 
high (145.9 units) in the eye with perforation. In the fellow eye, the ACPA levels were lower (55.8 units). 
(B) A 38 year old female with Sjogrens syndrome showing a corneal scar following sterile ulceration. 
Serum ACPA level was high (216 units) and tear ACPA levels in both eyes were also very high (121.8 
units in the right eye and 142.6 units in the left eye). (C) A 50 year old female with Sjogrens syndrome 
showing a corneal melt resulting in a corneal divot. Serum ACPA level was high (117 units) and tear 
ACPA levels in both eyes were also very high. (D) A 64 year old female with Sjogrens syndrome 
showing severe ocular surface disease as evidenced by extensive lissamine green punctate staining of 
corneal epitheliopathy. Serum ACPA level was high (160 units) and tear ACPA levels in both eyes were 
also very high (153.6 units in both eyes. Taken together, these four cases demonstrate that very 
high levels of ACPA in tear fluid is associated with severe ocular surface disease.  
1.5 Dry Eye Disease: Diagnostic Testing 
 
Clinicians use several diagnostic tests to diagnose DED and to assess disease severity. These tests 
fall into two groups: signs (objective) and symptoms (subjective). For DED signs, there are several 
quantitative tests, including: Schirmer Test, Schirmer I Test, Schirmer II test, tear film breakup time 
(TBUT), non-invasive tear film breakup time (NITBUT) epithelial staining scores (rose bengal, lissamine 
green, fluorescein) via slit-lamp examination, tear function index (TFI), tear fluid protein immunoassays, 
fluorophotometry, meibography, meibometry, meiboscopy, meniscometry, lacrimal gland biopsy, 
impression cytology, hypolysozyme measurement, hyperosmolarity measurement, and lipid layer 
analysis, ocular redness scoring, automated blink analysis, and meniscus evaluation utilizing Lipiview 
II, Keratograph 5M, or OCT equipment.4  

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Symptom measurements utilizing physician and/or patient disease scoring include: extensive 
dry eye questionnaire (DEQ), visual analog scale (VAS), ocular surface disease index (OSDI), national 
eye institute visual function questionnaire (NEI-VFQ-25), symptom assessment in dry eye questionnaire 
(SANDE), and standardized patient evaluation of eye dryness questionnaire (SPEED).19, 20 
 
Many of the above tests have been used in recent DED studies. In this feasibility study, there 
will be multiple exploratory endpoints based on conventional dry eye assessments, subjective 
and objective (section 2.4). Based on the results of this study, we will decide which sign and/or 
symptom to be used as the primary (or co-primary) endpoint(s) in later stage studies. 
1.6 Dry Eye Disease: Current Management  
 
Typically, clinicians prescribe artificial tear eyedrops and topical corticosteroids for short-term relief of 
DED. Antibiotics (tetracyclines and macrolides), non-steroidal anti-inflammatory agents, autologous 
serum drops, omega fatty acids, mucin secretagogues, and anti-inflammatory agents are also used to 
combat DED symptoms. In addition, prosthetic scleral lenses (i.e. PROSE) that also serve as 
supplemental tear reservoirs are increasingly being prescribed to enhance ocular surface hydration in 
patients with chronic DED. Hot eyelid compresses are often utilized to treat meibomian gland 
dysfunction, a primary driver of evaporative dry eye disease. In advanced cases of DED, punctual plugs 
can be installed to block tear drainage. In severe cases of dry eye, tarsorrhaphy surgery, tear duct 
cauterization, or amniotic membrane transplant might be required to reduce tear evaporation.4, 21 
Currently there are only two pharmaceutical agents that are FDA approved for the treatment of 
dry eye: cylcosporine an ophthalmic emulsion (Restasis®) and lifitegrast ophthalmic solution (Xiidra™). 
Restasis® 0.05% is a topical immunomodulator indicated to increase tear production in patients whose 
tear production is presumed to be suppressed due to ocular inflammation associated with 
keratoconjunctivitis sicca (Restasis® Prescribing Information). Xiidra™ 5% is a lymphocyte function-
associated antigen (LFA-1) antagonist indicated for the treatment of signs and symptoms of dry eye 
disease (Xiidra™ Prescribing Information). Given the complexity, severity, and frequency of DED, and 
given the limited modes of action by which these two compounds treat dry eyes, there is a medical 
need for other dry eye therapies, particularly those with multiple modes of action that target the wider 
dry eye population and are effective and safe for long-term daily use. 
1.7 Scientific Rationale for IVIG eye drops in Dry Eye Disease 
 
There is considerable scientific rationale to establish a medically plausible basis for the use of IVIG eye 
drops for the treatment of DED. It is well established that autoimmune processes underpin ocular 
surface inflammation in DED. For example, B cell over-activation is a key feature of Sjogren’s 
syndrome (a major cause of DED), attested by the wide spectrum of autoantibodies detected in these 
patients (e.g. antinuclear antibodies, anti-Ro/SSA, anti-La/SSB, rheumatoid factor).22 We, and others, 
have shown that autoantibodies are present in the tears of DED patients (Figures 3 & 4) that may 
contribute to ocular surface disease and inflammation (Table 1). IVIG has an immunomodulatory 
activity that is based on the modulation of biological processes that are implicated in innate or acquired 
immunity, therefore it has the potential to reduce autoimmune-mediated inflammation in DED.  
 
To date, IVIG has not been applied to the ocular surface as eye drops. However, IVIG has been 
administered by the intravenous route to treat ocular surface diseases like ocular cicatricial pemphigoid 
(OCP) and several intraocular inflammatory diseases like birdshot retinochoroidopathy.23-25 Our data 
shows that the levels of IgG in the tear fluid increase approximately 3 folds after intravenous 
administration of IVIG to treat OCP (Figure 13). We posit that topical application of IVIG-eye drops will 
achieve significantly higher levels of IgG over the ocular surface as compared to intravenous 

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administration without any of the side effects associated with systemic administration of IVIG, without 
need for hospitalization for administration of the drug and at a fraction of the cost of IVIG.  
 
We have shown in conjunctival impression cytology data that the receptors for autoantibodies (Fc 
gamma 1 receptor) are present on the cells (dendritic cells and neutrophils) in the superficial layers of 
the ocular surface, therefore these receptors are accessible to IVIG eye drops for exerting a therapeutic 
action (Figures 6 & 7).  Pooled normal polyspecific human IgG (IVIG) contain antiidiotypic antibodies 
against human autoantibodies may provide a mechanism for the suppressive effect of IVIG in human 
autoimmune diseases. Whereas pooled IgG from a high number of normal individuals express 
antiidiotypic antibodies directed against autoantibodies, antiidiotypic antibodies are rarely found in IgG 
prepared from individual normal donors.26, 27 This implies IVIG eye drops will have anti-idiotypic 
antibodies but serum tear eye drops will not have antiidiotypic antibodies. 
 
IVIG preparation contain pooled polyspecific IgG. Therefore, IVIG eye drops will increase the amount of 
IgG on the ocular surface.  This is no different that applying serum tear eye drops to the ocular surface 
as serum contains IgG (approximately 10 mg/ml). In fact, applying IVIG eye drops 0.4% places 4 mg/ml 
IgG on the ocular surface, which is the identical amount of IgG placed on the ocular surface when using 
50% serum tear eye drops. 50% serum tear eye drops have been used to treat a variety of ocular 
surface diseases and their use is widely accepted as a useful therapeutic strategy for severe ocular 
surface disease. Although autologous serum tears are more commonly used, there are several reports 
of use of allogeneic serum tears as well. We posit that use of IVIG 4 mg/ml will pose no more safety 
risk than that with use of 50% allogeneic serum tears that are already in clinical use.  
 
The immunomodulatory biological effects of IVIG that may reduce the deleterious effects of 
autoantibodies in tear fluid include: 
 
A. Functional Blockade of Fc Receptors. We have performed impression cytology of ocular surface in 
DED patients and found Fc receptor expressing neutrophils and mononuclear cells amongst ocular 
surface cells (Figure 6). We also found that IgG interacts with Fc gamma receptors that are expressed 
on neutrophils and dendritic cells on the ocular surface in DED patients (Figure 7). These IgG are likely 
to be autoantibodies.  Blockade of Fc receptors by IgG in IVIG-eye drops may reduce the interaction of 
autoantibodies with Fc receptors, thus reducing the deleterious effects of autoantibodies on the ocular 
surface. 
 
 

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Figure 6: Immunofluorescence staining of Fc gamma 1 receptors and ocular surface cells in 
conjunctival impression cytology specimen obtained from patient with DED due to Sjogren’s 
Syndrome. Since immunoglobulins (monomeric IgG or immune complexed IgG) bind to Fc gamma 1 
receptors to propagate the immune response, the presence of Fc gamma receptors on ocular surface 
cells is a prerequisite for induction of an immune response. Therefore, we performed conjunctival 
impression cytology on Sjogren’s Syndrome patients to determine whether Fc gamma 1 receptors 
(CD64 positive) are present on conjunctival epithelial cells (K14 positive) and bone marrow derived 
dendritic cells (CD11c positive) or neutrophils (neutrophils elastase positive) that are also present on 
the ocular surface. Impression filter papers were processed for immunofluorescence staining with anti-
CD64 antibody (mouse monoclonal anti-CD64 antibody; Santa Cruz, #sc-1184, 1:500), anti-K14 
antibody (rabbit polyclonal anti-cytokeratin 14 antibody; BioLegend, #905301, 1:1000), anti-CD11c 
antibody (rabbit monoclonal anti CD11c antibody; Abcam, #ab52632, 1:500), and anti-neutrophil 
elastase antibody (rabbit polyclonal anti neutrophil elastase antibody; Abcam, #ab21595, 1:500). Figure 
6A2 shows expression of Fc gamma receptors (red) and figure 6A3 shows conjunctival epithelial cells 
(green). Figure 6A4 shows that Fc receptors and conjunctival epithelial cells do not co-localize. 
Therefore, Fc gamma receptors are expressed on non-epithelial cells of the ocular surface. Figure 6B2 
shows expression of Fc gamma receptors (red) and figure 6B3 shows dendritic cells (green). Figure 
6B4 shows co-localization of Fc gamma receptors on dendritic cells. Therefore, Fc gamma receptors 
are expressed on bone-marrow derived dendritic cells. Figure 6C2 shows expression of Fc gamma 
receptors (red) and figure 6C3 shows neutrophils (green). Figure 6C4 shows co-localization of Fc 
gamma receptors on neutrophils. Since neutrophils express Fc gamma receptors only when activated, 
expression of these receptors on neutrophils on the ocular surface suggests that these neutrophils are 
in an activated state. Taken together, figure 6 data shows that Fc gamma receptors (effectors for 

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immunoglobulin induced immune reaction) are not expressed on conjunctival epithelial cells 
but are expressed on bone-marrow derived dendritic cells and neutrophils present on the ocular 
surface.  
 
 
Figure 
7: 
Immunofluorescence 
staining 
to 
demonstrate 
the 
interaction 
between 
immunoglobulins (IgG) and Fc gamma 1 receptors on ocular surface cells in conjunctival 
impression cytology specimen obtained from patient with DED due to Sjogren’s Syndrome. 
Since immunoglobulins bind to Fc gamma 1 receptors to propagate the immune response, the binding 
of IgG to Fc gamma receptors on ocular surface cells is a prerequisite for induction of an immune 
response. Therefore, we performed conjunctival impression cytology on Sjogren’s Syndrome patients to 
determine whether IgG and Fc gamma 1 receptors (CD64 positive) co-localize and to determine which 
ocular surface cells bind to IgG. Impression filter papers were processed for immunofluorescence 
staining with anti-CD64 antibody (mouse monoclonal anti-CD64 antibody; Santa Cruz, #sc-1184, 
1:500),anti-neutrophil elastase antibody (mouse monoclonal anti-neutrophil elastase antibody; Santa 
Cruz, #sc-53388, 1:500), anti-CD11c antibody (mouse monoclonal anti CD11c antibody; BD 
biosciences, #565805, 1:100) and anti-IgG antibody (rabbit monoclonal anti human IgG antibody; 
Abcam, #ab109489, 1:500) and confocal immunofluorescence microscopy was performed to localize 
the proteins. Figure 7A2 shows expression of Fc gamma receptors (red) and figure 7A3 shows IgG 
presence (green). Figure 7A4 shows that IgG co-localizes with Fc gamma 1 receptors, suggesting IgG-
Fc gamma receptor interaction. Figure 7B2 shows presence of neutrophils (neutrophil elastase positive, 
red) and figure 7B4 shows these neutrophils co-localize with IgG. Figure 7C2 shows presence of bone-
marrow derived dendritic cells (CD11c positive, red) and figure 7C4 shows these dendritic cells co-

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localize with IgG. Taken together, figure 7 data shows that IgG interacts with Fc gamma receptors 
that are expressed on neutrophils and dendritic cells that are present on the ocular surface in 
DED patients in Sjogren’s Syndrome.  
B. Autoantibody Neutralization and Inhibition of Autoantibody Production. IVIG preparations contain 
anti-idiotypic antibodies, i.e., antibodies that are able to interact specifically with the variable region 
(antigen recognition site) of autoantibodies. This interaction has the potential to neutralize an 
autoantibody and to hamper its production via binding to auto reactive B lymphocytes. Such a 
neutralizing or inhibitory activity has been shown, amongst others, for autoantibodies directed against 
factor VIII, DNA, intrinsic factor, thyroglobulin and anti-neutrophil cytoplasmic antibodies (ANCA). We 
have found the presence of anti-citrullinated protein antibodies (ACPAs) in the tear fluid of DED 
patients (Figure 3). Anti-idiotypic antibodies in IVIG-eye drops may neutralize ACPAs in the tear fluid of 
DED patients to reduce ACPA-induced ocular surface disease. 
 
C. Other Mechanisms: (i). Complement Inhibition. The Fc portion of IVIG can bind the C3b and C4b 
fragments of complement, and thereby inhibit their tissue deposition as well as the generation of the C5 
convertase (C4b2a3b), hampering the subsequent formation of the membrane attack complex. This 
cascade of events has been shown to occur in dermatomyositis and thereby contributes to the 
therapeutic effect of IVIG in that disease. (ii). Modulation of Cytokine and Cytokine Antagonist 
Production. IVIG may significantly modulate the production of several cytokines (including IL-1,-2,-3,-4,-
5,-10, TNF-alpha, and GM-CSF) and cytokine antagonists (IL-1 receptor antagonist) by monocyte-
macrophages and lymphocytes. (iii). Modulation of Dendritic Cell Properties. Recent work suggests that 
IVIG also affects the differentiation, maturation and functional status of dendritic cells (DCs). DCs 
appear to be a primary target for the immunosuppressive effects of IVIG on T-cell activation. (iv). 
Signaling through the Inhibitory Fc Receptor, Fcgamma RIIB. (v). Expansion of regulatory T cells and 
reciprocal inhibition of Th17 cells. 
1.8 Specific Agent in this Study 
 
The primary agent used in this study is a commercial Intravenous immunoglobulins (IVIG) formulation 
(Flebogamma DIF 5%) that will be diluted in 0.9% saline to achieve 4 mg/ml (0.4%) IgG concentration, 
and dispensed as eye drops. Intravenous immunoglobulins (IVIG) are a therapeutic preparation of 
pooled normal human IgGs obtained from large numbers of healthy donors. 
 
Flebogamma DIF 5% IVIG is an FDA-approved product available as 50 mg/ml an immune globulin 
intravenous (human) solution indicated in adults and pediatric patients 2 years of age and older for the 
treatment of primary immunodeficiency (PI), including the humoral immune defects in common variable 
immunodeficiency, x-linked agammaglobulinemia, severe combined immunodeficiency, and Wiskott-
Aldrich syndrome. It is stable at room temperature for more than two years.  
 
Flebogamma 5% DIF contains 5 g human normal immunoglobulin and 5 g D-sorbitol (as stabilizer) in 
100 mL of water for injection, and ≤ 3 mg/mL polyethylene glycol. There is no preservative in the 
formulation. The pH of the solution ranges from 5 to 6 and the osmolality from 240 to 370 mOsm/L, 
which is within the normal physiological range. 
 
From a safety perspective, IVIG eye drops would most closely resemble allogeneic unfractionated 
blood eye drops (serum or plasma). From an efficacy perspective, IVIG eye drops have the potential to 
significantly improve outcomes of autoimmune and inflammatory ocular surface disease, given the long 
shelf life at room temperature making storage & dispensing by pharmacies possible. 
 

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IgG at 4 mg/ml (0.4%) concentration (in the form of serum/plasma 50% eye drops) is routinely used to 
treat ocular surface diseases, however widespread use is limited because of short shelf life and limited 
number of blood processing compounding pharmacies. We propose to use IgG at a similar 4 mg/ml 
(0.4%) concentration (in the form of IVIG eye drops) to treat ocular surface diseases as this strategy 
offers significant advantages, chief amongst which is a long shelf life at room temperature that makes 
widespread dispensing possible. 
1.9 Safety Studies 
 
We have performed in vitro studies using cultured human epithelial corneal cells to determine whether 
IVIG (4 mg/ml) causes cytotoxicity. Our data shows that IVIG 4 mg/mL does not induce cytotoxicity in 
cultured corneal epithelial cells (Figure 8).  
 
We have performed in vivo studies to determine whether IVIG-eye drop (4 mg/mL) causes ocular 
surface toxicity when applied to murine corneas. Our data shows that there was no difference in 
corneal fluorescein staining between IVIG group and the control group. This suggests that topical 
application of IVIG eye drop (4 mg/mL) does not cause ocular surface toxicity (Figure 9). 
 
 
Figure 8: Wound scratch assay and LDH cytotoxicity assay in cultured human corneal epithelial 
cells (primary and immortalized). These experiments were performed to determine whether IVIG 
causes cytotoxicity in cultured human corneal epithelial cells. Human corneal epithelial cells were 
cultured under normal (serum) or stressed (serum free) conditions with or without incubation with IVIG 
(4 mg/mL or 10 mg/mL) in IncuCyte® S3 Live Cell Analysis System (Essen Biosciences). IVIG toxicity 
was assessed using the LDH assay kit from Thermo Scientific according to the manufacturer’s 
specification. (A1-A6): Representative IncuCyte images after 69 hours of incubation show that scratch 
wounds in primary human corneal epithelial cells close similarly with or without IVIG. (A7) LDH 
cytotoxicity assay shows absence of cytotoxicity with 4 mg/mL IVIG but significant cytotoxicity with 8 
mg/mL IVIG. Representative IncuCyte images after 12 hours of incubation show that scratch wounds in 
immortalized human corneal epithelial cells close similarly with or without IVIG under normal condition 
(B1-B6) as well as under stressed condition (C1-C6). LDH cytotoxicity assay shows absence of 

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cytotoxicity with 4 mg/mL IVIG but significant cytotoxicity with 10 mg/mL IVIG under both normal (B7) 
and stressed (C7) cultured conditions. Taken together, these experiments show that IVIG 4 mg/mL 
does not induce cytotoxicity in cultured corneal epithelial cells.   
 
 
Figure 9: In vivo toxicology study of IVIG application in murine corneas. These experiments were 
performed to determine whether IVIG-eye drop (4 mg/mL) causes ocular surface toxicity when applied 
to murine corneas. IVIG (10 uL of 4 mg/mL solution) or Refresh Optive (control) was applied once a day 
to the mouse corneas (n=8/group) for 28 consecutive days. After each application, the mice were 
restrained for 1 minute to allow for adequate contact time of eye drop with the eye. Fluorescein staining 
was performed at base line and at weekly intervals thereafter. (A1-A8) Representative mouse cornea 
images showing fluorescein staining after incubation with Refresh Optive (control group, A1-A4) and 
IVIG (experimental group, A5-A8). (A9) Graph showing the quantitative data for the fluorescein staining 
at Day 0, 7, 14, 21 and 28. There was no difference in fluorescein staining between IVIG group 
and the control group. This suggests that topical application of IVIG eye drop (4 mg/mL) does 
not cause ocular surface toxicity. 
1.10 Tissue Distribution Studies 
 
We were unable to detect increased IgG levels in ocular tissues or serum after applying IVIG as eye 
drops in non-inflamed and inflamed murine eye. The poor penetration of IVIG eye drops in ocular 
tissues may actually be desirable because it further improve its safety profile for use in DED because 
DED is rarely associated with intraocular inflammation, therefore intraocular penetration of drug is not 
needed to treat DED. 
 
 

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Figure 10: Tissue distribution study of IVIG application in naïve and inflamed murine corneas. 
This experiment was performed to determine whether IVIG eye drops applied topically penetrate ocular 
tissues (cornea, conjunctiva, retina and lacrimal gland) in a naïve (A1-A5) or inflamed (B1-B5) eye. 
Experiment 1 (Naïve eyes): Refresh Optive + IVIG (4 mg/mL) were applied to murine corneas 
(n=6/group) once a day for six consecutive days. Control eyes received Refresh Optive only. 
Experiment 2 (Inflamed eyes): Benzalkonium chloride (BAK, 0.1%) + IVIG (4 mg/mL) were applied to 
the murine corneas (n=6/group) once a day for six consecutive days. Control eyes received BAK 
(0.1%) only. In both experiments, after each application, the mice were restrained for 1 minute to allow 
for adequate contact time of eye drop with the eye. After 6 days, the samples (cornea, conjunctiva, 
retina, extraorbital lacrimal gland and serum) were collected, normalized to protein amount, and 
processed for Luminex detection of Human IgG (name of the panel). (A1-A5): Graphs show human 
immunoglobulin isotypes collected from tissues in experiment 1 (naïve eyes). (B1-B5): Graphs show 
human immunoglobulin isotypes collected from tissues in experiment 2 (inflamed eyes). No tissue or 
serum showed a significant increase or decrease in human IgG amount. Taken together, these 
experiments show that topical application of IVIG does not reach intraocular tissues or serum.  
1.11 IVIG Animal Efficacy and Clinical Data to Date 
1.11.1 IVIG Animal Efficacy Data 
 
 
 
Figure 11: In vivo efficacy study of IVIG-eye drop to treat corneal inflammation induced by 
Benzalkonium chloride (BAK).  These experiments were performed to determine whether IVIG-eye 
drop (4 mg/mL) reduces ocular surface inflammation in murine corneas. In the control groups, IVIG (4 
mg/mL) only or BAK (0.1%) only were applied to murine corneas (n=6/group) once a day for 6 
consecutive days to induce corneal inflammation. In the experimental group, BAK (0.1%) and IVIG (4 
mg/mL) were applied to the murine corneas (n=6) once a day for 6 consecutive days. After each 
application, the mice were restrained for 1 minute to allow for adequate contact time of eye drop with 
the eye. Fluorescein staining was performed at base line and every other day. (A1-A3): Representative 
mouse cornea images showing no increased in fluorescein staining in control group IVIG (4 mg/mL) 
only. Compared to BAK only group (A4-A6), IVIG and BAK group (A7-A9) showed significantly less 
corneal staining at Day 3 and Day 6. Corneas in BAK only group and IVIG + BAK group had epithelial 
defects. We compared the area of epithelial defect (A10) and the number of eyes (%) that had corneal 
epithelial defect (A11) between BAK only group and IVIG + BAK group. In the IVIG + BAK group, the 
corneal epithelial defect area was significantly less than in BAK only group (A10) and the percentage of 
eyes with corneal epithelial defect was also significantly less (A11). Taken together, these data show 
that IVIG application to the eye reduces corneal inflammation.  

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Figure 12: In vivo efficacy study to determine the therapeutic potential of blocking the 
interaction of Anti-Citrullinated Protein Antibody (ACPA) with Fc receptors on murine corneas. 
These experiments were performed to determine whether strategies to block ACPA-Fc receptor 
interaction (using either IgG for competitive blocking or peptides for Fc receptor blocking) abrogate 
ACPA-induced ocular surface disease. Citrullinated Histone H4 antibody (H4R3 ACPA, 100 ng/mL) was 
applied to the mouse cornea to produce ocular surface disease. Mouse IgG (100 ng/mL) was used for 
competitive blocking (Experiment 1) and a peptide (1:40 dilution) was used for Fc receptor blocking 
(Experiment 2). Experiment 1: In control group, H4R3 ACPA (10 uL solution) only was applied over the 
ocular surface of anesthetized mice for 40 minutes once a day for 7-8 consecutive days. In 
experimental group, H4R3 ACPA + mouse IgG was applied in identical amount and time as the control 
group. Ocular surface disease was assessed with fluorescein staining. Representative mouse cornea 
images showing fluorescein staining after incubation with H4R3 ACPA solution only (A1-A2) and H4R3 
ACPA + mouse IgG solution (A3-A4). Fluorescein staining of corneas in H4R3 ACPA + mouse IgG 
group was significantly lower than H4R3 ACPA group alone (A5). Experiment 2: In control group, a 
scrambled peptide (10 uL) was applied to the eye of an unanasthetized mice. After the application, the 
mice were restrained for 1 minute to allow for adequate contact time of eye drop with the eye. 30 
minutes after control peptide application, H4R3 ACPA (10 uL solution) was applied over the ocular 
surface of anesthetized mice for 40 minutes. In the experimental group, azide-free Fc receptor blocker 
(Innovex Biosciences # NB355) (10 uL) and H4R3 ACPA were applied to mouse eye in a manner 
identical to the control group. Representative mouse cornea images showing fluorescein staining after 
incubation with control peptide + H4R3 ACPA (B1-B2) and Fc receptor blocking peptide + H4R3 ACPA 
(B3-B4). Fluorescein staining of corneas in Fc receptor blocking peptide + H4R3 ACPA group was 
significantly lower than control peptide + H4R3 ACPA (B5). Taken together, these experiments show 
that blocking the interaction of ACPA with Fc receptors reduces ocular surface disease. 
Therefore, using IVIG eye drops may have therapeutic potential via this mechanism.   
1.11.2 IVIG Clinical Data to Date 
 
Although clinical data regarding IVIG eye drop use in ocular surface disease does not exist, sufficient 
clinical data is available regarding systemic administration of IVIG for treating ocular surface diseases. 
IVIG therapy (given via intravenous route) has been used to treat Mucous Membrane Pemphigoid 
(MMP), a severe ocular surface disease, in patients who do not respond to conventional therapy or 
stopped using them for various side effects. A review of literature identified 13 studies with a total 
number of 70 patients with MMP who responded favorably with IVIG therapy.28 Adverse effects 
associated with IVIG therapy were considerably lower than conventional therapy. We have measured 
tear fluid levels of IVIG after systemic administration for treating ocular MMP or ocular oGVHD. After 
systemic IVIG administration levels of IVIG are significantly higher in the tear fluid. This implies that the 
ocular surface is exposed to IVIG with systemic administration because IVIG is present in the tear fluid. 
Our hypothesis is that applying IVIG to the ocular surface as eye drops maybe a safer, more cost 

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effective and potentially more efficacious method of IVIG treatment of ocular surface disease as 
compared to systemic administration. Because IVIG is present in the tears with systemic administration 
and no ocular side effects have been reported, we expect IVIG-eye drops to have a similar safety 
profile.  
 
Immunoglobulins (IgG) have been placed on the ocular surface in the form of autologous/allogeneic 
serum/plasma eye drops for treating ocular surface diseases. Blood derived products (unfractionated 
serum or plasma eye drops) are essentially physiological IgG formulations, therefore clinical data 
pertaining to their use in treating ocular surface diseases is relevant to the proposed fractionated 
plasma product (IVIG eye drops). This is because the IgG concentration in unfractionated 
serum/plasma eye drops (50%) and the proposed IVIG eye drops is similar (4 mg/ml). Normal average 
serum IgG values are 10 mg/ml.11, 29 Serum also contains important nutritive elements (such as  vitamin 
A, epidermal growth factor, transforming growth factor-β, fibronectin, nerve growth factor and insulin-
like growth factor) that promote the viability of ocular surface cells.30-34 Serum can be formulated as 
autologous or allogeneic serum tear eye drops in specialized laboratories or compounding pharmacies. 
Autologous serum drops are produced from the patient’s own peripheral blood, whereas Allogeneic 
serum drops made from voluntary donors.35, 36   
 
Autologous Serum eye drops have been used for the treatment of ocular surface disorders, including 
dry eye, neurotrophic keratitis, exposure keratitis, graft-versus-host disease, Sjögren syndrome, and 
mucous membrane pemphigoid.37-49 Controlled clinical trials have shown the superiority of autologous 
serum eye drops compared with artificial tears when used to treat some of these conditions.43, 50, 51 Our 
research findings lead us to posit that IgG in serum contributes to its beneficial effects in autoimmune 
and inflammatory ocular surface diseases. 
 
Although autologous serum is more commonly used, Allogeneic serum eye drops made from 
voluntary donors52 have been used in Denmark,53 Norway,54 and the Netherlands55, 56 as a means of 
minimizing the hazards and costs associated with the preparation of an autologous product. Allogeneic 
serum may be an appropriate alternative for selected patients who would benefit from serum treatment 
but whose autologous serum is unavailable or unsuitable.52, 57-60  
 
Limitations of Serum eye drops: One important practical limitation in treatment with serum eye drops 
is the very short shelf life. The United States Pharmacopeia standard recommends a 45 day expiration 
date for the prescription while it is stored in the freezer. Once a bottle is thawed for use, they have to be 
kept refrigerated at 4 C and they expire after 3 days. Other practical issues are that only a 
compounding pharmacy can prepare the eye drops and serum eye drops lack insurance coverage. 

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Figure 13:  IgG levels in tear fluid after intravenous administration of IVIG to treat DED in a 
patient with ocular cicatricial pemphigoid (OCP). We determined whether IgG levels in tear fluid 
increase after IVIG is administered by the intravenous route. A 39 year old male had severe symptoms 
of ocular discomfort and severe tear deficient DED due to OCP. A decision was made to treat him with 
intravenous IVIG. Flebogamma 5% 60g/1200 mL IV per protocol was administered. Tear fluid was 
collected prior to IVIG infusion and following IVIG infusion and analyzed for total amount of IgG using 
Human Immunoglobulin Isotyping MILLIPLEX MAP kit (Cat. No. HGAMMAG-301K, EMD Millipore, 
Billerica, MA).. At day 3 post IVIG infusion, the IgG level in tear fluid showed 2.8 fold increase in right 
eye and 7.5 fold increase in left eye. At day 14 post IVIG infusion, IgG level in tear fluid showed 4.8 fold 
increase in right eye and 4.7 fold increase in left eye. Taken together, these data showed that IgG 
levels in tear fluid increases several fold after intravenous IVIG administration.  
1.12 Dose Rationale and Risk/Benefits 
 
Proposed dose: IVIG eye drops 4 mg/ml (0.4%) two times a day.  
 
Rationale: Serum eye drops, compounded by diluting serum by 50% in normal saline, are routinely 
used for treating ocular surface diseases. The amount of IgG in undiluted serum is approximately 10 
mg/ml, therefore 50% serum eye drops has approximately 5 mg/ml IgG, and serum eye drops are 
generally used four times a day. Since, at 50% dilution serum eye drops are effective in treating ocular 
surface diseases, we have proposed a similar dose of IgG in IVIG eye drops (4 mg/ml). In our in vitro 
experiments, we have determined 4 mg/ml IVIG to be non-toxic, as this dose, when added to medium 
of cultured epithelial cells for 24 hours, did not cause an increase in LDH concentration in the 
supernatant.  
Also, it is generally accepted that IVIG should be given at a concentration that is at least 4 times 
the concentration of IgG at the application site. In ocular surface diseases, we have estimated IgG 
amount on the ocular surface to be approximately 0.5 mg/ml, therefore the IVIG dose should be at least 
2 mg/ml to be effective. Taken together, our proposed dose of IVIG eye drops replicates the clinically 
in-use dose of IgG in serum tears, is non-toxic in vitro, and above the threshold required to be effective. 
 

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Adverse Effects of IVIG Treatment: To date, IVIG has been administered via systemic route only. Mild 
to moderate adverse reactions to high-dose IVIG therapy might be seen in nearly 30% of patients. 
Some of the common adverse reactions include fever, headache, chills, nausea, hypotension, and 
muscle cramps. Temporary cessation of the IVIG infusion, slow infusion, and use of general anti-
inflammatory agents can control these events. Switching to SCIG is another viable alternative. 
Anaphylaxis can occur in IgA-deficient patients and use of low IgA-containing IVIG preparations is 
recommended in such cases. Other effects include meningeal inflammation and aseptic meningitis due 
to the release of inflammatory cytokines and neutrophil activation by IgG Abs within IVIG that mimic 
antineutrophil cytoplasmic Abs; intravascular hemolysis due to the presence of anti-A or anti-B 
isoagglutinins or less commonly anti-D or anti-K Abs; thromboembolism because of contamination of 
IVIG with clotting factors and formation of platelet-leukocyte aggregates; and renal complications due to 
osmotic injury that could be prevented by using non–sugarstabilized IVIG. 
 
Possible contamination of IVIG with infectious agents like viruses and prions always exists. However, 
viral inactivation steps, caprylation, and nanofiltration aid in the safety profile of IVIG. 
2 Study Objectives 
 
The main objective of this study is to establish whether patients with Dry Eye Disease are able to safely 
tolerate receiving Intravenous Immunoglobulin (IVIG) eye drops two times a day for eight weeks 
(primary ‘safety and tolerability’ objective). The exploratory objective is to investigate the preliminary 
efficacy of the use of IVIG eye drops in treating Dry Eye Disease (exploratory efficacy objective) to 
estimate the effectiveness of the trial intervention and collecting data to inform the design of a future 
definitive trial. 
3 Study Design 
3.1 General Design 
 
This will be a Randomized controlled trial, in which a total of 28 subjects will be enrolled at 1 clinical 
site. Subjects will be randomly assigned to one of two groups (#1, #2), with 14 subjects per group. One 
group will be given placebo (Normal saline eye drops) and the other group will be given eye drops 
containing the study drug (IVIG).  
 
Patients with established Dry Eye Disease will be approached by a member of the research staff to 
determine if he/ she might be interested in participating in a research study. If the subject is interested, 
the research staff member will describe the study. If the subject is willing to enter the study, the study 
will be discussed and the subject will be asked to sign the informed consent form. Consent will be 
obtained prior to screening to determine eligibility. Screening procedures include documentation of Dry 
Eye Disease. Eligible subjects will be enrolled in the study. 
 
All enrolled subjects will receive their first dose of test medication (placebo/ study drug) on study Day 1 
in the doctor’s office, and after completion of the study assessments, will have the topical eye drops 
dispensed for self-administration. See Section 5.4 Preparation and Administration of Study Drug for 
details. 
 
Subjects will be provided with diaries to record the time of each dose and will also be asked to record 
any adverse symptoms. In addition, they will be asked to make a note of any missed doses together 
with the reason for the omission. Subjects will return at 4 weeks for further study assessments, 

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thereafter at 8 weeks (the last day of treatment), and again at 10 weeks after two weeks of no treatment 
with study drug for the final study assessments. 
 
There is no primary efficacy endpoint in this study. Instead several exploratory efficacy endpoints will 
be assessed. 
The primary tolerability endpoint is the change in the test substance tolerance between Day 1 (post-
dose) and 8 weeks (56 days). 
3.2 Tolerability End Point: Test Substance Tolerance (Visual Analogue Scale) 
 
Subjects will assess their tolerance to the administration of the test medication (placebo/ study drug), 
utilizing a Visual Analog Scale (VAS). The VAS is a horizontal line with verbal descriptors at either end. 
The VAS ratings will be completed after administration of the test medication on Day 1 (post-dose), 
week 4 and week 8. Subjects will place a single slash mark across the horizontal line between the end 
labeled “completely intolerable” (0 mm) and “easily tolerable” (100mm). The VAS rating is as follows:  
 
Please rate the degree of comfort or lack of comfort associated with administering the eye drop by 
making one slash mark on the line below:  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
3.3 Secondary Study Endpoint 
 
There are no secondary endpoints in this study. 
3.4 Exploratory Study Endpoints  
The exploratory study endpoints will include: 
1. The change in the Ocular Surface Disease Index (OSDI) which is a patient’s subjective rating 
scale 
2. Change in tear secretion as measured by Schirmer I test 
3. The proportion of eyes achieving complete corneal staining clearance after treatment 
4. Change in corneal staining score as measured by Lissamine dye staining 
Completely intolerable 
Easily tolerated 
Visual Analogue Scale 
On the scale of 0 to 100 seen below, please mark where you would rate your tolerability to 
administration of the test drug. 

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5. The change in subjective ocular surface redness score (OR) using the validated bulbar redness 
(VBR) grading scale 
6. Visual acuity change 
7. Change in frequency of administration of artificial tears or concomitant eye drops 
8. Change in number of corneal filaments (slit-lamp examination) 
9. Change in amount of mucoid films (slit-lamp examination) 
10. Clinical Global Impression (CGI) of change in symptoms from baseline (physician’s rating) 
11. Subject Global Assessment (SGA) of overall change from baseline (subject’s rating) 
12. Change in Non-Invasive Keratograph Tear Break-Up Time (NIKBUT) 
13. Change in Keratograph Ocular Bulbar Redness Score 
14. Change in MMP-9 Protein Detection 
15. Change in amount of Cytokines in ocular surface wash 
3.4.1 Exploratory Efficacy End Point: Ocular surface Lissamine Dye staining score 
 
Ocular surface staining will be assessed using Lissamine Green Dye for Cornea and Conjunctiva. The 
scoring pattern is represented below. 
  
Lissamine Green Dye Staining for Cornea and Conjunctiva: 
 
Using 5uL fixed pipette and a 10uL pipette tip 5uL of the Lissamine will be drawn from the Eppendorf 
vial and after slightly pulling the eye lid of the patient Lissamine dye will be released over the ocular 
surface of both eyes. Using the slit lamp nasal-bulbar and temporal-bulbar conjunctiva will be graded 
within 2 minutes for each eye.  
 
 
 
 
 
 
Corneal staining will be graded in 5 zones. Each zone will be graded from 0 to 3 based on the density 
of punctate staining. 
 
 
  
 
 
 
 
 
 
3.4.2 Exploratory Efficacy End Point: Ocular Surface Disease Index (OSDI) 
 
The OSDI rating scale has twelve questions in three discrete areas, with responses rated on a five 
point scale. Subjects will complete this scale on Day 1 prior to first dose (Baseline), week 4, week 8 and 
week 10. The questions and scoring system are shown below: 61 
 
 
 

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HAVE YOU EXPERIENCED ANY OF THE FOLLOWING DURING THE LAST WEEK: 
 
 
All of the 
time 
Most of 
the time 
Half of 
the time 
Some of 
the time 
None of 
the time 
1. Eyes that are sensitive to 
light? 
4 
3 
2 
1 
0 
2. Eyes that feel gritty? 
4 
3 
2 
1 
0 
3. Painful or sore eyes? 
4 
3 
2 
1 
0 
4. Blurred Vision? 
4 
3 
2 
1 
0 
5. Poor vision? 
4 
3 
2 
1 
0 
 
HAVE PROBLEMS WITH YOUR EYES LIMITED YOU IN PERFORMING ANY OF THE FOLLOWING 
DURING THE LAST WEEK:  
 
 
All of 
the time 
Most of 
the time 
Half of 
the time 
Some 
of the 
time 
None of 
the time 
 
6. Reading? 
4 
3 
2 
1 
0 
N/A 
7. Driving at night? 
4 
3 
2 
1 
0 
N/A 
8. Working 
with 
a 
computer 
Or 
bank 
machine (ATM)? 
4 
3 
2 
1 
0 
N/A 
9. Watching TV? 
4 
3 
2 
1 
0 
N/A 
 
HAVE YOUR EYES FELT UNCOMFORTABLE IN ANY OF THE FOLLOWING SITUATIONS DURING 
THE LAST WEEK: 
 
 
All of 
the time 
Most of 
the time 
Half of 
the time 
Some 
of the 
time 
None of 
the time 
 
10. Windy conditions? 
4 
3 
2 
1 
0 
N/A 
11. Places or areas with 
Low 
humidity 
(very 
dry)? 
4 
3 
2 
1 
0 
N/A 
12. Areas that are air 
conditioned? 
4 
3 
2 
1 
0 
N/A 
 
3.4.3 Exploratory Efficacy End Point: Clinical Global Impression (CGI) 
 
At each visit, the physician (Principal Investigator) will use his clinical evaluation (all signs and 
symptoms taken together) to provide a global assessment of the subjects’ change in symptoms and 
signs. The CGI is a follows: 62  
 
Question (to physician): In general, compared with the subjects’ symptoms and signs at baseline, 
how would you characterize his/ her overall signs and symptoms now? 
 
The responses will be categorized on a seven point scale as follows: 
 
 
Marked worsening 

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Moderate worsening 
Minimal worsening 
Unchanged 
Minimal improvement 
Moderate improvement 
Marked improvement 
3.4.4 Exploratory Efficacy End Point: Subject Global Assessment (SGA) 
 
At each visit, the subjects will be asked to assess their overall change from baseline. The SGA is as 
follows: 62 
Question 1 (to subject): Compared with your first visit, how are your eye symptoms now? 
 
The responses will be categorized on a five point scale as follows:  
Much worse 
Worse 
About the same 
Improved 
Much improved 
 
Question 2 (to subject): Compared with your first visit, how is the mucous strings or mucous 
discharge from your eyes now? 
 
The responses will be categorized on a five point scale as follows: 
Much worse 
Worse 
About the same 
Improved 
Much improved 
3.4.5 Exploratory Efficacy End Point: Ocular surface redness score 
 
Ocular surface redness (nasal or temporal) will be assessed using the Validated Bulbar Redness 
grading scale (VBR).63 The VBR consists of a set of ten images illustrating different degrees of ocular 
surface redness (OR), ranging from normal to severe, and each image is assigned a value in an order 
of ascending severity. Colored copies of these images will be made and put up in all the examination 
rooms.  Subjects will be examined by a slit-lamp and the bulbar conjunctival injection of the subject’s 
eye (nasal and temporal) will be compared to the reference images and graded accordingly.  
 
Photographic anchors and their respective grades for ocular surface redness are shown below: 

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3.4.6 Exploratory Efficacy End Point: Keratograph Oculus Redness Score 
 
Keratograph is FDA approved and is used in routine clinical care of patients in the US. The Oculus 
Keratograph 5M performs a non-invasive tear film analysis. It uses a Placido bowl with a camera 
aperture that has a fixation mark in the center. The device provides consistent illumination, allowing 
scanning of the exposed bulbar conjunctiva to take place. The keratograph then analyzes the scanned 
area. This system generates a BR score automatically, which is based on the area percentage ratio 
between the vessels and the rest of the analyzed area. For instance, if the ratio is 16%, then the score 
is 1.6. The maximum ratio, according to the manufacturer, is 40%; therefore, the BR scores that the 
machine generates range between 0.0 and 4.0. 
 
Non-invasive Keratograph Tear Film Break-up Time (NIKBUT) 
 
The non-invasive Keratograph tear film break-up time (NIKBUT) measures tear film stability. The 
NIKBUT is automatically measured within seconds, without fluorescein application. Tear Break-up Time 
(TBUT) will be measured twice for each eye using IR video derived from the Oculus noninvasive 
Keratograph tear breakup time (NIKBUT) tool. Based on the device IR video, the device generates 2 
measures for TBUT: NIKBUT-first (time at which the first breakup of tears occurs) and NIKBUT-average 
(average time of all breakup incidents) automatically and without touching the eye. 
 

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3.4.7 Exploratory Efficacy End Point: InflammaDry for MMP-9 Protein 
 
InflammaDry is FDA approved and is used in routine clinical care of patients in the US. Elevated levels 
of the MMP-9 protein in human tears will be detected visually, qualitatively, and in vitro using 
InflammaDry for MMP-9. InflammaDry will be performed PRIOR to instilling ocular anesthetic, topical 
dyes, or performing Schirmer testing. Tear fluid sample will be collected by gently dabbing the sampling 
fleece on the inside of the patient’s palpebral conjunctiva. The test is assembled by gently placing the 
sampling fleece of the sample collector into the sample transfer window of the test cassette body. The 
buffer vial is opened and immersed in the absorbent tip. The absorbent tip is removed from the buffer 
vial, the protective cap is replaced, and the test is laid flat on a horizontal surface.The results of the test 
are indicated through two (2) lines, the control line and the result line in the result window. 
 
POSITIVE RESULT: The presence of both a BLUE line in the control zone and a RED line in the result 
zone indicates a positive result. A positive result indicates the presence of MMP-9 >= 40 ng/ml. 
NEGATIVE RESULT: The presence of only a BLUE line in the control zone indicates a negative result. 
A negative result is indicative of an MMP-9 < 40 ng/ml. 
INVALID RESULT: If a BLUE line does not appear, the test may be invalid. Re-immerse the absorbent 
tip into the buffer vial for an additional ten (10) seconds. If a BLUE line still does not appear, the test 
must be discarded and the subject retested by resampling the eye using a new InflammaDry test. 
 
 
3.4.8 Exploratory Efficacy End Point: Symptom (Ocular Discomfort) Intensity  
 
Symptom (ocular discomfort) intensity will be assessed utilizing a Visual Analog Scale (VAS). The VAS 
is a horizontal line with verbal descriptor anchors at regular intervals. Symptom intensity will be 

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assessed on baseline, week 4, week 8, and week 10. Subjects will be asked to assess their symptom 
intensity as a fraction of 10. The symptom intensity will be assessed as follows: 
Question to the patient: On a scale from 0-10, what was the intensity of your ocular discomfort, at its 
worst, over the past 24 hours? 
 
 
 0 
1 
2 
3 
4 
5 
6 
7 
   8 
9 
10 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 None                              Mildly                         Nagging                      Distressing                       Intense                        Unbearable 
                                     Annoying                 Uncomfortable                 Miserable                        Horrible                      Excruciating 
 
3.5 Safety Endpoints 
 
Safety assessments include Vital Signs, recording of all complications and adverse events, as well as 
ophthalmic exam findings. All ocular and non-ocular adverse events will be assessed for severity and 
relationship to the investigational product. 
 
In addition to the primary tolerability endpoint (Section 2.2), the following safety endpoints will be 
assessed: 
 
• 
The proportion of screened subjects who are successfully recruited in the study (i.e., recruitment 
rate) 
• 
The proportion of eligible subjects at Day 56 who successfully complete (i.e., retention rate, 
(non)compliance or adherence rate) a full eight weeks (i.e., 56 days) of therapy with topical 
administration two times per day (BID).  
• 
All reported adverse events, classified by frequency, severity, and relatedness, from baseline 
(Day 1) through the last study visit (Day 70). 
• 
Clinically significant changes in vital signs or ophthalmic examination from baseline. 
3.5.1 Vital Signs 
 
Vital signs will be obtained and recorded at the Day 1 Visit, prior to the first administration of the test 
medication (placebo/ study drug) and week 4, week 8 and week 10. The following vital signs will be 
measured: 1) blood pressure measurements (mm Hg) will be taken while the subject is relaxed in a 
sitting position for at least 3 minutes with the arm at heart level. 2) Heart rate will be measured via 
auscultation of the heart or palpation of a peripheral pulse and will be recorded in beats per minute 
(bpm). 3) Oral temperature will be recorded in degrees Fahrenheit (0F). Subjects with an oral 
temperature less than (≤) 99.60F (37.40C) may continue. 
 
Clinically significant negative changes from baseline will be recorded on the adverse event forms. 
3.5.2 Ophthalmic Examination 
 
At all visits, the Investigator will conduct a complete undilated examination of the eyes using a binocular 
slit lamp. The Investigator will examine the tear film, eye lids, lashes, bulbar and palpebral conjunctiva, 
upper and lower lid puncta, cornea, anterior chamber, iris, lens, and anterior vitreous. Specific signs (if 
they are present) that will be recorded include: lacrimal sac area erythema, swelling or tenderness; 
froth or debris or mucous strands in tear film; eyelid hyperemia; punctal hyperemia or atresia; 
conjunctival/ episcleral hyperemia; papillary or follicular conjunctival reaction; chemosis, episcleral 
edema; superficial punctate keratopathy, corneal scar, corneal neovascularization; presence and 

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number of corneal filaments, presence or absence of mucoid films, anterior chamber cell, flare or KPs; 
pupil shape abnormalities, anterior or posterior synechiae, iris neovascularization; lenticular opacities; 
vitreous cells or pigment. Conjunctival hyperemia (ocular surface redness) will be graded at each visit 
using the VBR grading system as explained in section 3.4.5. Measurements at first and last visit will 
include: visual acuity (Snellen’s chart), manifest refraction and intraocular pressure measurement. 
Clinically significant changes from baseline examination will be recorded on the adverse event forms. 
Corneal filaments are mucous tags that are adherent to the surface of cornea. Mucoid films are mucous 
collections accumulating on the surface of the eye. The number of such mucus tags/ filaments will be 
counted on each clinical examination (slit-lamp examination). 
3.6 Other Study procedures: Ocular Surface Washings 
 
At the first (Baseline) and last treatment (8 week) visits, ocular surface washins will be collected as 
follows: 50 μL of artificial tear (Preservative Free Refresh Optive Sensitive, Allergan, Irvine, CA) was 
instilled into the lower fornix of the eye. The patient will be instructed to perform ductions in all 
directions, and after approximately 1 minute the conjunctival washings were collected with a 5 μL glass 
microcapillary tube (Mirocaps Drummond Scientific, Broomall, PA) and transferred to a sterile 0.2 mL 
microcentrifuge tube. The samples will stored at cold temperature (approximately 4 degrees C) until 
further analysis. Ocular Surface washings will be transported to the laboratory and used for potential 
biomarker analysis etc.  
4 Subject Selection and Withdrawal 
4.1 Inclusion Criteria 
 
Patients will be eligible for the study if all of the following criteria are met: 
 
1. Sign and date the informed consent form approved by the IRB 
2. ≥ 18 years of age 
3. Demonstrate at least any 2 of the following signs in the same eye or a sign and symptom. 
a) Conjunctival staining present ≥ 1 (out of possible score of 6 per eye) 
b) Corneal staining present ≥ 2 (out of a possible score of 15 per eye) 
c) Tear film break up time (TFBUT) ≤ 7 seconds 
d) Schirmer’s test ≥ 0 to ≤ 9 mm/5min 
e) SLK pattern staining ≥ 1 
f) Meiboscale grade ≥ 2 
g) Validated Bulbar Redness ≥ 40 
h) Demonstrate symptoms of dry eye disease OSDI score of at least ≥ 13. 
i) Demonstrate Symptom Intensity Assessment of ≥ 3.  
4. Patient reported dry eye-related ocular symptoms for at least 6 months before the Screening 
Visit and use or desire to use artificial tears on average 2 times per day in the 2 weeks 
preceding the screening visit 
5. Intraocular pressure (IOP) ≥ 5 mmHg and ≤ 22 mmHg in each eye 
6. Women of child-bearing potential must agree to use a reliable method of contraception 
during study participation and must demonstrate a negative pregnancy test at the Screening 
Visit 
7. Be willing/able to return for all study visits and to follow instructions from the study 
investigator and his/her staff 
8. Ocular Surface Wash Anti-Citrullinated Protein Antibody (ACPA) value of > 4.4 units in 
either eye at any time in the past.  

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4.2 Exclusion Criteria 
 
Subjects will not be eligible for the study if any of the following criteria are met: 
 
1. Allergic to IVIG or any similar products, or excipients of IVIG eye drops 4 mg/ml. 
2. Use of contact lenses within the last 2-weeks prior to the baseline Visit. 
3. Use of Allogenic serum or plasma eye drops within the last 2-weeks prior to the baseline Visit. 
4. Unwilling to commit to no use of contact lenses for the duration of the study. 
5. Pregnant or nursing/lactating 
6. Participation in a study of an investigational drug or device within the 30 days preceding the 
Screening Visit 
7. Current diagnosis of any of the following ocular conditions: 
i) Acute allergic conjunctivitis 
ii) Active infection (e.g. bacterial, viral, protozoan or fungal infection of the cornea, 
conjunctiva, lacrimal gland, lacrimal sac or eyelids) 
iii) Active intraocular inflammation (e.g., retinitis, choroiditis, uveitis) 
8. Ocular surgery (including cataract surgery), by patient report, within 3 months of Screening Visit 
9. Previous LASIK surgery or any other corneal transplant surgery, by patient report. 
10. Cognitive or psychiatric deficit that precludes informed consent or ability to perform 
11. Vulnerable 
populations, 
such 
as 
neonates, 
pregnant 
women, 
children, 
prisoners, 
institutionalized individuals, or others who may be considered vulnerable populations. 
12. Have active drug/alcohol dependence or abuse. 
13. Corneal epithelial defect larger than 1 mm2 in either eye. 
14. Active ocular infection or ocular allergies. 
 
Participants will be permitted to continue their chronic ocular treatments, including the use of artificial 
tears, ointments, prescription eye drops (Restasis, Xiidra, Steroids), eyelid massage, or warm 
compresses. Subjects will be asked to maintain their ocular treatments unchanged in frequency of use 
for the duration of the study. Subjects wearing contact lenses (Soft bandage contact lenses or PROSE 
lens) or using serum tears will be asked to discontinue contact lens wear or use of serum tears for 2-
weeks prior to being enrolled (Baseline visit) and will be required to not wear contact lenses or use of 
serum tears for the duration of the study (until week 10 visit). All systemic medications will continue 
unchanged. 
4.3 Subject Recruitment and Screening 
 
Potential subjects will be recruited from the clinical practice of the investigator at the time of their 
routine eye examination visit. The clinical practice is located in the Illinois Eye and Ear Infirmary, 
Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago (UIC). Subjects will 
include patients who have been diagnosed with DED in the investigator’s eye clinic (cornea clinic or the 
comprehensive eye clinic), in the Illinois Eye and Ear Infirmary. Furthermore, these patients would 
include only those who have had an ACPA value of > 4.4 units in ocular surface washings of either eye 
at any time in the past. Patients diagnosed with DED, and willing to enter the study, may be referred to 
the PI’s clinic by other ophthalmologists at UIC, as well as the ophthalmology departments at Loyola 
University Chicago, University of Chicago, RUSH University, Cook County Hospital, and Northwestern 
University. These centers will be provided with ‘information sheets’ to provide to subjects before they 
come to the PI’s clinic. Although patients may be referred from these sites, no study procedures, 
including enrollment will be performed at any site, other than the PI’s clinic in Illinois Eye and Ear 
Infirmary. All subjects will be will be screened, recruited, and will attend all study related visits only at 
the PI’s clinic in Illinois Eye and Ear Infirmary. 

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Patients with Dry Eye Disease (with Schirmer’s test ≥ 0 to ≤ 9 mm/5min and annoying or activity limiting 
visual symptoms) will be approached by a member of the research staff to determine if the subject 
might be interested in participating in a research study. If the subject is interested, the research staff 
member will describe the study. If the subject is willing to enter the study, the subject will be asked to 
review the study consent form, the PI will meet with the subject to review the form, the study will be 
discussed to confirm the subject’s understanding of the study, and to answer any questions that the 
subject might have. Once the subject demonstrates understanding of the study and agrees to 
participate in the study, the subject will be asked to sign the informed consent form in the presence of 
the PI. Consent will be obtained prior to performing any screening tests to determine eligibility. 
Screening procedures include documentation of DED as well as other assessments as detailed in 
section 6.5.1. Eligible subjects will be enrolled in the study.  
4.4 Early Withdrawal of Subjects 
4.4.1 When and How to Withdraw Subjects 
 
Subjects have the right to withdraw from the study at any time, for any reason, without jeopardizing 
their medical care. Where possible, subjects will be followed for safety and encouraged to return for 
follow-up visits for any unresolved safety events. 
 
The IRB and Investigator also have the right to withdraw subjects from the study for the following 
reasons: when continuation may jeopardize the health of the subject, protocol violations, adverse 
events or concurrent conditions, administrative or other reasons. 
4.4.2 Data Collection and Follow-up for Withdrawn Subjects 
 
If a subject withdraws from the study prior to 8 weeks, the subject will be asked to complete the 
procedures outlined in the 10 week visit as well as the Test Substance Tolerance scale from 8 weeks, 
as soon as possible. Subjects who voluntarily withdraw from the study between 8 weeks and 10 weeks 
will be asked to complete procedures outlined in the 10 weeks visit as soon as possible. Subjects who 
are withdrawn due to adverse events will be followed at least until resolution or stabilization of the 
adverse event. 
 
If the subject remains in the study for safety evaluation, follow-up visits will be scheduled according to 
the schedule of visits and procedures found in the synopsis. 
5 Study Drug  
5.1 Description 
 
The study drug, IVIG-eye drops, will be compounded in the UIC Eye and Ear Infirmary (EEI) Pharmacy 
and supplied as a 4 mg/ml (0.4%) preservative free solution in single use vials for administration as 
topical eye drops. The control group will receive Normal saline eye drops as placebo. 
 
Each subject will receive either IVIG-eye drops (study drug) or Normal saline (placebo) solution, as a 
single eye drop in each eye two times a day (BID) for eight weeks. Except for the first dose on Day1, 
subjects will self-administer the test medication eye drops at home.  
 

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Subjects will not be charged for the test medication in any way (neither the cost of the medication nor 
its dispensing cost).  
5.2 Treatment Regimen 
 
Study drug group- IVIG-eye drops, 4mg/ml eye drops will be applied to both eyes b.i.d for 8 weeks. 
Control group – Normal saline eye drops will be applied to both eyes b.i.d for 8 weeks. For either group, 
the subject will be instructed to instill the first dose of the study medication in the morning at 
approximately 8 a.m., and then the other dose at approximately 12 hour interval. Therefore, doses will 
be scheduled at approximately 8 a.m. and 8 p.m.  
5.3 Method for Assigning Subjects to Treatment Groups 
 
This Randomized placebo-controlled trial will have two study groups. Subjects will be randomly 
assigned to one of two groups (#1, #2). One group will receive the study drug (IVIG 4mg/ml; test 
group), and the other group will receive placebo (Normal saline; control group). We will use a computer-
based random code generator (Research Randomizer; http://randomizer.org/) to generate 1 set of 24 
non-unique, unsorted numbers with a range from 1 to 2 representing the group number (#1/ #2). Each 
subject will be assigned a study identification (ID) number at screening, e.g. Subject #1, subject #2, and 
subject #3 and so on. Based on the randomizer generated table, subject #1 will receive either placebo 
or study drug. This will be repeated for each subject. For reproducibility purpose, we will document the 
final randomization schedule and the random SEED number used to generate the schedule. 
Randomization will be performed by the Illinois Eye and Ear Infirmary's pharmacy, and neither 
participants nor research staff will be aware of the assigned treatments. The person conducting the 
randomization will remain masked as well. 
 
The study identification (ID) number will be used on all study-related documents. The drug vial number 
will be linked to the subject identification number. 
5.4 Preparation and Administration of Study Drug  
 
The study medications will be stored, packaged and dispensed from the UIC Eye and Ear Infirmary 
(EEI) Pharmacy. No modifications, except dilution with preservative free normal saline to achieve 
4mg/ml concentration, will be made to the study medication constituents. The drug and placebo will be 
dispensed in sterile eye droppers as single use vials, as explained below: 
 
The study medications will be dispensed in sterile eye droppers of 3.0 ml volume. The commercially 
available product (Flebogamma or an equivalent IVIG preparation) is a single-use ampule containing 
5% (50mg/ml) concentration of IVIG. Flebogamma (5%) will be diluted in normal saline to achieve IVIG-
eye drops 0.4% (4mg/ml). 0.5 ml to 1.0 ml of IVIG-eye drop (4mg/ml) will be transferred into one sterile 
eye droppers of 3.0 ml volume. IVIG-eye drops preparation (by diluting Flebogamma) will be done at 
Illinois eye and ear infirmary (EEI) pharmacy, under standard aseptic precautions. The eye droppers 
will be used by subjects as single-dose applications.  
 
One drop of the drug/ placebo solution will be administered to each eye. Therefore, 2 eyedroppers will 
be required per day. At each visits, subjects will receive 56 sterile multi-dose eye droppers that 
will be used as single-dose applications for 28 days. Prepared eye droppers will be placed in a dark 
(brown) colored zip-lock packet before being dispensed to the subject. The medication can be stored at 
room temp, away from direct strong light. 
 

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Instructions for Drug Use: 
 
1. Wash your hands thoroughly with soap and water. 
2. Check the dropper tip to make sure that it is not chipped or cracked. 
3. Avoid touching the dropper tip against your eye or anything else – eye drops and droppers 
must be kept clean. 
4. While tilting your head back, pull down the lower lid of your eye with your index finger to 
form a pocket. 
5. Hold the dropper (tip down) with the other hand, as close to the eye as possible without 
touching it. 
6. While looking up, gently squeeze the dropper so that a single drop falls into the pocket 
made by the lower eyelid. Remove your index finger from the lower eyelid. 
7. Close your eye for 2 to 3 minutes and tip your head down as though looking at the floor. Try 
not to blink or squeeze your eyelids. 
8. Place a finger on the tear duct and apply gentle pressure. 
9. If you are to use more than one drop in the same eye, wait at least 5 minutes before 
instilling the next drop. 
10. Do not reuse the dropper after use. Use another dropper for next dose. 
 
The subject should repeat the above procedures for the other eye to demonstrate to the Investigator or 
designee that they are able to perform the drug administration satisfactorily. Subjects will be instructed 
to perform these steps on each administration of the study medication. Instructions for use will be 
included in the zip-lock packet with the study medication and site personnel will ensure that these 
instructions are given to the subject. 
5.5 Subject Compliance Monitoring 
 
Subjects will receive their first dose of study medication on study Day 1 in the doctor’s office and after 
completion of the study assessments will have the topical eye drops dispensed for self-administration. 
 
Subjects will be provided with diaries to record the time of each dose and will also be asked to record 
any adverse symptoms. In addition, they will be asked to make a note of any missed doses together 
with the reason for the omission. Subjects will be asked to bring their diaries with them at the 4, and 8 
week visits.  Diaries will be reviewed with the subject by a member of the research team at each visit. 
Additionally, subjects will be asked to bring back the used and unused drug eye droppers at each study 
visit. Participants will be asked to return the unused eye droppers each study visit as a method to 
determine compliance.  
5.6 Prior and Concomitant Therapy 
  
Prior medications are defined as all medications taken within 30 days prior to Day 1, whether there is 
continued use or not. Concomitant medications must be identified in the subject’s medical record, 
including all lubricants administered for Dry Eye Disease. These medications will be recorded in the 
case report form (CRF). 
 
• For each medication taken, the following information will be collected: 
 
• 
Medication trade name 
• 
Eye that was treated, if applicable 
• 
Indication for which the medication was given 

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• 
Date started 
• 
Date stopped   
• 
Dose of medication used. 
 
 In general, patients will be required to maintain the treatments that they were using at entry into the 
study throughout the follow-up period. Patients will be instructed to continue using the same brand of 
eye drops during the study as they were using at the screening visit. If patients are wearing contact 
lenses (Soft bandage contact lenses or PROSE lens) or using serum tears, they will be asked to 
discontinue contact lens wear or use of serum tears for 2-weeks prior to being enrolled (Baseline visit) 
and will be required to not wear contact lenses or use serum tears for the duration of the study (until 
week 10 visit). This is necessary as one of the proposed exploratory study outcome measure is corneal 
Staining. Contact lenses can directly reduce corneal epitheliopathy and staining due to ensconcing and 
acting like a bandage that prevents corneal exposure to tear fluid inflammatory materials. Thus, 
because of overlapping effects on the exploratory outcome measure, it may not be possible to attribute 
any observed clinical benefit to IVIG-eye drops treatment if contact lenses are used concurrently. This 
approach has been used in other clinical trials that have investigated the use of an anti-inflammatory 
agent in dry eye disease (NIH funded ‘Dry Eye Evaluation and Management (DREAM) study’).64 
Stopping contact lens wear may increase the risk of worsening of Dry Eye Disease (DED) during the 
wash-out period and during the course of the study. However, because other eye drop treatments will 
continue during the wash out period as well as during the course of the study, we do not expect any 
significant clinical worsening during the study. We do however expect the frequency of use of artificial 
tears to go up during the wash out period and during the course of the study. 
 
Patients will be enrolled if they have been using their eye treatments for at least 30 day prior to the 
baseline visit and patients will be asked to commit to continue using the same treatments for the 
duration of the study. Participants will also be permitted to continue ancillary treatments such as eyelid 
massage or warm compresses of the eyelids. The number of drops and frequency must be recorded in 
the subject diary provided. The use of any investigational agent during past 30 days is prohibited.   
 
The subjects will be monitored at 4 week intervals to ensure that they are not subjected to any undue 
risks during the course of the study. Additionally, they will be warned of the possible signs and 
symptoms of clinical worsening of DED, and advised to contact the research team immediately in case 
any of those symptoms occur.  Subjects will also be encouraged to contact the research team in case 
they experience any ocular discomfort during the wash out period or during the course of the study. The 
subject’s condition will be monitored by the physician (Principal Investigator) at each study visit, as well 
as at any interim visit (in case of adverse symptoms, as mentioned above). Any worsening of DED or 
any adverse event due to the study drug will be recorded. In case of clinical worsening, based on the 
individual subject’s clinical condition, one or more of the following therapeutic decisions may be 
implemented: (1) Increasing/adding the use of artificial tears or ointments (2) Increasing/adding the use 
of anti-inflammatory therapy (Restasis/ Xiidra/ Steroids) or Serum Tears, (3) Withdrawal of the use of 
study drug (if worsening occurs during the course of the study). The decision will be made by the 
physician (Principal Investigator) based upon his clinical judgment as per the individual subject’s clinical 
condition. If contact lens wear is instituted during the course of the study and/or the study drug is 
withdrawn, the subject will be withdrawn from the study. After any clinical worsening is noted, the 
subjects will be followed more closely (weekly) until complete resolution of symptoms and return to the 
subject’s previous baseline. Subjects will be withdrawn from the study for presumed ocular allergic 
reaction to the product and ocular infection. The study will be stopped if the incidences of presumed 
ocular allergic reaction to the product and ocular infection surpasses 20% for each. 

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5.7 Rescue Plan 
 
The research staff, including the PI, will be masked to randomization, thus will not be aware if a 
particular subject receives study drug or placebo.  Subjects will be monitored by the Principal 
Investigator at each study visit. Any worsening of DED or any adverse event (AEs) will be recorded and 
in the case of AEs followed to resolution. In case of clinical worsening/ adverse event(s), based on the 
individual subject’s clinical condition, one or more of the following therapeutic decisions may be 
implemented:  
(1) Increasing/adding the use of artificial tears or ointments,  
(2) Increasing/adding the use of anti-inflammatory therapy (Restasis/ Xiidra/ Steroids) or Serum 
Tears  
(3) Discontinue the study drug. 
(4) Other eye drops/measures (example, contact lens or surgeries), if indicated.  
The decision will be made by the Principal Investigator based on his clinical judgment and the individual 
subject’s clinical condition. If contact lens wear is reinstituted and/or the study drug is discontinued, the 
subject will be withdrawn from the study. If an adverse event is severe enough to discontinue the 
subject from the study, the PI may decide to break the subject’s randomization code if it seems relevant 
to the treatment of his/her ocular condition at that time. He/ She will receive the treatment required for 
his/ her eye condition as per established clinical guidelines. 
5.8 Packaging 
 
The study medications will be dispensed in sterile eye droppers of 3 ml volume, which will be used as 
single-dose applications. One drop of the placebo/ drug solution will be administered to each eye. 
Therefore 2 eye droppers will be required per day because the placebo/drug is administered two times 
a day. At each visit, subjects will receive 56 sterile eye droppers that will be used as single-dose 
applications.  The eye droppers will be placed in a dark (brown) colored packet before being dispensed 
to the subject. A label with abbreviated information will be placed on each eye dropper.  The zip-lock 
packet will include the subject’s name, stage of visit, instructions for drug use and storage and the drug 
expiration date.  The label will also include the study name (abbreviated) and a statement that the drug 
is investigational for use only in this research study.” The first dose will be administered to the subject 
by the researcher from one of the eye droppers that will be dispensed to the subject at the first 
treatment visit (visit 2, day 1). No separate packing will be done for the study medication to be used in 
the MD’s office. The subjects will receive the 4 weeks of remaining doses in a dark packet to take 
home. 56 sterile eye droppers will be dispensed at each visit. 
5.9 Receiving, Storage, Dispensing and Return 
5.9.1 Receipt of Drug Supplies 
 
The UIC Investigational Drug Service (IDS) or EEI Pharmacy will order the study drug. The study drug 
will be stored in the Taylor Street/ EEI pharmacy and dispensed to subjects as needed.  
5.9.2 Storage 
 
Study medication will be stored at EEI pharmacy until such time as a subject visit is scheduled. The 
study medication will be directly dispensed to the subject from the EEI pharmacy on each treatment 

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visit, except for the first dose that is administered in the clinic under the supervision of research 
personnel. The study medication will not be stored in the MD’s office, except when a subject receives 
his/her first dose, when the medication may be kept in the MD’s office at room temp, away from direct 
strong light.  
5.9.3 Dispensing of Study Drug 
 
At the first treatment visit (day 1), the first study medication dose will be administered to the subject in 
the clinic and eye droppers sufficient to last for 4 weeks will be given to them to take home. The 
subjects will be asked to return the used and unused eye droppers at the follow- up visits. We will then 
retrieve the previously -dispensed eye droppers and a fresh 4 week supply will be dispensed by the 
pharmacy. This will be done at first treatment visit (day 1) and week 4. No new drug eye droppers will 
be given on the week 8 visit.  
5.9.4 Return or Destruction of Study Drug 
 
At the completion of the study, there will be a final reconciliation of drug ordered/ received, drug 
consumed, and drug remaining.  Any discrepancies will be investigated, resolved, and documented.  
The used drug eye droppers will finally be disposed by the pharmacy according to the pharmacy 
standard protocols. 
6 Study Procedures 
6.1 Subject Recruitment and Screening 
 
Prior to recruitment of any subjects into the study, written approval of the protocol and informed consent 
will be obtained from the Institutional Review Board (IRB).  
 
Potential subjects will be recruited from the clinical practice of the principal investigator (PI) at the time 
of their routine eye examination visit. The clinical practice is located at the Department of 
Ophthalmology and Visual Sciences, Eye and Ear Infirmary, 1855 W. Taylor Street, Chicago IL 60612. 
Subjects will include patients who have been diagnosed with dry eye in the investigator’s eye clinic 
(cornea clinic or the comprehensive eye clinic), in the Illinois Eye and Ear Infirmary. Patients may also 
be referred to the PI’s clinic by other Ophthalmology physicians at UIC, as well as the Ophthalmology 
departments at Loyola University Chicago, University of Chicago, RUSH University, Cook County 
Hospital, and Northwestern University. These centers will be provided with ‘information sheets’ to 
provide to subjects before they come to the PI’s clinic. The referring physicians shall inform the patients 
briefly about the study and provide them with the information sheet (enclosed), but no study related 
procedures (including screening and recruitment) will be performed at any location outside the PI’s 
clinic at UIC (Illinois Eye and Ear Infirmary). Even the patients referred to the PI’s clinic for possible 
enrollment in the study, will be screened and, if eligible, recruited in the study only at the PI’s clinic. The 
information sheet that will be given to the subjects are attached. 
Patients with established Dry Eye Disease (for at least 6 months, with Schirmer’s test ≥ 0 to ≤ 9 
mm/5min and annoying or activity limiting visual symptoms) will be approached by a member of the 
research staff to determine if the patient might be interested in participating in a research study. If the 
subject is interested, the research staff member will describe the study. If the subject is willing to enter 
the study, the subject will be asked to review the study consent form, the PI will meet with the subject to 
review the form, the study will be discussed to conform the subject’s understanding of the study, and to 
answer any questions that the subject might have. Once the subject demonstrates understanding of the 
study and agrees to participate in the study, the subject will be asked to sign the informed consent form 

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in the presence of the PI. Patients that contact the researchers in response to a flyer and information 
sheet provided by their physician will be scheduled for a visit to discuss the study and participate in the 
consent process. Consent will be obtained prior to screening to determine eligibility. Subjects will be 
screened for eligibility, as per the inclusion/ exclusion criteria, and as detailed in section 6.5.1. Eligible 
subjects will be enrolled in the study. 
6.2 Assignment of Subject Identification 
 
A study identification (ID) number will be assigned to each subject at screening. This study ID number 
will be used on all study-related documents. To maintain confidentiality, the subject’s name will not be 
recorded on any study document other than the informed consent form. The master code list will link 
the subject MRN to the study ID number given to each subject. The master code list will be stored on 
password protected desktop in PI’s OFFICE in Lions of Illinois Eye Research Institute (LIERI). The data 
collected and master code list will be accessible only to the PI and the research team involved in this 
project. The desktops will be password protected as well. Data will not be shared over the internet and 
will remain password protected. Confidentiality will be maintained. Data will be de-identified post 
publication of the study results and for subjects determined to not meet eligibility criteria or who later 
decline participation in the consent process. 
6.3 Screen Failure 
 
A record of screen failures and the reasons for non-eligibility to the study will be maintained. 
6.4 Subject Enrollment  
 
Subjects meeting the enrollment criteria (see Sections 4.1) will be eligible for the study.   
6.5 Study Assessments 
 
The following detailed procedures are performed at the designated clinic visit. All results will be 
documented on the subject’s medical/research charts, source documents, and CRFs as required. All 
ophthalmic procedures will be performed on both eyes. 
6.5.1 Visit 1 Screening  
Day -21 to 0 
 
After obtaining informed consent, the following assessments will be performed within fourteen days 
prior to the subject receiving the first dose of study medication: 
• Demographic information including: birth date, gender, race or ethnic origin.  
• Medical History including prior medication use and prior procedures: Medical history will be 
obtained by interviewing the subject and will include a review of the following systems: 
cardiovascular, dermatologic, gastrointestinal, genitourinary, musculoskeletal, neurologic and 
respiratory. An allergic history (including medications and food), substance abuse history 
(including alcohol) and a history of medication use (including prescription, OTC, and herbal 
products) during the past 30 days will also be completed. 
• Ophthalmic and Dry Eye Disease history including: date when the Dry Eye Disease began, 
verification that the subject has had Dry Eye Disease for at least 6 months, medications used by 
the subject to treat Dry Eye Disease, previous procedures to treat Dry Eye Disease. 

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• Ophthalmic Examination (slit lamp examination, Ocular Surface Redness Score, Ocular Surface 
Disease Index, Lissamine Dye staining, and a Schirmer I test) 
• 
Pregnancy test, if applicable. Women of reproductive age will be asked to use a method of birth 
control that is acceptable to the subject and the study doctor. This may include oral 
contraceptive pills, birth control implants/shots or patches, barrier methods or abstinence. 
Women of reproductive age will not be included in the study if they refuse to use any birth 
control measure, including abstinence. 
 
Subjects currently treating DED with corticosteroids and/or Restasis will continue these treatments 
during the whole study.   If patients are wearing contact lenses (Soft bandage contact lenses or PROSE 
lens) or using serum tears, they will be asked to discontinue contact lens wear or use of serum tears for 
2-weeks prior to being enrolled (Baseline visit) and will be required to not wear contact lenses or use 
serum tears for the duration of the study (until week 10 visit). The study doctor will provide advice about 
decreasing DED symptoms with artificial tears, eyelid massage, or warm compresses. 
 
If the subject agrees to enter the study after screening, the “Visit 2 Day 1 (Randomization and First 
treatment visit)” will be scheduled. Visit 2 can be scheduled any time in the next 2 weeks after the 
screening visit.  If a subject wears contact lenses or uses serum tears and wants to participate in the 
study, then they will be asked to discontinue the use of contact lenses or use of serum tears and a 
washout period of 2-weeks (±2 days) will be needed before baseline visit (Visit 2).   
 
In some subjects, detailed screening may not have to be performed as the subjects may have been 
followed and treated for Dry Eye in the PI’s clinic. In these cases, some or all of the screening test may 
have been performed during the subject’s routine dry eye care. These subjects will not be screened 
formally. An informed consent will be administered and subjects will be given an appointment for 
baseline visit examination. 
6.5.2  Visit 2 Day 1 (Randomization and First treatment visit) 
Prior to first dose (Baseline) 
 
• 
Record concomitant medications 
• 
Vital Signs: Blood pressure, Pulse, and Temperature taken while subject is in a sitting 
position. 
• 
Visual Acuity (Snellen’s chart) with eye glasses (if applicable) 
• 
OSDI 
• 
Symptom Intensity Assesment 
• 
Keratograph Oculus Redness Score 
> Non-invasive Keratography Tear Film Break-up Time (NIKBUT) 
• 
Schirmer I test 
• 
Baseline Ophthalmic Examination (slit lamp examination, VBR) 
• 
Ocular surface wash collection for analysis (Potential biomarkers) 
• 
InflammaDry Test for MMP-9 Protein 
• 
Lissamine Dye Corneal and Conjunctival staining 
• 
Adverse events since screening visit. 
 
- 
Randomization (by pharmacy) 
- 
Dispensing of study drug/placebo (by Pharmacy) 
- 
Investigator/designee administers first dose of study drug/ placebo 
 
Post-Dose 
 

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• 
Test Substance Tolerance (Visual Analogue Scale; VAS) 
• 
Subjects will be trained on how to self-administer the study eye drops and be given a 
sufficient supply to last for 4 weeks to take home. 
• 
Subjects will receive a study diary on which to record the day/time of each dose and any 
adverse effects. 
• 
Post dose evaluation for any adverse effects. 
• 
Intraocular pressure measurement after topical anesthesia to eye  
6.5.3 Visit 3: Week 4 (± 4 days)  
Treatment Visit (after any dose for that day) 
 
• 
Review the subject’s diary and record changes in concomitant medication, deviations 
from drug schedule and adverse events. 
• 
Vital Signs: Blood pressure, Pulse, and Temperature taken while subject is in a sitting 
position. 
• 
Visual Acuity (Snellen’s chart) with eye glasses (if applicable) 
• 
OSDI 
• 
Symptom Intensity Assessment, SGA and CGA 
• 
Test Substance Tolerance (VAS) 
• 
Baseline Ophthalmic Examination (slit lamp examination, VBR) 
 
- 
Dispensing of study drug/placebo (by Pharmacy to patient) 
- 
Returning of unused study drug/ placebo (by patient to pharmacy) 
6.5.4 Visit 4: Week 8 (± 4 days) 
Treatment Visit (after any dose for that day) 
 
• 
Review the subject’s diary and record changes in concomitant medication, deviations 
from drug schedule and adverse events. 
• 
Vital Signs: Blood pressure, Pulse, and Temperature taken while subject is in a sitting 
position. 
• 
Visual Acuity (Snellen’s chart) with eye glasses (if applicable) 
• 
OSDI 
• 
Symptom Intensity Assessment, SGA and CGA 
• 
Test Substance Tolerance (VAS) 
• 
Keratograph Oculus Redness Score 
> Non-invasive Keratography Tear Film Break-up Time (NIKBUT) 
• 
Schirmer I test 
• 
Baseline Ophthalmic Examination (slit lamp examination, VBR) 
• 
Ocular surface wash collection for analysis (Potential biomarkers) 
• 
InflammaDry Test for MMP-9 Protein 
• 
Lissamine Dye Corneal and Conjunctival staining 
• 
Intraocular pressure measurement after topical anesthesia to eye 
 
- 
Returning of unused study drug/ placebo (by patient to pharmacy) 
6.5.5 Visit 5: Week 10 (± 4 days) 
Follow-Up Visit 
 

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• 
Review the subject’s diary and record changes in concomitant medication and adverse 
events. 
• 
Vital Signs: Blood pressure, Pulse, and Temperature taken while subject is in a sitting 
position. 
• 
Visual Acuity (Snellen’s chart) with eye glasses (if applicable) 
• 
OSDI 
• 
Symptom Intensity Assessment, SGA and CGA 
• 
Baseline Ophthalmic Examination (slit lamp examination, VBR) 
 
- 
Returning of patient diary (by patient to PI) 
7 Statistical Plan 
7.1 Sample Size Determination 
 
As this is a feasibility trial intended to guide the planning of larger future investigations, there are no 
formal sample size calculations.65 The aim of the study is to recruit a sufficient number of patients to 
evaluate the acceptability and safety of the intervention and the study design. An outcome of this study 
will be to estimate parameters such as the SD for a sample size calculation of a subsequent full-scale 
trial. A sample of 24 patients (12 in each arm) is considered adequate for obtaining reliable sample size 
estimates.66, 67 To allow for a conservative attrition rate of 10%, we aim to recruit 28 patients into the 
trial. 
7.2 Statistical Methods 
 
Based on the classification of reasons for conducting pilot studies by Thabane et al, in this pilot study 
we will assess the following: (i) Process– recruitment rate, retention rate, (non)compliance or 
adherence rate; and (ii) Scientific– safety (adverse event/SAE rate), tolerability, and efficacy, including 
reduction in clinical signs and symptoms (OSDI, Corneal staining, Redness etc as detailed in section 
3.4) and treatment effect size. We will calculate the observed rate with 95% confidence interval for each 
rate by treatment group. Other descriptive statistics, including median with interquartile or mean with 
standard deviation for continuous variables and frequency with percentage for categorical variables will 
be reported as well. To estimate the preliminary efficacy under the scientific category, one eye (target 
eye) will be selected at screening visit as follows: (i) if only 1 eye meets inclusion criteria, this eye is 
used; (ii) if both eyes meet inclusion criteria, the eye with the higher corneal stain score is used; (iii) if 
both eyes have the same corneal stain score, then the one with the lower Schirmer I score is used; (iv) 
if both eyes have same scores, the right eye is used. Secondary analyses will be performed for the 
non-target eye as well. Due to the nature of this feasibility study, any efficacy statistical tests and 
adjusted analyses will not be conducted.  Detailed data validation will examine completeness, existence 
and accuracy of collected data to assess data quality and identify missing and conflicting data. 
Statistical analysis will be performed on an intention-to-treat basis i.e., inclusion of all patients randomly 
assigned, regardless of adherence, actual treatment received, and subsequent withdrawal of treatment 
and/or deviation from the protocol and per-protocol (i.e., inclusion of those who completed the 
treatment as planned)1 and will be reported according to 2010 CONSORT guidelines.2 All statistical 
analyses will be completed using SPSS Statistics V.22.0.31 
7.3 Subject Population(s) for Analysis 
 
Statistical analysis will be performed on: (i) intention-to-treat basis (i.e., inclusion of subjects randomly 
assigned, regardless of adherence, actual treatment received, and subsequent withdrawal of treatment 

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and/or deviation from the protocol); and (ii) per-protocol basis (i.e., inclusion of subjects who completed 
the treatment as planned).  
8 Safety and Adverse Events 
8.1 Adverse Event Definitions 
 
The following are specific definitions of terms guided by the International Conference on Harmonization 
(ICH) Guidelines for Good Clinical Practice (GCP) and the U.S. Code of Federal Regulations that apply 
to this section: 
 
Adverse Event: Any untoward medical occurrence in a subject or clinical investigation subject 
administered a pharmaceutical product and which does not necessarily have to have a causal 
relationship with this treatment.  An AE is any unfavorable and unintended sign, symptom, or disease 
temporally associated with the use of an investigational medicinal product (IMP) or other protocol-
imposed intervention, regardless of attribution. This includes the following: 
• 
AEs not previously observed in the subject that emerge during the protocol-specified AE 
reporting period, including signs or symptoms associated with Dry Eye Disease (DED) that were 
not present prior to the AE reporting period. 
• 
Complications that occur as a result of protocol-mandated interventions. 
• 
If applicable, AEs that occur prior to assignment of study treatment associated with medication 
washout, no treatment run-in, or other protocol-mandated intervention. 
• 
Preexisting medical conditions (other than the condition being studied) judged by the 
investigator to have worsened in severity or frequency or changed in character during the 
protocol-specified AE reporting period 
 
Subjects will be reminded to inform the study staff of any adverse effects that they have experienced or 
are experiencing after the first administration of study drug. In addition, subjects will record adverse 
events in their diary throughout the study. All reports of adverse events during the study will be 
recorded on an Adverse Event Case Report Form (CRF). The subject should not be prompted about 
any adverse events that may occur during this trial. 
 
All AEs and SAEs whether volunteered by the subject, discovered by study personnel during 
questioning, or detected through physical examination, laboratory test, or other means will be reported 
appropriately. For each adverse event, the following information will be recorded on the subject’s Case 
Report Form(s): onset date, end date or continues, intensity, duration, relationship to test patch, action 
taken, and outcome. If a subject experiences a serious adverse event (SAE), study staff may 
discontinue the subject from study participation. The study staff must notify the IRB within 24 hours of 
receipt of the information. The study staff will instruct the subject to notify the research facility should 
any adverse event occur within 7 days of study completion. (For definitions of an AE and SAE, see 
below). Subjects who withdraw due to an adverse event may be replaced. 
 
• Serious Adverse Event:  An AE should be classified as an SAE if the following criteria are met: 
1. It results in death (i.e., the AE actually causes or leads to death.). 
2. It is life-threatening (i.e., the AE, in the view of the investigator, places the subject at 
immediate risk of death. It does not include an AE that, had it occurred in a more 
severe form, might have caused death.). 
3. It requires or prolongs inpatient hospitalization. 
4. It results in persistent or significant disability/incapacity (i.e., the AE results in 
substantial disruption of the subject’s ability to conduct normal life functions). 

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5. It results in a congenital anomaly/ birth defect in a neonate/infant born to a mother 
exposed to the investigational medicinal product (IMP). 
6. It is considered a significant medical event by the investigator based on medical 
judgement (e.g., my jeopardize the subject or may requires medical or surgical 
intervention to prevent any of the occurrences listed above. 
 
To ensure consistency of AE and SAE causality assessments, the following general guideline will be 
applied: 
 
Yes 
There is a plausible temporal relationship between the onset of the AE and administration of the IVIG, 
and the AE cannot be readily explained by the subject’s clinical state, intercurrent illness, or 
concomitant therapies; and/or the AE follows a known pattern of response to the IVIG; and/or the AE 
abates or resolves upon discontinuation of the IVIG or dose reduction and, if applicable, reappears 
upon re-challenge 
 
No 
Evidence exists that the AE has an etiology other than the IVIG (e.g., preexisting medical condition, 
underlying disease, intercurrent illness, or concomitant medication); and/or the AE has no plausible 
temporal relationship to IVIG administration (e.g., cancer diagnosed 2 days after first dose of study 
drug) 
 
Life-threatening: Any adverse drug experience in which the subject was at risk of death at the time of 
the event. It does not refer to an event which hypothetically might have caused death if it were more 
severe. 
Expected adverse event: Expected adverse events are those adverse events that are listed or 
characterized in the Package Insert (P.I) or current Investigator Brochure (I.B). 
 
Unexpected adverse event: Any adverse event, the specificity or severity of which is not consistent 
with the current Investigator’s Brochure. 
8.2 Classification of Adverse Events by Severity 
 
All toxicities/adverse events will be graded according to the following definitions to code the intensity of 
the event. 
 
Mild: Usually transient, requiring no special treatment, and does not interfere with the subject’s daily 
activities. 
Moderate: Traditionally introduces a low level of inconvenience or concern to the subject and may 
interfere with daily activities, but are usually relieved by simple therapeutic measures. 
Severe: Causes an interruption of the subject’s usual daily activity and traditionally required systemic 
drug therapy or other treatment. 
Note: If the intensity of an adverse event changes, the event will be reentered as a separate event. 
There is a distinction between the severity and the seriousness of an adverse event. Severity is a 
measurement of intensity; thus, a severe reaction is not necessarily a serious adverse event. For 
example, a headache may be severe in intensity, but would not be serious unless it met one of the 
criteria for serious adverse events listed previously. 

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8.3 Action(s) Taken 
One or more of the following will be recorded by the Investigator for each adverse event: 
 
• No action taken 
• Discontinued study drug (Subject withdrawn due to this adverse event) 
• Administered therapy 
• Hospitalized subject (due to this adverse event) 
• Other (specify) - includes tests, labs confirming reaction 
8.4 Outcome 
 
The status of each adverse event will be recorded as follows, if applicable: SAE: Indicates that the 
adverse event met the criteria of a serious adverse event (SAE) and the SAE was reported to the IRB. 
Caused Withdrawal: Indicates that the adverse event caused the subject’s withdrawal from the study.  
8.5 Adverse Event Reporting 
 
All subjects who have been exposed to study drug will be evaluated for adverse events. Adverse 
events will be recorded starting after the first dose of study drug and continuing until the end of the 
study. All adverse events will be evaluated beginning with onset, and evaluation will continue until 
resolution is noted, or until the Investigator determines that the subject’s condition is stable, whichever 
is earlier. The Investigator will take all appropriate and necessary therapeutic measures required for 
resolution of the adverse event. Any medication necessary for the treatment of an adverse event must 
be recorded on the concomitant medication case report form. If more than one distinct adverse event 
occurs, each event should be recorded separately. Procedures such as surgery should not be recorded 
as adverse events. However, the medical condition for which the procedure was performed should be 
reported if it meets the definition of adverse event as described previously. 
8.6 Serious Adverse Event Reporting 
 
All Serious Adverse Events (SAE) that occur during the course of the study, including death, which are 
unanticipated require reporting to the IRB within 5 business days of the investigator becoming aware.   
Serious adverse events will be recorded starting after first dose of study drug and continuing until the 
end of the study. The minimum information to be provided includes: 
 
1. Protocol Number 
2. Initial reporter 
3. Subject identification 
4. Nature and date of the event/effect 
5. Country of the event/effect 
6. Severity of the event/effect 
7. Reporting criteria 
8. Narrative description of the event/effect 
9. Outcome if known 
10. Causal relationship to the investigational product 
11. Additional and follow-up information as requested by the medical monitor. 
 
Events requiring reporting to the IRB within 15 business days of the investigator becoming aware 
include: 
  

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1. Local adverse events or problems that are unanticipated and, while not meeting the criteria of 
serious, indicate research is associated with a greater risk of harm to participants or others than 
previously known.  
2. New information indicating an unexpected change to the risks or benefits of the research (i.e., 
an unanticipated problem).  
3. Administrative hold by investigator, regulatory authorities or other entities.  
8.7 In Case of an Emergency 
 
In medical emergencies, the Investigator should use medical judgment and remove the subject from 
immediate hazard. The IRB should be notified as to the type of emergency and the course of action 
taken. The CRF and the source document for the subject must describe the departure from the protocol 
and state the reason. 
8.8 Data Safety Management Plan 
 
The study protocol will be reviewed and approved by the UIC IRB.  Adverse events and compliance will 
be monitored. Research staff will be trained on the protocol requirements and data collection methods 
before completing study related procedures. Privacy, coding, storage: Research staff will be trained on 
the protocol requirements and data collection methods before completing study related procedures.  
Random study ID numbers will be assigned to study subjects. A master code list will link the subject 
MRN to the study ID number. The data collected will be stored on PI’s desktop in a HIPPA compliant 
encrypted folder at the Ear and Eye Infirmary and Lions Eye Research building. The data collected, 
master code list will be accessible only to the PI and the research team involved in this project. The 
desktops will be password protected as well. 
  
All Serious Adverse Events (SAE) that occur during the course of the study, and possibly related to the 
study intervention, including death, which are unanticipated will be reported to the IRB within 5 
business days of the investigator becoming aware. A copy of the report will be sent to the FDA. 
 
Events requiring reporting to the IRB within 15 business days of the investigator becoming aware 
include: 
 
• 
Local adverse events or problems that are unanticipated and, while not meeting the criteria of 
serious, indicate research is associated with a greater risk of harm to participants or others than 
previously known. 
• 
New information indicating an unexpected change to the risks or benefits of the research (i.e., 
an unanticipated problem). 
 
A copy of this report will be sent to the FDA. 
 
The minimum information to be provided includes: 
 
1. Protocol Number 
2. Initial reporter 
3. Subject identification 
4. Nature and date of the event/effect 
5. Country of the event/effect 
6. Severity of the event/effect 

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7. Reporting criteria 
8. Narrative description of the event/effect 
9. Outcome if known 
10. Causal relationship to the investigational product 
11. Additional and follow-up information as requested by the medical monitor. 
8.9 Study Oversight 
 
The Study PI has primary oversight responsibility for this study. Sandeep Jain, MD is a board certified 
Ophthalmologist with an active practice in the area of Dry Eye Disease, including those with Meibomian 
Gland Disease. He routinely takes care of patients with severe ocular surface disease. He's also the 
director of Dry Eye service at UIC. Therefore, he's well qualified to recognize the symptoms and clinical 
signs of an adverse event. Dr. Jain has been the PI of past and active IRB approved clinical studies 
and has monitored data related to those studies. Therefore, he has experience in data and safety 
monitoring.   
 
The Principal Investigator and his research team are responsible for identifying adverse events. Safety 
monitoring will include careful assessment and appropriate reporting of adverse events.  Subjects will 
be reminded to inform the study staff of any adverse effects that they have experienced or are 
experiencing after the first administration of study drug.  Subjects will be provided with diaries to record 
at home the time of each dose and any adverse symptoms. All reports of adverse events during the 
study will be recorded on an Adverse Event Case Report Form (CRF). In addition, subjects will be 
asked to make a note of any missed doses together with the reason for the omission.  A member of the 
research staff will review diary entries with the subject at each study visit.  Subjects will be asked to 
bring back the left-over drug at each study visit. The amount of drug remaining in the used vial will also 
give an estimate of the compliance. 
9 Confidentiality 
 
Information about study subjects will be kept confidential and managed according to the requirements 
of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).  Those regulations require a 
signed subject authorization informing the subject of the following:  
• What protected health information (PHI) will be collected from subjects in this study 
• Who will have access to that information and why 
• Who will use or disclose that information 
• The rights of a research subject to revoke their authorization for use of their PHI.  
 
In the event that a subject revokes authorization to collect or use PHI, the investigator, by regulation, 
retains the ability to use all information collected prior to the revocation of subject authorization.  For 
subjects that have revoked authorization to collect or use PHI, attempts should be made to obtain 
permission to collect at least vital status (i.e. that the subject is alive) at the end of their scheduled study 
period. 
10 Source Documents 
 
Source data is all information, original records of clinical findings, observations, or other activities in a 
clinical trial necessary for the reconstruction and evaluation of the trial.  Source data are contained in 
source documents.  Examples of these original documents, and data records include: hospital records, 
clinical and office charts, laboratory notes, memoranda, subjects’ diaries or evaluation checklists, 
pharmacy dispensing records, recorded data from automated instruments, copies or transcriptions 

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certified after verification as being accurate and complete, microfiches, photographic negatives, 
microfilm or magnetic media, x-rays, subject files, and records kept at the pharmacy, at the 
laboratories, and at medico-technical departments involved in the clinical trial. 
10.1 Records Retention 
 
It is the investigator’s responsibility to retain study essential documents for the full duration of the study. 
This includes, but is not limited to, the following: completed Informed Consent forms, Case Report 
Forms, AE/SAE report forms, all study correspondence and associated documentation. Per regulations, 
these records should be maintained for a period of two years following a marketing approval for the 
study drug or two years following shipment and delivery of the drug for investigational use is 
discontinued. 
11 Ethical Considerations 
 
This study is to be conducted according to US and international standards of Good Clinical Practice 
(FDA Title 21 part 312 and International Conference on Harmonization guidelines), applicable 
government regulations and Institutional research policies and procedures. 
 
This protocol and any amendments will be submitted to a properly constituted independent Institutional 
Review Board (IRB), in agreement with local legal prescriptions, for formal approval of the study 
conduct.  The decision of the IRB concerning the conduct of the study will be made in writing to the 
investigator.  The study may not commence until IRB approval is granted.  
 
All subjects for this study will be provided a consent form describing this study and providing sufficient 
information for subjects to make an informed decision about their participation in this study.  This 
consent form will be submitted with the protocol for review and approval by the IRB for the study.  The 
formal consent of a subject, using the IRB-approved consent form, must be obtained before that subject 
undergoes any study procedure.  The consent form must be signed by the subject or legally authorized 
representative, and the investigator-designated research professional obtaining the consent.  
12 Study Finances 
12.1 Funding Source 
 
(i) UIC Office of Technology Management Proof of Concept Award 
(ii) Departmental funds  
12.2 Conflict of Interest 
 
Any investigator who has a conflict of interest with this study (patent ownership, royalties, or financial 
gain greater than the minimum allowable by their institution, etc.) must have the conflict reviewed by a 
properly constituted Conflict of Interest Committee with a Committee-sanctioned conflict management 
plan.  All UIC investigators will follow the University conflict of interest policy. 
12.3 Subject Stipends or Payments 
 
The subjects will receive $50 cash for baseline and week 8 visit and $40 cash for all other completed 
study visits. If the subjects do not finish the study, they will be compensated for the visits they have 

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completed. The compensation will be provided as cash after each visit. If the subject completes the 
study, the total amount of compensation will be $180.00. 
  

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