Safety and Efficacy Of Recombinant Human Deoxyribonuclease Eye Drops In Patients With Sjogren's and Non-Sjogren Dry Eye Disease
Phase: PHASE1
Conditions: Dry Eye
Sponsor: University of Illinois at Chicago

 
CONFIDENTIAL 
CLINICAL RESEARCH PROTOCOL 
  
 
 
 
 
 
A Phase I/II Randomized Placebo-Controlled, Double-Blind, Single-Center, 
Tolerability And Preliminary Efficacy Clinical Trial Of Recombinant Human 
Deoxyribonuclease (Rhdnase) Eye Drops In Patients With Dry Eye Disease 
 
 
 
 
 
Regulatory Sponsor: 
 
Sandeep Jain, MD 
UIC Corneal Neurobiology Laboratory 
L239, LIERI 
1905 W Taylor Street 
Chicago, IL 60612 
Phone: 312-996-8936 
Fax: 312-996-7770 
 
Funding Sponsor: 
 
None 
Study Product: 
Recombinant human deoxyribonuclease I (rhDNase1) 
 
Protocol Number: 
UIC-CNBL-1001 
IND Number: 
118544 
 
Initial version:  
10.0; 07/06/2015 

DNase treatment for dry eyes 
Version: 10.0;07-06-2015 
 
Page 2 of 34 
 
CONFIDENTIAL 
 
Table of Contents 
 
Table of Contents 
STUDY SUMMARY .................................................................................................................................................. 6 
1 
INTRODUCTION .............................................................................................................................................. 7 
1.1 
BACKGROUND .................................................................................................................................................... 7 
1.2 
AGENT .............................................................................................................................................................. 8 
1.3 
PRECLINICAL DATA .............................................................................................................................................. 9 
1.4 
CLINICAL DATA TO DATE ...................................................................................................................................... 9 
1.5 
DOSE RATIONALE AND RISK/BENEFITS .................................................................................................................. 10 
2 
STUDY OBJECTIVES ....................................................................................................................................... 10 
3 
STUDY DESIGN ............................................................................................................................................. 11 
3.1 
GENERAL DESIGN.............................................................................................................................................. 11 
3.2 
PRIMARY STUDY ENDPOINTS ............................................................................................................................... 11 
3.2.1 
Efficacy End Point: Ocular Surface Disease Index (OSDI) ..................................................................... 12 
3.2.2 
Efficacy End Point: Clinical Global Impression (CGI)............................................................................. 13 
3.2.3 
Efficacy End Point: Subject Global Assessment (SGA) .......................................................................... 13 
3.2.4 
Efficacy End Point: Ocular surface Rose Bengal dye staining score ..................................................... 13 
3.2.5 
Efficacy End Point: Ocular surface redness score ................................................................................. 14 
3.2.6 
Tolerability End Point: Test Substance Tolerance (Visual Analogue Scale) .......................................... 15 
3.3 
SECONDARY ENDPOINTS ..................................................................................................................................... 16 
3.4 
PRIMARY SAFETY ENDPOINTS .............................................................................................................................. 16 
3.4.1 
Vital Signs ............................................................................................................................................ 16 
3.4.2 
Ophthalmic Examination ..................................................................................................................... 16 
4 
SUBJECT SELECTION AND WITHDRAWAL ...................................................................................................... 17 
4.1 
INCLUSION CRITERIA .......................................................................................................................................... 17 
4.2 
EXCLUSION CRITERIA ......................................................................................................................................... 17 
4.3 
SUBJECT RECRUITMENT AND SCREENING ............................................................................................................... 17 
4.4 
EARLY WITHDRAWAL OF SUBJECTS ....................................................................................................................... 18 
4.4.1 
When and How to Withdraw Subjects ................................................................................................. 18 
4.4.2 
Data Collection and Follow-up for Withdrawn Subjects ...................................................................... 18 
5 
STUDY DRUG ................................................................................................................................................ 18 
5.1 
DESCRIPTION ................................................................................................................................................... 18 
5.2 
TREATMENT REGIMEN ....................................................................................................................................... 19 
5.3 
METHOD FOR ASSIGNING SUBJECTS TO TREATMENT GROUPS .................................................................................... 19 
5.4 
PREPARATION AND ADMINISTRATION OF STUDY DRUG ............................................................................................ 19 
5.5 
SUBJECT COMPLIANCE MONITORING .................................................................................................................... 20 
5.6 
PRIOR AND CONCOMITANT THERAPY .................................................................................................................... 20 
5.7 
RESCUE PLAN ................................................................................................................................................... 22 
5.8 
PACKAGING ..................................................................................................................................................... 22 
5.9 
RECEIVING, STORAGE, DISPENSING AND RETURN .................................................................................................... 22 
5.9.1 
Receipt of Drug Supplies ...................................................................................................................... 22 
5.9.2 
Storage ................................................................................................................................................. 22 
5.9.3 
Dispensing of Study Drug ..................................................................................................................... 23 
5.9.4 
Return or Destruction of Study Drug .................................................................................................... 23 

DNase treatment for dry eyes 
Version: 10.0;07-06-2015 
 
Page 3 of 34 
 
CONFIDENTIAL 
6 
STUDY PROCEDURES .................................................................................................................................... 23 
6.1 
PATIENT RECRUITMENT AND SCREENING ............................................................................................................... 23 
6.2 
ASSIGNMENT OF PATIENT IDENTIFICATION ............................................................................................................. 23 
6.3 
SCREEN FAILURE ............................................................................................................................................... 24 
6.4 
PATIENT ENROLLMENT ....................................................................................................................................... 24 
6.5 
STUDY ASSESSMENTS ........................................................................................................................................ 24 
6.5.1 
Visit 1 Screening ................................................................................................................................... 24 
6.5.2 
Visit 2 Day 1 (Randomization and First treatment visit) ...................................................................... 25 
6.5.3 
Visit 3: Week 2 (± 2 days) ..................................................................................................................... 25 
6.5.4 
Visit 4:  Week 4 (± 2 days) .................................................................................................................... 25 
6.5.5 
Visit 5: Week 6 (± 2 days) ..................................................................................................................... 26 
6.5.6 
Visit 6: Week 8 (± 2 days) ..................................................................................................................... 26 
6.5.7 
Visit 7: Week 10 (± 2 days) ................................................................................................................... 26 
7 
STATISTICAL PLAN ........................................................................................................................................ 26 
7.1 
SAMPLE SIZE DETERMINATION ............................................................................................................................ 26 
7.2 
STATISTICAL METHODS ...................................................................................................................................... 27 
7.3 
SUBJECT POPULATION(S) FOR ANALYSIS ................................................................................................................ 27 
8 
SAFETY AND ADVERSE EVENTS ..................................................................................................................... 27 
8.1 
ADVERSE EVENT DEFINITIONS ............................................................................................................................. 27 
8.2 
CLASSIFICATION OF ADVERSE EVENTS BY SEVERITY .................................................................................................. 28 
8.3 
CLASSIFICATION OF ADVERSE EVENTS BY RELATIONSHIP TO STUDY TREATMENT ............................................................ 28 
8.4 
ACTION(S) TAKEN ............................................................................................................................................. 29 
8.5 
OUTCOME ....................................................................................................................................................... 29 
8.6 
ADVERSE EVENT REPORTING ............................................................................................................................... 29 
8.7 
SERIOUS ADVERSE EVENT REPORTING ................................................................................................................... 29 
8.8 
IN CASE OF AN EMERGENCY ................................................................................................................................ 30 
8.9 
DATA SAFETY MANAGEMENT PLAN ...................................................................................................................... 30 
8.10 
STUDY OVERSIGHT ............................................................................................................................................ 30 
9 
CONFIDENTIALITY ........................................................................................................................................ 31 
10 
SOURCE DOCUMENTS .............................................................................................................................. 31 
10.1 
RECORDS RETENTION ........................................................................................................................................ 31 
11 
ETHICAL CONSIDERATIONS ....................................................................................................................... 31 
12 
STUDY FINANCES ...................................................................................................................................... 32 
12.1 
FUNDING SOURCE ............................................................................................................................................. 32 
12.2 
CONFLICT OF INTEREST ....................................................................................................................................... 32 
12.3 
SUBJECT STIPENDS OR PAYMENTS ........................................................................................................................ 32 
13 
REFERENCES ............................................................................................................................................. 33 
 
 

DNase treatment for dry eyes 
Version: 10.0;07-06-2015 
 
Page 4 of 34 
 
CONFIDENTIAL 
 
SCHEDULE OF VISITS AND PROCEDURES 
 
 
Screening 
Day 1   
(Pre-Dose) 
Day 1  
(Post-Dose) 
  
Week 2 
Week 4 
Week 6 
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 
X 
X 
 Ophthalmic Examination (Slit lamp) 
X 
X 
 
X 
X 
X 
X 
X 
Ocular surface redness score 
X 
X 
 
X 
X 
X 
X 
X 
Schirmer 1 test and Rose Bengal staining 
X 
 
 
 
 
 
X 
 
Pregnancy Test (urine)* 
X 
 
 
 
 
 
 
 
Best Spectacle Corrected Visual Acuity 
 
X 
 
 
 
 
 
X 
Randomization visit 
 
X 
 
 
 
 
 
 
First Study Medication 
 
X 
 
 
 
 
 
 
Drug dispensation visits 
 
 
X 
X 
X 
X 
 
 
Instruction on study medication self-
administration  
 
 
X 
 
 
 
 
 
Ocular Surface Disease Index (OSDI) 
 
X 
 
X 
X 
X 
X 
X 
Visual Analogue Scale (VAS) 
 
 
X 
X 
X 
X 
X 
 
Physical inspection of nose & oropharynx 
 
 
 
X 
X 
X 
X 
X 
Clinical Global Impression (CGI) 
 
X 
 
X 
X 
X 
X 
X 
Subject Global Assessment (SGI) 
 
X 
 
X 
X 
X 
X 
X 
Adverse Events/ Concomitant Medications 
 
X 
X++ 
X 
X 
X 
X 
X 
*If applicable    ++ AEs only 
 

DNase treatment for dry eyes 
Version: 10.0;07-06-2015 
 
Page 5 of 34 
 
CONFIDENTIAL 
ABBREVIATIONS 
AE  
 
Adverse Event 
APC 
 
Antigen-presenting cells  
BSCVA   
Best Spectacle Corrected Visual Acuity 
EC  
Ethics Committee  
eDNA   
Extracellular DNA 
CNL   
Corneal Neurobiology Laboratory  
CRF   
Case Report Form 
CGI 
 
Clinical Global Impression 
DCF   
Data Clarification Form 
DED 
 
Dry Eye Disease 
DNase I  
Deoxyribonuclease I 
FDA   
Food and Drug Administration 
FVC 
 
Forced vital capacity 
GCP   
Good Clinical Practice 
ICH  
 
International Conference on Harmonization 
IB  
 
Investigator’s Brochure 
IOP  
 
Intraocular pressure 
IRB  
 
Institutional Review Board 
KCS   
Keratoconjunctivitis sicca 
Net 
 
Neutrophil extracellular trap 
OSDI   
Ocular Surface Disease Index 
Otc 
 
Over the counter 
QID 
 
Four times per day 
rhDNase1  
Recombinant human deoxyribonuclease I 
SAE   
Serious Adverse Event 
SGI 
 
Subject Global Assessment 
SP  
 
Substance P 
UIC  
 
University of Illinois at Chicago 
VA  
 
Visual Acuity 
VAS 
 
Visual Analog Scale 
 
 
 
 
 
 
 

DNase treatment for dry eyes 
 
Page 6 of 34 
Version:10.0; 07-06-2015 
CONFIDENTIAL 
Study Summary 
Title 
A Phase I/II Randomized Placebo-Controlled, Double-Blind Single-
Center, tolerability and preliminary efficacy clinical trial of recombinant 
human deoxyribonuclease (rhDNase) eye drops in patients with dry eye 
disease. 
Short Title 
DNase treatment for dry eyes 
Protocol Number 
UIC-CNBL-1001 
Phase 
Phase I/II 
Methodology 
Double-blind 
Study Duration 
10 weeks 
Study Center(s) 
Single-center 
Objectives 
To evaluate the tolerability and preliminary efficacy of rhDNAse1 eye 
drops in patients with Dry Eye Disease. 
Number of Subjects 
72 (study drug at least 30, placebo at least 30) 
Diagnosis and Main 
Inclusion Criteria 
Men and women ≥ 18 years of age with a diagnosis of established Dry 
Eye Disease, with Schirmer I<10, Ocular surface staining >1 and OSDI 
mild (>13). 
Study Product, 
Dose, Route, 
Regimen 
Study drug: rhDNase1 (Pulmozyme®), 0.1% eye drops four times a day 
for eight weeks.  
Control: drug vehicle eye drops four times a day for eight weeks.  
Duration of 
administration 
8 weeks 
 
Reference therapy 
None 
Statistical 
Methodology 
Descriptive statistics will be used for all primary and safety endpoints, 
when appropriate. A Wilcoxon test will be used to compare changes in 
subjective symptoms from Baseline to follow-up values at 2 weeks, 4 
weeks, 6 weeks, 8 weeks and 10 weeks. Primary efficacy measure is 
the change in the OSDI reported between Baseline and Week 8. 
Primary safety measure is the proportion of patients at week 8 who 
were able to successfully complete a full eight weeks of therapy with 
topical administration four times per day (q.i.d). 
 

DNase treatment for dry eyes 
Version: 10.0; 07/06/2015 
 
Page 7 of 34 
 
CONFIDENTIAL 
1 Introduction 
 
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.  
1.1 Background 
 
Keratoconjunctivitis sicca (KCS) or Dry Eye Disease is a disease of the surface of the eye, tear film and 
related ocular tissues. Millions of people suffer from one form of the disease or another and its 
prevalence increases with age. Dry Eye Disease sufferers experience a broad range of symptoms 
including discomfort, irritation, burning, itching, redness, pain, gritty feeling, foreign body sensation, 
blurred vision and ocular fatigue. These symptoms can progress and lead to ulceration and perforation 
of the cornea, lead to increased ocular infections and even result in an inability to produce emotional 
tears. 
 
Dry eye as a disease entity is considered to fall in to two broad categories: 1) Aqueous tear deficiency 
(as seen in Sjögren’s syndrome) and 2) increased tear evaporation (as seen with infectious blepharitis, 
lid abnormalities, or associated with wearing contact lenses). 
 
Until recently, the only treatment options for Dry Eye Disease (DED) were palliative in nature and 
limited to lubricating eyedrops or punctual occlusion procedures, which attempt to supplement natural 
tears, or improve the resistance time of the limited quantity of tears produced naturally by the patient. 
 
Although DED pathogenesis is not fully understood, inflammation has a prominent role in DED 
symptom development and amplification.1,2 The current paradigm suggests that ocular surface 
inflammation is triggered by surface epithelium stress caused by tear hyperosmolarity. Inflammation is 
sustained by activated antigen-presenting cells (APCs) and T cells via the afferent and efferent limbs of 
the adaptive immune system.3,4 
 
The immunopathological events that sustain the systemic adaptive immune response in DED have 
been characterized.2-4 However, the mechanisms that activate the adaptive immune response are 
poorly understood. Ocular surface epithelial stress is a key initial event and a major source of innate 
cytokines and chemokines that can damage epithelial cells and activate APCs. Tear hyperosmolarity is 
recognized as an important stressor. However, tear replacement to decrease osmolarity provides 
limited therapeutic benefit. Therefore, additional stressors may activate DED ocular surface 
inflammation and link the innate and adaptive immune mechanisms. 
 
The ocular surface epithelium undergoes continuous, dynamic turnover5,6, which is increased in DED 
patients.7 Superficial corneal cells are shed into the precorneal tear film.8,9 The corneal epithelial cell 
shedding process, or desquamation, is regulated by apoptotic mechanisms.10 Dead and dying cells 
release extracellular DNA (eDNA), a type of damage-associated molecular pattern molecule, that can 
stimulate the innate immune system and link it to adaptive immune system.11,12 eDNA strands have 
been reported in corneal filaments, which are frequently present on the corneas of patients with severe 
DED.13 Desquamated cells in the precorneal tear film are a potential source of eDNA. Tear fluid 
nucleases, including lipocalin and DNase1, can hydrolyze and clear eDNA from the precorneal tear 
film.14,15 Additionally, tear fluid contains several neutrophil extracellular trap (NET) components. 
Neutrophils undergo a low level of recruitment on the ocular surface,16 and numerous neutrophils are 

DNase treatment for dry eyes 
Version: 10.0; 07/06/2015 
 
Page 8 of 34 
 
CONFIDENTIAL 
present in the tear film during ocular surface inflammation.17 Neutrophil elastase and histone proteins 
have also been reported in tear fluid.18 Taken together, these reports document the presence of eDNA, 
histones, neutrophils, neutrophil elastase, and nucleases in tear fluid and suggest mechanisms exist for 
the continual production and clearance of eDNA in the precorneal tear film.  
 
We have performed investigations in dry eye disease patients that have yielded several important 
findings.19 First, eDNA and NETs are present in excessive amounts on the ocular surface of patients 
with severe, tear-deficient DED. Immunolocalization experiments revealed that the molecular 
components of NETs include histones, cathelicidin, and neutrophil elastase. Next, using a DNA 
digestion assay, we determined that tear fluid nuclease activity was >0.05 Kunitz units. Using a FRET-
based assay, we found that tear fluid nuclease activity was reduced in DED patients. We determined 
that DNase I is a DNA hydrolyzing nuclease present in lacrimal glands and a normal concentration in 
tear fluid is 3.14 ng/ml, similar to that in serum and saliva. We also determined that mucoid films are 
present on the ocular surface or inferior conjunctival fornix in some patients with severe DED 
(particularly with GVHD) and are rich in neutrophils, eDNA, and NETs. Finally, exfoliated ocular surface 
cells from DED patients had increased expression of inflammatory cytokines and eDNA signaling 
pathway genes.  
 
Taken together, these findings suggest that in healthy eyes, eDNA is produced in the precorneal tear 
film and cleared by tear fluid nucleases. In patients with severe DED, tear fluid nuclease deficiency 
allows eDNA, neutrophils, and NETs to accumulate in the precorneal tear film and cause ocular surface 
inflammation. The practical implication of our findings is the suggestion of new therapeutic interventions 
based on clearing eDNA, NETs, and their molecular components from the ocular surface, as well as 
inhibiting eDNA signaling pathway gene expression. These findings have been published in 
Investigative Ophthalmology and Visual Sciences19, and were quoted as a new insight into dry eye 
inflammation by an editorial comment in the same publication.20 These findings underpin the basis of 
this research protocol. 
1.2 
Agent 
The agent used in this study is recombinant human deoxyribonuclease I (rhDNase1). This agent is FDA 
approved for human use and is marketed as Pulmozyme (Genentech, San Francisco, CA). Pulmozyme 
is a sterile, clear, colorless, highly purified solution of recombinant human deoxyribonuclease I 
(rhDNase1). The protein is produced by genetically engineered Chinese Hamster Ovary (CHO) cells 
containing DNA encoding for the native human protein, deoxyribonuclease I (DNase1). Fermentation is 
carried out in a nutrient medium containing the antibiotic gentamicin, 100–200 mg/L. However, the 
presence of the antibiotic is not detectable in the final product. The product is purified by tangential flow 
filtration and column chromatography. The purified glycoprotein contains 260 amino acids with an 
approximate molecular weight of 37,000 daltons. The primary amino acid sequence is identical to that 
of the native human enzyme.  
 
Each Pulmozyme single-use ampule has 2.5 mL of the solution. The aqueous solution contains 1.0 
mg/mL dornase alfa (0.1%), 0.15 mg/mL calcium chloride dihydrate and 8.77 mg/mL sodium chloride. 
The solution contains no preservative. The nominal pH of the solution is 6.3. 
 
Pulmozyme is approved by FDA for use in humans. Daily administration of Pulmozyme® (dornase alfa) 
Inhalation Solution in conjunction with standard therapies is indicated in the management of cystic 
fibrosis patients to improve pulmonary function. In patients with an FVC ≥ 40% of predicted, daily 
administration of Pulmozyme has also been shown to reduce the risk of respiratory tract infections 
requiring parenteral antibiotics. 
 

DNase treatment for dry eyes 
Version: 10.0; 07/06/2015 
 
Page 9 of 34 
 
CONFIDENTIAL 
When 2.5 mg Pulmozyme was administered by inhalation to eighteen CF patients, mean sputum 
concentrations of 3 μg/mL DNase were measurable within 15 minutes. Mean sputum concentrations 
declined to an average of 0.6 μg/mL two hours following inhalation. Inhalation of up to 10 mg TID of 
Pulmozyme by 4 CF patients for six consecutive days, did not result in a significant elevation of serum 
concentrations of DNase above normal endogenous levels.21,22 After administration of up to 2.5 mg of 
Pulmozyme twice daily for six months to 321 CF patients, no accumulation of serum DNase was noted. 
Pulmozyme, 2.5 mg by inhalation, was administered daily to 98 patients aged 3 months to ≤ 10 years, 
and bronchoalveolar lavage (BAL) fluid was obtained within 90 minutes of the first dose. BAL DNase 
concentrations were detectable in all patients but showed a broad range, from 0.007 to 1.8 μg/mL. Over 
an average of 14 days of exposure, serum DNase concentrations (mean ± s.d.) increased by 1.3 ± 1.3 
ng/mL for the 3 months to < 5 year age group and by 0.8 ± 1.2 ng/mL for the 5 to ≤ 10 year age group. 
The relationship between BAL or serum DNase concentration and adverse experiences and clinical 
outcomes is unknown. 
 
1.3 Preclinical Data 
We performed experiments that showed that eDNA, NETs, and neutrophils were present on the ocular 
surface in DED patients and abundant in mucoid films. NETs consisted of eDNA, histones, cathelicidin, 
and neutrophil elastase. Tear fluid nuclease activity was significantly decreased in DED patients, 
whereas the amount of eDNA on the ocular surface was significantly increased. Expression of genes 
downstream of eDNA signaling, such as TLR9, MyD88, and type I interferon, as well as the 
inflammatory cytokines interleukin-6 and tumor necrosis factor alpha, was significantly increased in 
DED patients. Therefore, based on our findings we conclude that extracellular DNA production and 
clearance mechanisms are dysregulated in DED.19 Nuclease deficiency in tear fluid allows eDNA and 
NETs to accumulate in precorneal tear film and results in ocular surface inflammation. These findings 
point to novel therapeutic interventions in severe DED based on clearance of eDNA, NETs, and other 
molecular components from the ocular surface. DNase I, an enzyme which selectively cleaves DNA, is 
one such therapeutic intervention. Our data showed that DNase I is naturally present in the lacrimal 
glands and tear fluid in humans. The concentration in tear fluid is 3.14 ng/ml. This concentration is 
similar to that in serum. Serum tear eye drops (containing DNase I) have been topically applied to the 
eye with significant therapeutic benefit to patients with severe dry eyes. To date there are no reports of 
direct application of DNase I to the eye. 
 
1.4 Clinical Data to Date 
 
To date, there is no published report of applying the study drug to the ocular surface as eye drops. 
However, eyes do get exposed to the study drug when it is administered to the lungs via a face mask. 
Eye exposure to nebulized drug is unavoidable.23,24 To date, no serious ocular side effects have been 
reported while using nebulized study drug, other than conjunctivitis in 0.4% patients, which was very 
mild and did not warrant drug discontinuation.25 This is in contrast to other nebulized drugs such as 
albuterol (causes pupil dilatation and angle closure glaucoma) and steroids (causes cataracts and 
increase in eye pressure).26-28 Therefore, almost certainly, the eyes are exposed to study drug but there 
are no reports of serious adverse effects.  
 
Further, we have used the study drug off label as a mucolytic agent to treat patients with recalcitrant 
filamentary keratitis to dissolve excessive mucus. In this patient, other mucolytics had failed (eg.- acetyl 
cysteine eye drops). Use of the study drug (0.1% four times a day for one month) did not cause any 
symptoms of ocular discomfort (burning, irritation or soreness) and no adverse side effects were 
observed (ocular inflammation or eye pressure changes). Although the IRB application study involves a 

DNase treatment for dry eyes 
Version: 10.0; 07/06/2015 
 
Page 10 of 34 
 
CONFIDENTIAL 
different patient population than the patient in which DNase1 eye drop was used, our anecdotal 
evidence suggests that the drug is well tolerated when applied topically to the eyes in this concentration 
(0.1%) and dose (four times a day).  
 
Based on documented lack of adverse effects in eyes exposed to the nebulized drug and our anecdotal 
evidence that the drug is well tolerated when applied topically to the eyes, we do not expect any severe 
adverse events with ocular use of this drug. 
 
1.5 Dose Rationale and Risk/Benefits 
 
RhDNase1 1mg/ml (0.1%) will be applied topically to the ocular surface as eye drops. This is the same 
dose as is currently in use in patients with Cystic Fibrosis. The drug formulation is being used 
unchanged. This dose has been effective in reducing eDNA content when given to patients with cystic 
fibrosis. We do not expect any serious adverse events with this dose. 
 
Drugs are routinely applied topically to the ocular surface as eye drops because of easy access to the 
ocular tissues and good drug bioavailability. Therefore, we will use rhDNase1 topically. We have 
chosen an eight week duration of therapy because we expect rhDNase1 to be used continually; eight 
weeks of treatment will give us better data to predict side effects during long-term use. Since rhDNase1 
is not expected to increase the production of natural DNase I, but rather it only supplements it so that 
the imbalance of decreased tear fluid DNase I is corrected, we expect long-term use of rhDNase1. 
 
RhDNase is currently used as an inhaled drug in adults and children with cystic fibrosis. Patients with 
cystic fibrosis have experienced a change in or loss of their voice, discomfort in the throat, chest pain, 
red watery eyes, rash, dizziness, fever, or runny nose. Most of these are systemic side-effects that are 
not generally seen with eye drops. These side effects are usually mild and short-lived.  
 
The most likely discomforts a subject may experience by having RhDNase administered as eye drops 
are eye burning or irritation, red watery eyes, or feeling like there is something in the eye. To see how 
subjects react to the study medication, their first dose will be given by the investigator in the clinic itself.  
Afterwards subjects will be asked to rate tolerability of the drug on the Visual Analogue Scale. Also, at 
each) visit, subjects will be asked to complete the Visual Analogue Scale.  
 
An allergic reaction to the drug cannot be predicted beforehand. In event of an allergic reaction, the 
drug will be stopped immediately, and symptoms will be managed appropriately depending on the 
severity of the reaction. 
 
Restasis, a drug used to treat DED, is held during the 14 day wash-out period and over the entire 
course of the study.  Holding Restasis may increase the subject’s risk of worsening DED. 
 
Participants randomized to the placebo have a risk of worsening dry eye disease. All study subjects will 
be encouraged to contact the research team immediately if they experience worsening of their DED. 
 
No psychological, social, legal, or financial risk is expected from participating in the research. 
 
There is always a risk of a loss of confidentiality. 
2 Study Objectives 
 

DNase treatment for dry eyes 
Version: 10.0; 07/06/2015 
 
Page 11 of 34 
 
CONFIDENTIAL 
The objective of this study is to establish whether patients with Dry Eye Disease are able to tolerate 
receiving rhDNase1 0.1% eye drops four times a day for eight weeks (primary tolerability objective)  
and to investigate the preliminary efficacy of rhDNase1 topical eye drop solution 0.1% in treating Dry 
Eye Disease (primary efficacy objective). 
 
3 Study Design 
3.1 General Design 
 
This will be a Randomized controlled trial, in which a total of 72 patients will be enrolled at 1 clinical 
site. Subjects will be randomly assigned to one of two groups (#1, #2), with at least 30 subjects per 
group. Group #1 will be given placebo (drug vehicle- eye drops without rhDNase 0.1%) and Group #2 
will be given study drug (rhDNase 0.1%).  
 
Patients with established Dry Eye Disease 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 patient is 
interested, the research staff member will describe the study. If the patient is willing to enter the study, 
the study will be discussed and the patient will be asked to sign the informed consent form. Consent will 
be obtained prior to screening to determine eligibility. Screening procedures include documentation of 
prior Dry Eye Disease. Eligible patients 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 two weeks later on Day 14 for further study 
assessments, thereafter at 4 weeks, 6 weeks and 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. 
3.2 Primary Study Endpoints 
 
Primary Efficacy End Point: The primary end points after 8 weeks of treatment include the following: (1) 
the change in the Ocular Surface Disease Index (OSDI) which is a patient subjective rating scale; the 
Clinical Global Impression (CGI) of change in dry eye disease symptoms (physician’s rating) and 
Subject Global Assessment (SGA) of overall change from baseline (patient’s rating) will serve as 
anchors to OSDI, as has been described previously29; (2) a mean reduction in ocular surface staining 
as measured by Rose Bengal dye staining and (3) the change in ocular surface redness score OR slit-
lamp examination. 
 
Primary Tolerability End Point: The change in the test substance tolerance between Day 1 (post-dose) 
and at weeks 2, 4, 6 and 8. 

DNase treatment for dry eyes 
Version: 10.0; 07/06/2015 
 
Page 12 of 34 
 
CONFIDENTIAL 
3.2.1 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 2, week 4, 
week 6, week 8 and week 10. The questions and scoring system are shown below: 
 
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 
 
 

DNase treatment for dry eyes 
Version: 10.0; 07/06/2015 
 
Page 13 of 34 
 
CONFIDENTIAL 
3.2.2 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 patients’ change in Dry Eye symptoms 
and signs. The CGI is a follows:  
 
Question (to physician): In general, compared with the patients’ dry eye 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 
Moderate worsening 
Minimal worsening 
Unchanged 
Minimal improvement 
Moderate improvement 
Marked improvement 
3.2.3 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: 
 
Question 1 (to subject): Compared with your first visit, how are your dry 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 
3.2.4 Efficacy End Point: Ocular surface Rose Bengal dye staining score 
 
Ocular surface staining will be assessed using Rose Bengal dye. Saline moistened 1% Rose Bengal 
dye impregnated strips will be used to instill the dye on the inferior palpebral conjunctiva and scoring of 
corneal and conjunctival staining will be performed by a slit lamp examination after 15 seconds using 
the grading system described by the 1995 NEI workshop.30 Corneal staining will be graded in 5 zones 

DNase treatment for dry eyes 
Version: 10.0; 07/06/2015 
 
Page 14 of 34 
 
CONFIDENTIAL 
and conjunctival staining will be graded in 6 zones. Each zone will be graded from 0 to 3 based on the 
density of punctate staining. The final staining score will be the sum of individual scores from all 11 
zones (5 corneal, 6 conjunctival). The scoring pattern is represented below. 
 
 
Complete ocular surface staining clearance means absence of any punctate or confluent staining with 
Rose Bengal dye defined as Rose Bengal staining score of 0. 
 
3.2.5 Efficacy End Point: Ocular surface redness score 
 
Ocular surface redness (nasal or temporal) will be assessed using the Validated Bulbar Redness 
grading scale (VBR).31 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 using a single printer and constant 
settings and put up in all the examination rooms.  Subjects will be examined by a slit-lamp at 10X 
magnification using direct diffuse illumination (slit fully opened, angled at 30°- 50° approximately; at half 
illumination intensity with rheostat set to maximum voltage) and the bulbar conjunctival injection of the 
subject’s eye (nasal and temporal) will be compared to the reference images and graded accordingly. 
To maintain uniformity, all subjects will be graded by a single physician (Principal Investigator) under 
constant illumination conditions. The subjects will be asked to look at nasal or temporal fixation marks 
while the physician will examine the temporal or nasal bulbar conjunctivae, respectively.  
  
 
 Photographic anchors and their respective grades for ocular surface redness are shown below: 
 

DNase treatment for dry eyes 
Version: 10.0; 07/06/2015 
 
Page 15 of 34 
 
CONFIDENTIAL 
 
3.2.6 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 100 mm 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 2, week 4, week 6 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:  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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. 

DNase treatment for dry eyes 
Version: 10.0; 07/06/2015 
 
Page 16 of 34 
 
CONFIDENTIAL 
3.3 
Secondary Endpoints 
The secondary study endpoints will include:  
1. Change in tear secretion as measured by Schirmer I test 
2. The proportion of eyes achieving complete ocular surface staining clearance after treatment 
3. Visual acuity change 
4. Change in frequency of administration of artificial tears or concomitant eye drops 
5. Change in number of corneal filaments (slit-lamp examination) 
 
Corneal filaments are mucous tags that are adherent to the surface of cornea. The number of such 
mucus tags will be counted on each clinical examination (slit-lamp examination). 
 
3.4 
Primary 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. 
 
Primary safety endpoint:  
- The proportion of subjects at week 8 who were able to successfully complete a full eight weeks of 
therapy with topical administration four times per day (q.i.d.) 
 
Secondary safety endpoint: 
- All adverse events reported, whether deemed related to treatment, or not. 
- Clinically significant changes in vital signs or ophthalmic examination from baseline. 
 
3.4.1 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 on week 2, week 4, week 6, 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. 
 
3.4.2 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 
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 number of corneal filaments, 
presence or absence of mucoid films, anterior chamber cell, flare or KPs; pupil shape abnormalities, 

DNase treatment for dry eyes 
Version: 10.0; 07/06/2015 
 
Page 17 of 34 
 
CONFIDENTIAL 
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 3.2.5. Measurements at first and last visit will include: visual acuity 
(BCSVA), manifest refraction and intraocular pressure measurement. Clinically significant changes 
from baseline examination will be recorded on the adverse event forms. 
 
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. Aged 18 years or older.  
2. Capable of giving informed consent and does provide informed consent.  
3. Documented Dry Eye Disease for at least 6 months. 
4. Schirmer I <10 
5. Corneal/ conjunctival (Rose Bengal) staining >1 
6. Ocular symptoms must be considered as annoying or activity limiting (OSDI >13; mild). 
7. Women must be post-menopausal ≥ 1 year, or surgically sterilized. If not, a negative urine 
pregnancy test is required within 14 days of receiving her first dose of test medication 
(placebo/ study drug) along with definite evidence of contraceptive use during the duration 
of the study. Women of reproductive age should 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, barrier methods or abstinence. If a subject mentions she suspects she 
may be pregnant after being enrolled, another pregnancy test will be administered.  If the 
test is positive, she will be discontinued from the study immediately.  
4.2 Exclusion Criteria 
 
Subjects will not be eligible for the study if any of the following criteria are met: 
 
1. Allergic to rhDNase1 or any similar products, or excipients of rhDNase1 eye drops 0.1%. 
2. Receiving or have received within 30 days any experimental systemic medication. 
3. Active ocular infection or ocular allergies. 
4. Any history of eyelid surgery or ocular surgery within the past 3 months. 
5. Corneal epithelial defect larger than 1 mm2 in either eye.  
6. The use of topical cyclosporine or corticosteroids within 2 weeks of enrollment 
7. Are homeless. 
8. Have active drug/alcohol dependence or abuse history. 
 
Except for a 2-week washout period of topical corticosteroids and topical cyclosporine before 
enrollment, participants will be permitted to continue their other chronic treatments, including the use of 
artificial tears, eyelid massage, or warm compresses. 
4.3 Subject Recruitment and Screening 
 
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 in the Illinois Eye and Ear Infirmary, 
Department of Ophthalmology and Visual Sciences, University of Illinois at Chicago. Subjects will 

DNase treatment for dry eyes 
Version: 10.0; 07/06/2015 
 
Page 18 of 34 
 
CONFIDENTIAL 
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, and Ophthalmology physicians at Loyola and 
North-Western Universities. The referring physicians shall inform the patients briefly about the study and 
provide them with the recruitment flier/ 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 physician letter 
(requesting for referrals for the study by the PI), and 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 I < 10 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 patient is interested, the 
research staff member will describe the study. If the patient is willing to enter the study, the study will be 
discussed and the patient will be asked to sign the informed consent form. Consent will be obtained 
prior to screening to determine eligibility. Screening procedures include documentation of prior Dry Eye 
Disease as well as other assessments as detailed in section 6.5.1. Eligible patients 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 
 

DNase treatment for dry eyes 
Version: 10.0; 07/06/2015 
 
Page 19 of 34 
 
CONFIDENTIAL 
The study drug, rhDNase1, will be supplied as a 1 mg/ml (0.1%) solution for administration as topical 
eye drops. The control group will receive drug vehicle eye drops as placebo. 
 
Each subject will receive either 0.1% rhDNase1 (study drug) or drug vehicle  (placebo) solution ,as a 
single eye drop in each eye four times a day (QID) for eight weeks. Except for the first dose on Day1, 
subjects will self-administer the test medication eye drops at home.  
 
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- rhDNase1, 1mg/ml (0.1%) eye drops will be applied to both eyes q.i.d for 8 weeks. 
Control group - drug vehicle eye drops will be applied to both eyes q.i.d for 8 weeks. For either group, 
the patient will be instructed to instill the first dose of the study medication in the morning at 
approximately 8 a.m., and then the remaining doses at approximately 4 hourly intervals. Therefore, 
doses will be scheduled at approximately 8 a.m., 12 noon, 4 p.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). Group #1 will receive placebo (drug vehicle; control group) and 
Group #2 will receive study drug (rhDNase 0.1%; test group). We will use a computer-based random 
code generator (Research Randomizer; http://randomizer.org/) to generate 1 set of 72 non-unique, 
unsorted numbers with a range from 1 to 2 representing the group number (#1 is control group, #2 is 
test group). Each subject will be assigned a study identification (ID) number at screening, eg. subject 
#1, subject #2, subject #3 and so on. Based on the randomizer generated table, subject #1 will receive 
either placebo (#1 group) or study drug (#2 group). 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. To maintain 
confidentiality, the subject’s name will not be recorded on any study document other than the informed 
consent form. The drug vial number will be linked to the patient 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. The study medications will be dispensed in sterile eye droppers of 3 ml volume (each 
containing 400- 500l of the study medications), which will be used as single-dose applications. One 
drop of the drug/ placebo solution will be administered to each eye. Therefore 4 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. Prepared eye droppers will be placed in a dark (brown) colored zip-
lock packet before being dispensed to the subject. The medications will need to be stored in a 
refrigerator (4 0C), away from direct strong light. 
 
Instructions for Drug Use: 
 

DNase treatment for dry eyes 
Version: 10.0; 07/06/2015 
 
Page 20 of 34 
 
CONFIDENTIAL 
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 patient. 
 
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 2, 4, 6 
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 patient’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: 
 
1. Medication trade name 
2. Eye that was treated, if applicable 
3. Indication for which the medication was given 

DNase treatment for dry eyes 
Version: 10.0; 07/06/2015 
 
Page 21 of 34 
 
CONFIDENTIAL 
4. Date started 
5. Date stopped   
6. Dose of medication used. 
 
There will be a 2-week washout period of topical corticosteroids and topical cyclosporine before 
enrollment and these medications are prohibited throughout the study. Other than these, participants 
will be permitted to continue their chronic DED treatments which include the use of artificial tears, eyelid 
massage, or warm compresses. The number of drops and frequency must be recorded in the patient 
diary provided. 
 
• The use of any investigational agent during past 30 days is prohibited. 
 
There is only one FDA approved treatment currently available to treat patients with Keratoconjunctivitis 
Sicca (dry eye disease)- Cyclosporine 0.05% (marketed as Restasis). The FDA approved indication for 
Restasis use is the following: “to increase tear production in patients whose tear production is 
presumed to be suppressed due to ocular inflammation associated with keratoconjunctivitis sicca”. 
Restasis will be withheld during the course of this study. This is necessary as the proposed mechanism 
of action of rhDNase in dry eyes is to reduce inflammation on the surface of the eye. Restasis can also 
reduce inflammation albeit via a different mechanism. Thus, because of over lapping anti-inflammatory 
actions, it may not be possible to attribute any observed clinical benefit to rhDNase treatment if 
Restasis is 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.32  
 
It is ethical to withhold Restasis because, as its FDA approved indication suggests, the clinical benefit 
of using Restasis is increased production of tears. While receiving DNase1, patients will continue to 
receive artificial tears as needed. Therefore, although the patients may not have an increase in tear 
production if Restasis is withheld, the ocular surface will receive sufficient lubrication and hydration due 
to the use of artificial tears. 
 
Holding Restasis may increase the risk of worsening of DED during the wash-out period and during the 
course of the study. However, because artificial tears will be used during the wash out period as well as 
during the course of the study as needed, 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.  
 
The subjects will be monitored frequently (at 2 weekly intervals) to ensure that they are not subjected to 
any undue risks during the wash out period or 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 the frequency of use of artificial 
tears, (2) Re-starting the use of anti-inflammatory therapy (Restasis/ corticosteroids), (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 his clinical judgment as per the individual subject’s clinical 
condition. If additional anti-inflammatory therapy (Restasis/ corticosteroids) is instituted during the 
wash-out period, the subject will be excluded from the study. Also, if additional anti-inflammatory 
therapy (Restasis/ corticosteroids) is instituted during the course of the study and/or the study drug is 

DNase treatment for dry eyes 
Version: 10.0; 07/06/2015 
 
Page 22 of 34 
 
CONFIDENTIAL 
withdrawn, the subject will be excluded 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. 
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 the frequency of artificial tears use,  
(2) Re-starting the use of anti-inflammatory therapy (Restasis/ corticosteroids),  
(3) Discontinue the study drug.  
The decision will be made by the Principal Investigator based on his clinical judgment and the 
individual subject’s clinical condition. If additional anti-inflammatory therapy (Restasis/ 
corticosteroids) is instituted 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 multi-dose 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 4 eye droppers will be required per day. At each visit, subjects will receive 56 
sterile multi-dose 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 patient 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 week’s remaining doses in a dark packet with an ice pack to take home. Fifty-six 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) 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 

DNase treatment for dry eyes 
Version: 10.0; 07/06/2015 
 
Page 23 of 34 
 
CONFIDENTIAL 
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 for a maximum of 2- 3 hrs in the 
ice pack provided by the EEI pharmacy.  
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 2 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 2 week supply will be dispensed by the 
pharmacy. This will continue from week 2 to week 8. No new drug eye droppers will be given on the 6th 
(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 Patient Recruitment and Screening 
Prior to recruitment of any patients 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 investigator at the time of their 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. Patients with established 
Dry Eye Disease (for at least 6 months with 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 patient is interested, the research staff member will describe the 
study. If the patient is willing to enter the study, the study will be discussed and the patient will be asked 
to sign the informed consent form. 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 patients will be enrolled in the study. 
 
6.2 Assignment of Patient 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 
the 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 once study is 
completed and for subjects determined to not meet eligibility criteria or who later decline participation in 
the consent process. 

DNase treatment for dry eyes 
Version: 10.0; 07/06/2015 
 
Page 24 of 34 
 
CONFIDENTIAL 
6.3 Screen Failure 
 
A record of screen failures and the reasons for non-eligibility to the study will be maintained. 
6.4 Patient Enrollment  
 
Patients meeting the enrollment criteria (see Sections 4.1 and 4.2) 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 -18 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. 
• 
Ophthalmic Examination (slit lamp examination, Ocular surface redness score, Rose 
Bengal staining, and a Schirmer 1 test) 
 
 
Pregnancy test (urine),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. 
 
Patients currently treating DED with corticosteroids and/or Restasis will stop these treatments 
during a wash-out period (2 weeks before the start the study drug) and during the whole study.  The 
study doctor will provide advice about decreasing DED symptoms with artificial tears, eyelid 
massage, or warm compresses. 
 
If the patient agrees to enter the study, the first treatment visit will be scheduled.  If a washout 
period is needed, Visit 2 will be after 2 weeks (± 4 days).  If a washout period is not necessary, Visit 
2 can be scheduled any time in the next 2 weeks after the Screening Visit.   
 

DNase treatment for dry eyes 
Version: 10.0; 07/06/2015 
 
Page 25 of 34 
 
CONFIDENTIAL 
 
6.5.2  Visit 2 Day 1 (Randomization and First treatment visit) 
 
 Prior to first dose (Baseline) 
• 
Vital Signs (blood pressure taken while subject is relaxed in a sitting position for at least 
3 minutes, pulse, temperature, and height and weight (at this visit only). 
• 
Baseline Ophthalmic Examination (slit lamp examination, Ocular surface redness score) 
• 
BSCVA (Snellen) 
• 
OSDI 
• 
Clinical Global Impression, Subject Global Assessment 
• 
Record changes in concomitant medication 
• 
Adverse events since screening visit. 
 
Investigator/designee administers first dose 
 
Post-Dose 
• 
Visual Analogue Scale  
• 
Subjects will be trained on how to self-administer the study eye drops and be given a 
sufficient supply to last for 2 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. 
 
6.5.3 Visit 3: Week 2 (± 2 days)  
Treatment Visit (after any dose for that day) 
 
• 
Vital Signs 
• 
Ophthalmic Examination (slit lamp examination, Ocular surface redness score) 
• 
Physical Inspection of the Nose and Oropharynx 
• 
OSDI 
• 
Visual Analogue Scale 
• 
Clinical Global Impression, Subject Global Assessment 
• 
Review the subject’s diary and record changes in concomitant medication, deviations 
from drug schedule and adverse events. 
• 
Subjects will be given study medication, sufficient to last for 2 weeks, to take home. 
 
6.5.4 Visit 4:  Week 4 (± 2 days)  
Treatment Visit (after any dose for that day) 
 
• 
Vital Signs 
• 
Ophthalmic Examination (slit lamp examination, Ocular surface redness score) 
• 
Physical Inspection of the Nose and Oropharynx 
• 
OSDI 
• 
Visual Analogue Scale 
• 
Clinical Global Impression, Subject Global Assessment 
• 
Review the subject’s diary and record changes in concomitant medication, deviations 
from drug schedule and adverse events. 

DNase treatment for dry eyes 
Version: 10.0; 07/06/2015 
 
Page 26 of 34 
 
CONFIDENTIAL 
• 
Subjects will be given study medication, sufficient to last for 2 weeks, to take home. 
 
6.5.5 Visit 5: Week 6 (± 2 days) 
 Treatment Visit (after any dose for that day) 
 
• 
Vital Signs 
• 
Ophthalmic Examination (slit lamp examination, Ocular surface redness score) 
• 
Physical Inspection of the Nose and Oropharynx 
• 
OSDI 
• 
Test Substance Tolerance 
• 
Clinical Global Impression, Subject Global Assessment 
• 
Review the subject’s diary and record changes in concomitant medication, deviations 
from drug schedule and adverse events. 
• 
Subjects will be given study medications, sufficient to last for 2 weeks, to take home. 
 
6.5.6 Visit 6: Week 8 (± 2 days) 
 Treatment Visit (after any dose for that day) 
 
• 
Vital Signs 
• 
Ophthalmic Examination (slit lamp examination, Ocular surface redness score, Rose 
Bengal staining, and a Schirmer 1 test) 
• 
Physical Inspection of the Nose and Oropharynx 
• 
OSDI 
• 
Test Substance Tolerance 
• 
Clinical Global Impression, Subject Global Assessment 
• 
Review the subject’s diary and record changes in concomitant medication, deviations 
from drug schedule and adverse events. 
 
6.5.7 Visit 7: Week 10 (± 2 days) 
Follow-Up Visit 
 
• 
Vital Signs 
• 
Ophthalmic Examination (slit lamp examination, Ocular surface redness score) 
• 
Physical Inspection of the Nose and Oropharynx 
•     BSCVA (Snellen) 
• 
OSDI  
• 
Clinical Global Impression, Subject Global Assessment 
• 
Review the subject’s diary and record changes in concomitant medication and adverse 
events. 
 
7 Statistical Plan 
7.1 Sample Size Determination 
Our intention is to have at least 30 subjects in each group (study drug/ vehicle) complete the study. 
This number is based on published reports of similar randomized clinical trials designed to determine 

DNase treatment for dry eyes 
Version: 10.0; 07/06/2015 
 
Page 27 of 34 
 
CONFIDENTIAL 
efficacy and tolerability of a test drug in Dry Eye Disease.32-34 A total of 72 subjects will be enrolled so 
that even if 20% of subjects are unable to complete the study, we will still remain with the intended 
number of subjects who complete the study (at least 30 subjects in each group). Subjects will be 
randomized to either of the two groups (#1, placebo; #2, study drug) as explained in section 5.3. 
However, all subjects who received at least two weeks of treatment with study eye drops and attended 
at least the first post-treatment (week 2) follow up visit will be included for analysis. 
 
7.2 Statistical Methods 
Descriptive statistics will be used for all primary and secondary endpoints, when appropriate. 
 
We will define outcome measures on the basis of the change for each subject from baseline to each 
follow-up point, controlling for chance imbalances in the mean baseline values between treatment 
groups. A Wilcoxon Signed-rank test will be used for paired comparison of quantitative variables (OSDI 
score) between the baseline and each post-baseline time points. Chi-square test will be used to 
compare qualitative variables (Investigator’s rating scale/ changes in concomitant medications) 
between the 2 groups. Two-sided P < .05 will be considered statistically significant for all comparisons. 
95% Confidence interval will be provided for comparison between the investigational drug and placebo 
for the primary efficacy, the primary safety, and the secondary endpoints. 
7.3 Subject Population(s) for Analysis 
Subject population for analysis will include any subject enrolled in the study who received at least two 
weeks of treatment with study eye drops and attended atleast the first post-treatment (week 2) follow up 
visit.  
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 adverse event can be any unfavorable sign (including an abnormal 
laboratory finding), symptom, or disease temporally associated with the use of the investigational 
product, whether or not considered related to the investigational product. 
 
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. 
 
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 

DNase treatment for dry eyes 
Version: 10.0; 07/06/2015 
 
Page 28 of 34 
 
CONFIDENTIAL 
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 untoward medical occurrence that at any dose: 
1. results in death 
2. is life-threatening 
3. requires inpatient hospitalization or prolongs existing hospitalization 
4. results in persistent or significant disability/incapacity 
5. is a congenital anomaly/ birth defect 
6. requires medical or surgical intervention to prevent any of the occurrences noted 
above. 
 
• 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. 
 
• 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. 
 
8.3 
Classification of Adverse Events by Relationship to Study Treatment 
The relationship or association of the study medication to an adverse event, as causing or contributing 
to the adverse event, will be characterized as defined below: 
 
Probable: The adverse event follows a reasonable temporal sequence from administration of the drug 
(including the course after withdrawal of the drug) and the possibilities of factors other than the drug, 
such as underlying disease, concomitant drugs or concurrent treatment, can be excluded. 
 
Possible: The adverse event follows a reasonable temporal sequence from administration of the drug 
(including the course after withdrawal of the drug) and the possibility that drug involvement cannot be 

DNase treatment for dry eyes 
Version: 10.0; 07/06/2015 
 
Page 29 of 34 
 
CONFIDENTIAL 
excluded, e.g. existence of similar reports attributable to the suspected drug, its analog or its 
pharmacological effect. However, other factors such as underlying disease, concomitant drugs or 
concurrent treatment are presumable. 
 
Not Related: The adverse event has no temporal sequence from administration of the drug, or it can be 
explained by other factors, including underlying disease, concomitant drugs or concurrent treatment. 
8.4 
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 
8.5 
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. 
8.6 
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. 
8.7 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 

DNase treatment for dry eyes 
Version: 10.0; 07/06/2015 
 
Page 30 of 34 
 
CONFIDENTIAL 
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: 
  
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.  
 
8.8 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. 
8.9 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. 
 
 
8.10 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. 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. 
 
Accumulated safety and data information will be reviewed after 10 subjects complete the study. The 
research team will then evaluate whether it is safe to proceed with the study, and if the protocol or 
informed consent documents require revision based on that review.   

DNase treatment for dry eyes 
Version: 10.0; 07/06/2015 
 
Page 31 of 34 
 
CONFIDENTIAL 
 
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 
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. Research file documents will 
be uniformly held indefinitely after the closure of the research file per UIC IRB requirements.   
 
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.  

DNase treatment for dry eyes 
Version: 10.0; 07/06/2015 
 
Page 32 of 34 
 
CONFIDENTIAL 
 
12 Study Finances 
12.1 Funding Source 
Departmental funds have been committed to the Corneal Neurobiology Laboratory. Also, 
Genentech is partially funding this research. For the release of funds, they will have 
access to some study data. We will email Genentech the enrollment updates and clinical 
visit logs at regular intervals. The data emailed to Genentech will be linked with a code. 
Only the PI, and Key Research personnel listed in Appendix P will have access to 
the linked code. PHI and sensitive identifiable data will not be shared via email 
with any entity. Genentech may also inspect records relevant to the study, to ensure 
compliance with the terms of agreement between the study PI and Genentech. Any 
inspection of study records by Genentech will be performed on site only (here at UIC). 
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 
$30/ visit will be given to each patient on baseline visit and on the five subsequent visits 
afterwards till week 10 to offset to some extent their parking/ transportation expenses. 

DNase treatment for dry eyes 
Version: 10.0; 07/06/2015 
 
Page 33 of 34 
 
CONFIDENTIAL 
References 
1. [No authors listed]. The definition and classification of dry eye disease: report of the Definition and 
Classification Subcommittee of the International Dry Eye Workshop Ocul. Surf. 2007;5 :75–92. 
2. Stevenson W, Chauhan SK, Dana R. Dry eye disease: an immune-mediated ocular surface disorder. Arch 
Ophthalmol. 2012;130:90-100. 
3. Pflugfelder SC, de Paiva CS, Li DQ, Stern ME. Epithelial-immune cell interaction in dry eye. Cornea. 2008 
Sep;27 Suppl 1:S9-11. 
4. Barabino S, Chen Y, Chauhan S, Dana R. Ocular surface immunity: homeostatic mechanisms and their 
disruption in dry eye disease. Prog Retin Eye Res. 2012;31:271-85. 
5. Cenedella RJ, Fleschner CR. Kinetics of corneal epithelium turnover in vivo. Studies of lovastatin. Invest 
Ophthalmol Vis Sci. 1990;31:1957-62. 
6. Hanna C, O'Brien JE. Cell production and migration in the epithelial layer of the cornea. Arch 
Ophthalmol. 1960;64:536-9. 
7. Kunert KS, Tisdale AS, Gipson IK. Goblet cell numbers and epithelial proliferation in the conjunctiva of 
patients with dry eye syndrome treated with cyclosporine. Arch Ophthalmol. 2002;120:330-7. 
8. Thoft RA, Friend J. The X, Y, Z hypothesis of corneal epithelial maintenance. Invest Ophthalmol Vis Sci. 
1983;24:1442–1443.  
9. Ladage PM, Jester JV, Petroll WM, et al. Vertical movement of epithelial basal cells toward the corneal 
surface during use of extended-wear contact lenses. Invest Ophthalmol Vis Sci. 2003;44:1056–1063.  
10. Ren H, Wilson G. Apoptosis in the corneal epithelium. Invest Ophthalmol Vis Sci. 1996;37:1017–1025.  
11. Zhang Q, Raoof M, Chen Y, Sumi Y, Sursal T, Junger W, Brohi K, Itagaki K, Hauser CJ. Circulating 
mitochondrial DAMPs cause inflammatory responses to injury. Nature. 2010 Mar 4;464(7285):104-7. 
12. Pisetsky DS. The origin and properties of extracellular DNA: From PAMP to DAMP. Clin Immunol. 
2012;144:32-40. 
13. Tanioka H, Yokoi N, Komuro A, Shimamoto T, Kawasaki S, Matsuda A, Kinoshita S. Investigation of the 
corneal filament in filamentary keratitis. Invest Ophthalmol Vis Sci. 2009;50(:3696-702.  
14. Yusifov TN, Abduragimov AR, Narsinh K, Gasymov OK, Glasgow BJ. Tear lipocalin is the major 
endonuclease in tears. Mol Vis. 2008;14:180-8. 
15. Junko F, Yoko H, Koji T, Yuing X, Norihito N, Shinji I, Kaori K, Hariuo T. Deoxyribonuclease I typing from 
tears. Shimane J Med Sci. 2004;22:44-9. 
16. Napirei M, Ricken A, Eulitz D, Knoop H, Mannherz HG. Expression pattern of the deoxyribonuclease 1 
gene: lessons from the Dnase1 knockout mouse. Biochem J. 2004 15;380(Pt 3):929-37. 
17. Yusifov TN, Abduragimov AR, Gasymov OK, Glasgow BJ. Endonuclease activity in lipocalins. Biochem J. 
2000;347:815-9. 
18. Sakata M, Sack RA, Sathe S, Holden B, Beaton AR. Polymorphonuclear leukocyte cells and elastase in 
tears. Curr Eye Res. 1997;16:810-9. 
19. Sonawane S, Khanolkar V, Namavari A, Chaudhary S, Gandhi S, Tibrewal S, Jassim SH, Shaheen B, Hallak 
J, Horner JH, Newcomb M, Sarkar J, Jain S. Ocular Surface Extracellular DNA and Nuclease Activity 
Imbalance: A New Paradigm for Inflammation in Dry Eye Disease. Invest Ophthalmol Vis Sci. 
2012;53:8253-63. 
20. McDermott AM. New insight into dry eye inflammation. Invest Ophthalmol Vis Sci. 2012;53:8264. 

DNase treatment for dry eyes 
Version: 10.0; 07/06/2015 
 
Page 34 of 34 
 
CONFIDENTIAL 
21. Hubbard RC, McElvaney NG, Birrer P, Shak S, Robinson WW, Jolley C, et al. A preliminary study of 
aerosolized recombinant human deoxyribonuclease I in the treatment of cystic fibrosis. N Engl J Med 
1992;326:812–5. 
22. Aitken ML, Burke W, McDonald G, Shak S, Montgomery AB, Smith A. Recombinant human DNase 
inhalation in normal subjects and patients with cystic fibrosis. JAMA 271 1992;267(14):1947–51. 
23. Kalra L, Bone MF. The effect of nebulized bronchodilator therapy on intraocular pressures in patients 
with glaucoma. Chest 1988;93:739-41. 
24. Geller DE. Clinical side effects during aerosol therapy: cutaneous and ocular effects. J Aerosol Med. 
2007;20 Suppl 1:S100-8; discussion S109.  
25. Harms HK, Matouk E, Tournier G, von der Hardt H, Weller PH, Romano L, Heijerman HG, FitzGerald MX, 
Richard D, Strandvik B, Kolbe J, Kraemer R, Michalsen H. Multicenter, open-label study of recombinant 
human DNase in cystic fibrosis patients with moderate lung disease. DNase International Study Group. 
Pediatr Pulmonol. 1998;26:155-61. 
26. Hall SK: Acute angle-closure glaucoma as a complication of combined b-agonist and ipratropium 
bromide therapy in the emergency department. Ann Emerg Med. 1994;23:884-887. 
27. Guner SN, Kilic M, Boyraz S, Yurdakul E, Kalkan G, Ozturk F. Bilateral posterior subcapsular cataracts 
after inhaled budesonide for asthma: have patients been given their medications correctly? J Investig 
Allergol Clin Immunol. 2011;21:80. 
28. Weatherall M, Clay J, James K, Perrin K, Shirtcliffe P, Beasley R. Respirology. Dose-response relationship 
of inhaled corticosteroids and cataracts: a systematic review and meta-analysis. 2009;14:983-90. 
29. Miller KL, Walt JG, Mink DR, Satram-Hoang S, Wilson SE, Perry HD, Asbell PA, Pflugfelder SC. Minimal 
clinically important difference for the ocular surface disease index. Arch Ophthalmol. 2010;128:94-101. 
30. Lemp MA. Report of the National Eye Institute/Industry workshop on Clinical Trials in Dry Eyes. CLAO J 
1995;21:221-32. 
31. Schulze MM, Jones DA, Simpson TL. The development of validated bulbar redness grading scales. Optom 
Vis Sci 2007;84:976-83. 
32. Amparo F, Dastjerdi MH, Okanobo A, Ferrari G, Smaga L, Hamrah P, Jurkunas U, Schaumberg DA, Dana 
R. Topical Interleukin 1 Receptor Antagonist for Treatment of Dry Eye Disease: A Randomized Clinical 
Trial. JAMA Ophthalmol. 2013;18:1-9. 
33. Scuderi G, Contestabile MT, Gagliano C, Iacovello D, Scuderi L, Avitabile T. Effects of phytoestrogen 
supplementation in postmenopausal women with dry eye syndrome: a randomized clinical trial. Can J 
Ophthalmol. 2012;47:489-92. 
34. Nichols JJ, Bickle KM, Zink RC, Schiewe MD, Haque RM, Nichols KK. Safety and efficacy of topical 
azithromycin ophthalmic solution 1.0% in the treatment of contact lens-related dry eye. Eye Contact 
Lens 2012;38:73-9.