Safety and Preliminary Efficacy of IVMED-80 Eye Drops in Keratoconus Patients
Condition: Keratoconus; Corneal Ectasia
MeSH terms: Keratoconus; Dilatation, Pathologic
Study type: Interventional
Phase: Phase 1/Phase 2

Summary: 
      We investigated the use of a copper sulfate eye drop (IVMED-80) for the treatment of
      keratoconus. Preliminary laboratory data shows that the addition of copper sulfate increase
      crosslinking of the structural proteins of the cornea thereby halting the progressing corneal
      thinning and bulging seen in keratoconus. We conducted a Phase 1/2a study to evaluate the
      safety and preliminary efficacy of a 6-week and a 16-week regimen using IVMED-80 and studied
      its impact on ocular safety and the change/progression in patients' vision and clinical
      measurements.
    

Detailed description: 
      Standard Operating Procedures:

      This study was designed to evaluate the safety and preliminary efficacy of IVMED-80 (0.15
      mg/mL copper sulfate pentahydrate) in controlling the progression of corneal changes which
      typically occur in keratoconus patients.

      This was a randomized, double-masked, placebo-controlled, and single-site clinical trial with
      eligible patients randomly assigned to one of three treatment groups:

        -  Group 1 (IVMED-6Wk) received topical copper sulfate eye drops 2x/day (BID) for 6 weeks
           and followed by an additional 20 weeks without treatment (total 26 weeks).

        -  Group 2 (IVMED-16Wk) received topical copper sulfate eye drops BID for 16 weeks and
           followed for an additional 10 weeks without treatment (total 26 weeks).

        -  Group 3 (Placebo) received IVMED-80 vehicle eye drops BID for 16 weeks and followed for
           an additional 10 weeks without treatment (total 26 weeks).

      All patients were seen at Screening Visit, at Day 0 (Dispensing), and on Weeks 1, 3, 6, 12,
      16, 21 and 26. In-office ophthalmology examinations used marketed medical diagnostic devices
      and routine clinical procedures. If a patient presents with two eyes meeting the eligibility
      criteria, the eye with the worst keratoconus based on maximum keratometry was selected as the
      Study Eye.

      Any adverse events (AEs), suspected adverse events, and serious adverse events were recorded
      on the Adverse Event Report Form and in the patient's source documents. Laboratory, vital
      sign, or ECG abnormalities were recorded as AEs if medically relevant. The
      sponsor-investigator submitted a safety report to the review board no later than 15 calendar
      days after any suspected adverse reaction. Any unexpected fatal or life-threatening suspected
      adverse reactions was reported to the review board no later than 7 days after the
      sponsor-investigator's is made aware. Accidental or intentional overdose of the study drug or
      concomitant medication or discovery of pregnancy was reported to the Medical Monitor within
      24 hours. Any AEs that led to a patient's withdrawal from the study were reported to the
      Medical Monitor within 30 days. In the case of an emergency, the Investigator could complete
      the subject treatment code breaking procedure. This was only done if awareness of the
      treatment had a direct impact on the subject's immediate medical management. The Medical
      Monitor was contacted prior to emergency unmasking or within 24 hours. The circumstances
      leading to unmasking of a subject were promptly communicated to the Sponsor and review board.
      A patient had the right to withdraw from the study at any time, for any reason, and without
      repercussion. The investigator had the right to withdraw a patient from the study in the
      event of an intercurrent illness, onset of pregnancy, adverse event (AE), treatment failure,
      or protocol violation. If a subject withdrew due to an AE(s), the reason for withdrawal was
      recorded as an adverse event. Subjects who failed to come to follow up visits and could not
      be contacted after 3 telephone calls followed by a certified letter were classified as "lost
      to follow-up".

      Collected Data:

      Corneal topography was obtained at every visit using the Oculus Pentecam. This device
      provided data for Maximum Central Keratometry (Kmax), Mean Central Keratometry (Kmean),
      Corneal Astigmatism, and Posterior Maximum Corneal Elevation.

      The maximum central keratometry is a measure of the maximal corneal steepness and is a very
      commonly used in the diagnosis of keratoconus as well as monitoring and evaluating treatment
      effects. Normal Kmax is <49.00 diopters.

      The mean central keratometry is a measure of the mean corneal steepness and anterior
      curvature. It is one of the measures of corneal topography which is the evaluation of the
      anterior curvature of the cornea. Normal Kmean is <47.20 diopters.

      Corneal astigmatism is a measure of corneal irregularity leading to multiple focal points of
      light within the eye and impaired vision. Corneal astigmatism ranges greatly in magnitude and
      may be found in healthy patients to varying degrees, but it is also known to be present in
      keratoconus and worsens with disease progression. Keratoconus is the progressive and inferior
      bulging of the cornea. Therefore, corneal thickness is useful in diagnosis and disease or
      treatment monitoring. This was measured using the Oculus Pentecam at every visit. Central
      corneal thickness ranges from 472-651 micrometers and minimal thickness is normally >400
      micrometers.

      Intraocular pressure (IOP) above or below normal ranges may lead to pain or damage and may be
      affected by topical medications. IOP ranges from 8-21 millimeters of mercury.

      An early sign of keratoconus is posterior thinning or "elevation". This measure is also
      useful in monitoring progression or treatment of the disease. Normal values are <17
      micrometers.

      The Ocular Response Analyzer (ORA) or Oculus Corvis were used at each visit. These are
      noncontact tonometers that use a puff of air to investigate the dynamic reaction and surface
      deformation of the cornea. These instruments provide an in vivo assessment of corneal
      biomechanics (i.e., resistance to corneal deformation) which may be used to monitor the
      progression and treatment of corneal diseases such as keratoconus. Normal values for measured
      parameters vary in the literature with no consensus currently. Analyzed variables from these
      machines include the corneal resistance factor (CRF) and corneal hysteresis from the ORA and
      stiffness parameter highest concavity (SP-HC), stress-strain index (SSI), and peak distance
      from the Oculus Corvis.

      Mean Best Corrected Distance Visual Acuity (BCVA) is the vision patients achieve with proper
      correction of refractive error, i.e., wearing glasses. Uncorrected distance visual acuity
      (UCVA) is without correction. A standard Snellen Visual acuity chart was used to measure
      visual acuity at every visit.

      Endothelial cells are located on the posterior surface of the cornea and are responsible for
      dehydration of corneal stroma ensuring its clarity. Damage to these cells and decrease in
      cell density may be caused by cytotoxic of topical medications. Endothelial cell count (EEC)
      was assessed at the Screening, Day 0, Week 6, and Week 26 (exit) visits with a specular
      microscope. EEC ranges from >1,500 to 3,500 cells per square millimeter.

      Patients with discomfort and redness upon instillation was evaluated at each study visit. the
      Investigator recorded patient responses concerning perceived discomfort and redness following
      instillation away from the clinic. The case report form stated, "Did the patient experience
      discomfort immediately after using the assigned study drops?". Possible answers were "No" or
      "Yes". A "Yes" response was graded on a 5 point scale ranging from 1(slight discomfort) to 5
      (very uncomfortable). Similarly, redness was measured with a 0 to 5 scales: 0 (white
      conjunctiva) to 5 (completely red conjunctiva).

      Routine ophthalmic examination variables (external slit-lamp examination and dilated fundus
      examination) were also obtained performed.

      Data Quality Assurance:

      The progress of the study was monitored by on-site visits and with the use of telephone
      calls, e mails, and written communication between personnel at the study sites and the
      sponsor's representatives. Site personnel weighed assigned treatment bottles at each visit to
      monitor compliance. The Investigator allowed the clinical monitors or designees to inspect
      all completed case report forms, subject records (e.g., source documents), signed informed
      consent forms, records of study medication receipt, storage, and dispensation, and regulatory
      files related to this study. Monitoring and study management followed Good Clinical
      Practices. Patient data required for the study were recorded on paper case report forms
      completed during each office visit. The site sent copies of all case report forms and other
      study records to the sponsor in the form of PDF files. PDF files, with images of case report
      forms and printouts from the measuring equipment, were reviewed by the sponsor, indexed and
      archived in a Dropbox folder with limited access. All data were entered into Microsoft Excel
      spreadsheets by a masked clinical research monitor. Key efficacy and safety data was reviewed
      by a second masked individual and differences reconciled prior to unmasking. Some
      questionable Pentecam images were reviewed and validated by the masked medical monitor and
      invalid data was not included in the database. All original documents and source
      documentation were stored at the study site. All study documentation and source documents
      were made available upon request for inspection by authorized representatives from the
      sponsor or regulatory authorities.

      The Data Safety Monitoring Committee:

      The Committee included Balamurali Ambati, M.D. and Arturo Chayet, M.D. Types of adverse
      events monitored for and reviewed included, but were not limited to, endophthalmitis,
      increased IOP, cystoid macular edema, and retinal detachment. Study progress and safety
      reports were created by the monitoring committee. Findings of the monitoring committee were
      submitted to the review board after each meeting. In addition, the monitoring committee
      reviewed the data if any participant experienced a serious, unexpected adverse event. The
      investigator will retain all essential study documents, including ICFs, source documents,
      CRFs, and drug accountability records for at least 5 years following the completion or
      discontinuation of the study, or longer if a longer period is required by relevant regulatory
      authorities. Records will be destroyed in a manner that ensures confidentiality.

      Determination of Sample Size:

      This was a first-in-human study designed to assess safety and preliminary efficacy. No formal
      hypothesis testing, formal power calculations or sample size calculations were used to
      determine sample size. A sample size of up to 36 patients was targeted based on establishing
      a reasonable number of patients to provide adequate safety and preliminary efficacy
      information to proceed to the next phase of clinical development.

      Statistical and Analytical Plan:

      The Statistical Analysis Plan (SAP) was developed prior to the database lock for the primary
      and secondary efficacy and safety variables. This plan identified the primary endpoints,
      analysis and populations, and also the handling of missing data. The SAP was signed and
      approved before the data were unmasked for analysis. This is a proof of concept study to
      determine viability of topical copper sulfate eyedrops at slowing progression of keratoconus.
      The number of subjects enrolled is appropriate for a proof of concept study and not
      necessarily powered to demonstrate statistically significant differences between the groups.
      Reported statistics were descriptive (e.g., means, variance) and comparing results baseline
      measures with t-tests. Missing data for keratometry measures, Kmax, were imputed using a last
      z-score carried forward analysis. For the keratometry measure of interest, Kmax, additional
      analysis with a longitudinal linear mixed effects model was performed. Difference in slopes
      or means at 26 weeks will be compared between the IVMED-16Wk and Placebo group. Baseline
      measurements will be considered the average of measurements collected at the screening and
      day 0 visits if both are available. Data points that appear to be outliers will be
      investigated and will not be excluded from the listings unless the clinical investigator
      concludes the value is not clinically possible. If a clinically impossible outlier was found,
      two analyses were performed, one with and without clinically impossible data with footnotes
      to indicate the analyses. Slit-lamp findings and non-ophthalmic adverse events though
      collected were not analyzed for the topline analysis.
    

Intervention name(s): IVMED-80; Placebo
Intervention type(s): Drug; Other
Intervention description(s): Good Manufacturing Practices-grade copper (ІІ) sulfate pentahydrate (CuSO4 #5H2O MW 249.69) was dissolved in a vehicle solution comprised of a balanced salt solution (BSS) with osmolality of approximately 500 mOsm/L. Copper sulfate was concentrated to 0.15 mg/mL. The drops were manufactured on prior to the study at a compounding pharmacy in Salt Lake City, Utah.; This was identical to the IVMED-80 product, but without the active ingredient, copper sulfate.
Other intervention name(s): IVMED-80 Vehicle
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: This study used a three-arm, parallel design. Eligible study patients were randomly assigned to 1 of 3 treatment group following a 1:1:1 schedule.
Masking: Quadruple (Participant, Care Provider, Investigator, Outcomes Assessor)
Primary purpose: Treatment
Keywords: Keratoconus; Corneal Ectasia; Copper; Micronutrients; Eye drops; Topical Therapy