Clinical trial NCT05403827
Conditions: Dry Eye Disease
Sponsor: Kowa Research Institute, Inc.
Start date: 2022-07-03; Completion date: 2023-12-05
Enrollment: 644 participants; Allocation: RANDOMIZED; Intervention model: PARALLEL

Brief summary:
The purpose of this study is to assess the efficacy and safety of K-161 ophthalmic solution for the treatment of moderate to severe dry eye disease.

Detailed description:

Arms: arm 1: K-161 Ophthalmic Solution arm 2: Vehicle Solution
Interventions: intervention 1: K-161 intervention 2: Placebo
Intervention descriptions: intervention 1: K-161 Ophthalmic Solution intervention 2: Vehicle Solution

Protocol documents:
SAP_004.pdf: 
NCT05403827


Kowa Research Institute, Inc.
Addendum to Statistical Analysis Plan, Version 1.0
K-161-3.01
Date Issued: 2023-10-03
II
Signature Page:
Kowa Research Institute, Inc.
Kowa Research Institute, Inc


Kowa Research Institute, Inc. 
 
Addendum to Statistical Analysis Plan, Version 1.0 
K-161-3.01 
 
Date Issued: 2023-10-03 
 
3 
 
Introduction: 
 
The objective of this Statistical Analysis Plan (SAP) addendum is to provide modifications and 
corrections to the final K-161-3.01 SAP, dated May 24, 2023. 
 
 






Kowa Research Institute, Inc. 
 
Addendum to Statistical Analysis Plan, Version 1.0 
K-161-3.01 
 
Date Issued: 2023-10-03 
 
6 
 
6. Treatment compliance 
 
Compliance will be considered as missing if the numerator or denominator in SAS Section 7.7.2 
is not calculated due to missing data. 
 
 
7. Statistical approach for primary efficacy endpoints 
 
Originally, two statistical approaches were planned, namely multiple imputation (as outlined in 
SAP Section 8.1.2) and control-based mean imputation (as described in SAP Section 8.1.4). The 
former approach was planned to switch the latter one if there were not enough patients to 
develop imputation models. The decision to use the latter approach for the primary analyses was 
made based on the results of the data review meeting, which determined the final approach: 
control-based mean imputation. 
 
8. Typo in the SAS code 
 
From the formula in SAP Section 8.1.4:  
𝑉𝑉෠൫𝛿𝛿̂𝑛𝑛𝑛𝑛𝑛𝑛[𝑐𝑐]൯= ቂ𝐴𝐴2 + ൫𝑓𝑓2
𝑘𝑘=1൯
2ቃ൫𝑉𝑉෠2
𝑘𝑘=1 + 𝑉𝑉෠1,𝑀𝑀𝑀𝑀𝑀𝑀൯+ ቂ𝐴𝐴2൫𝜇𝜇̂2
𝑘𝑘=1 −𝜇𝜇̂1,𝑀𝑀𝑀𝑀𝑀𝑀−𝑐𝑐൯
2ቃ, 
 
the sign is modified from "+" to "-" in the code in SAP Section 8.1.4 as follows: 
 
V_delta_new_c= (A2 + (f2_k1)**2)*(V2_k1 + V1_MAR) + (A2*(mu2_k1 - mu1_MAR - c)**2); 
 
Final programs have been corrected to reflect this. 
 
9. Range of conservative values (𝑐𝑐) for sensitivity analysis in SAP Section 8.1.6 
 
The following ranges of 𝑐𝑐 will be defined to find the tipping point 𝑐𝑐𝑡𝑡: 
- 
Eye dryness score (visual analog scale): 0 to (100 - 𝜇𝜇̂1,𝑀𝑀𝑀𝑀𝑀𝑀), 
- 
Conjunctival sum fluorescein staining score: 0 to (24 - 𝜇𝜇̂1,𝑀𝑀𝑀𝑀𝑀𝑀). 
 

Prot_002.pdf: 
NCT #: 
         NCT05403827


CONFIDENTIAL 
 
Kowa Research Institute, Inc. 
K-161-3.01, Study Protocol 
 
K-161 
 
 
December 7, 2022 
Page 2 of 83 
INVESTIGATOR’S STATEMENT 
I, the Investigator, understand that all information concerning the product supplied to me 
by Kowa Research Institute, Inc. (KRI) in connection with this study and not previously 
published is confidential information. This information includes the Investigator’s 
Brochure, protocol, case report forms, assay methods, technical methodology, and basic 
scientific data. 
I understand that any changes to the protocol must be approved in writing by KRI or 
representative 
and 
the 
Institutional 
Review 
Board/Independent 
Ethics 
Committee/Research Ethics Committee (IRB/IEC/REC) before implementation, except 
where necessary to eliminate apparent immediate hazards to the patients. 
I confirm that I will report all adverse events (AEs) following the regulations indicated in 
the protocol. 
I confirm that I will conduct this study in conformance with the ethical principles that have 
their origin in the Declaration of Helsinki, Health Insurance Portability and Accountability 
Act (HIPAA), as applicable, and, as applicable, the International Council for 
Harmonisation (ICH) tripartite guideline E6 (R2): Good Clinical Practice (GCP). I will 
also conduct this study, as applicable, in compliance with the requirements of the United 
States (US) Food and Drug Administration (FDA) as outlined in Title 21 of the Code of 
Federal Regulations (CFR) (Parts 11, 50, 54, 56, and 312) and all other applicable regional 
or local regulatory requirements. 
I confirm that I am informed of the need for record retention and that no data can be 
destroyed. 
By my signature below, I hereby attest that I have read, understood, and agree to abide by 
all conditions, instructions, and restrictions contained in this version of the protocol dated 
December 7, 2022. 
 
Investigator’s 
Signature: 
 
Date:  
 
 
 
 
 
mm/dd/yyyy 
Investigator’s 
Name: 
 
 
 
 
 
 
 


CONFIDENTIAL 
 
Kowa Research Institute, Inc. 
K-161-3.01, Study Protocol 
 
K-161 
December 7, 2022 
Page 3 of 84 
SIGNATURE PAGE 
Date  ____________________ 
mm/dd/yyyy 
Kowa Pharma Development Company 
 
 
  ___________________
mm/dd/yyyy 
Kowa Pharma Development Company 
_________________
 
mm/dd/yyyy 
Kowa Pharma Development Company 




CONFIDENTIAL 
 
Kowa Research Institute, Inc. 
K-161-3.01, Study Protocol 
 
K-161 
 
 
December 7, 2022 
Page 5 of 83 
Criteria for Evaluation: 
Primary Efficacy Endpoints: 
The primary efficacy endpoint (symptom) is: 
• 
Change in EDS (VAS) from baseline to Day 85 
The primary efficacy endpoint (sign) is: 
• 
Change in conjunctival sum fluorescein staining score from baseline to Day 85 as assessed by 
expanded NEI scale 
 
Key Secondary Efficacy Endpoint: 
Change from baseline to Day 85 in: 
• 
Total eye fluorescein staining score as assessed by expanded NEI scale 
 
Secondary Efficacy Endpoints: 
Change from baseline to Day 85 in: 
• 
Corneal sum fluorescein staining score as assessed by expanded NEI scale 
• 
OSDI 
• 
Schirmer’s test (unanesthetized) 
• 
TFBUT 
 
Safety Endpoints: 
Safety assessments from baseline up to Day 85 
• 
Adverse events (AEs) 
 
 
 
 
 
 
 
 
• 
Systemic clinical evaluation  
• 
Clinical laboratory measurement 
 
 
 
 
 
Extension Endpoints: 
• 
Safety assessments, as described for up to Day 85, from baseline up to Day 365 
• 
Change in all efficacy and exploratory endpoints from baseline to Day 365 
 
Exploratory Endpoints: 
 
 
 
 
 
 
 
 
 
 
 








CONFIDENTIAL 
 
Kowa Research Institute, Inc. 
K-161-3.01, Study Protocol 
 
K-161 
 
 
December 7, 2022 
Page 9 of 83 
who were assigned to K-161 
 and did not have an ICE, (3) patients who were assigned to 
vehicle and had an ICE, and (4) patients who were assigned to vehicle and did not have an ICE. 
 
Regarding EDS (VAS), a population mean in each pattern is assumed as follows: 
 
Assigned Treatment 
Intercurrent Event 
Not Occurred 
Occurred 
K-161 
 
(1) -10.0 
(2)   -3.6 
Vehicle 
(3)   -3.6 
(4)   -3.6 
 
A common variance, 431.2, and a common ICE occurrence rate, 8%, are assumed among the patterns. 
In order for EDS (VAS) to have at least 90% power when Holm’s method is applied, i.e., in order to have 
90% probability that EDS (VAS) is statistically significant when an alpha is set to 0.025 (two-sided), 
310 patients/arm will be needed. 
Targeted Estimand: 
The summary of the targeted estimand is as follows: 
Treatment Condition 
Treatment condition based on the assigned treatment group. 
Population 
DED patients based on the Inclusion and Exclusion criteria of the study. 
Variable 
Change from baseline to Day 85 in conjunctival sum fluorescein staining score and EDS (VAS) 
including measurements after intercurrent events (i.e., treatment policy strategy). Potential 
intercurrent events of the study are as follows: 
 Discontinuation of the study treatment due to an adverse event 
 Discontinuation of the study treatment due to lack of efficacy 
Population-level Summary 
Difference in means between the two treatment conditions. 
 
Primary Efficacy Analyses: 
The primary efficacy endpoints are change from baseline to Day 85 in conjunctival sum fluorescein 
staining score and EDS (VAS) on study eye, which are used regardless of whether or not the following 
ICEs occur: discontinuation of the study treatment due to an AE or lack of efficacy. Patients’ 
measurements will be made even after occurrence of those ICEs. For each of the primary endpoints, the 
Analysis of Covariance with baseline value, sex and treatment as covariates is used in order to make a 
comparison between the treatment groups. Least squares means will be calculated for the comparison. 
 
The data set to be used for the primary analyses is the FAS. 
 
Missing values will be imputed using the PMM with MI. Patterns to be used for the PMM are, as feasible, 
determined in each treatment group by whether or not patients had an ICE, or the type of ICEs if patients 
had an ICE. For example, if patients who discontinued the study treatment due to an AE had missing 
values, their missing values will be imputed from the patients who had the same ICE, i.e., discontinuation 
of the study treatment due to an AE. If enough patients to develop an imputation model in each pattern 
does not exist, the control-based mean imputation proposed by Mehrotra et al. (2017) will be applied 
instead of the PMM with MI. 
 








CONFIDENTIAL 
 
Kowa Research Institute, Inc. 
K-161-3.01, Study Protocol 
 
K-161 
 
 
December 7, 2022 
Page 13 of 83 
8.2 
Prohibited Medication ....................................................................................................... 63 
8.3 
Permitted Medication and Rescue Therapy ...................................................................... 63 
 
AEs AND SAEs ............................................................................................................... 65 
9.1 
AEs ................................................................................................................................... 65 
 
AE Definition .................................................................................................................... 65 
 
Reporting of AEs .............................................................................................................. 65 
 
Follow-up of AEs .............................................................................................................. 67 
9.2 
SAEs ................................................................................................................................. 67 
 
SAE Definition ................................................................................................................. 67 
 Life-Threatening AEs ....................................................................................................... 68 
 Hospitalization .................................................................................................................. 68 
 
Reporting of SAEs ............................................................................................................ 68 
 
Serious Unexpected Suspected Adverse Reactions .......................................................... 69 
9.3 
 
9.4 
Patient Withdrawal and Drug Discontinuation ................................................................. 70 
 
STATISTICAL METHODS AND DATA ANALYSIS ............................................... 71 
10.1 
Sample Size Justification .................................................................................................. 71 
10.2 
Targeted Estimand ............................................................................................................ 71 
10.3 
Study Populations ............................................................................................................. 72 
10.4 
Analysis of Efficacy Parameters ....................................................................................... 72 
 Analysis of Secondary Efficacy Parameters ..................................................................... 73 
10.5 
Analysis of Safety Data .................................................................................................... 73 
10.6 
Analysis of Exploratory Endpoints ................................................................................... 74 
10.7 
Demographic/Baseline Information .................................................................................. 74 
10.8 
Interim Analysis ................................................................................................................ 74 
10.9 
Pharmacokinetic/Pharmacodynamic Analysis .................................................................. 74 
 
STUDY MANAGEMENT AND DATA COLLECTION ............................................ 75 
11.1 
Ethical Conduct of the Trial .............................................................................................. 75 
11.2 
IRB/IEC/REC ................................................................................................................... 75 
11.3 
Patient Informed Consent ................................................................................................. 75 
11.4 
Amendments to the Protocol ............................................................................................. 76 
11.5 
Study Initiation ................................................................................................................. 76 
11.6 
Study Monitoring .............................................................................................................. 77 
11.7 
Case Report Form ............................................................................................................. 77 
11.8 
Verification Procedures .................................................................................................... 77 
11.9 
Retention of Records ........................................................................................................ 78 
11.10 Insurance and Indemnity ................................................................................................... 78 
11.11 Audit and Inspection ......................................................................................................... 78 
 
USE OF INFORMATION ............................................................................................. 80 
12.1 
General Aspects ................................................................................................................ 80 
12.2 
Patient Confidentiality and Data Protection ..................................................................... 80 
12.3 
Final Report and Publication Policy ................................................................................. 80 
 
REFERENCES ................................................................................................................ 82 
 
 


CONFIDENTIAL 
 
Kowa Research Institute, Inc. 
K-161-3.01, Study Protocol 
 
K-161 
 
 
December 7, 2022 
Page 14 of 83 
 
List of Tables 
 
Table 1 
Clinical Evaluation Schedule ..................................................................................... 23 
 
 
List of Figures 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 




CONFIDENTIAL 
 
Kowa Research Institute, Inc. 
K-161-3.01, Study Protocol 
 
K-161 
 
 
December 7, 2022 
Page 16 of 83 
OD 
oculus dexter; right eye  
OS 
oculus sinister; left eye 
OSDI 
ocular surface disease index 
OTC 
over-the-counter 
PI 
principal Investigator 
PMM 
pattern mixture model 
PPS 
per protocol set 
REC 
Research Ethics Committee 
SAE 
serious adverse event 
SUSAR 
serious unexpected suspected adverse reaction 
TEAE 
treatment-emergent adverse event 
TFBUT 
tear film break-up time 
 
 
US 
United States 
 
 
VAS 
visual analog scale 
 














CONFIDENTIAL 
 
Kowa Research Institute, Inc. 
K-161-3.01, Study Protocol 
 
K-161 
 
 
December 7, 2022 
Page 23 of 83 
Table 1 
Clinical Evaluation Schedule 
ASSESSMENTS 
PERFORMED 
STUDY PERIOD 
Screening 
/Run-in 
Period 
Days of Dosing and Assessments 
Post-dose 
Assessments 
52-week Overall Period 
12-week Primary Period 
40-week Extension Period 
Visit 1 
Day -14 
(Day -21 
to -12) 
Visit 2 
Day 1 
(Baseline) 
Visit 3 
Day 15 
± 2 
(Remote)a 
Visit 4 
Day 29 
± 2 
Visit 5 
Day 57 
± 7 
Visit 6 
Day 85 
± 7 
Visit 7b 
Day 169 
± 7 
Visit 8b 
Day 253 
± 7 
Visit 9b 
Day 365 
± 7 
Visit 6.5b  
Day 99 ± 7c  
or 
Visit 10b 
Day 379 
± 7c 
Informed Consent/HIPAA 
X 
 
 
 
 
 
 
 
 
 
Medical/Medication/Ocular 
History and Demographics 
X 
 
 
 
 
 
 
 
 
 
Medical/Medication Update 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Vehicle Run-In Dispensation 
X 
 
 
 
 
 
 
 
 
 
Vehicle Run-In Instillation 
X 
 
 
 
 
 
 
 
 
 
Vehicle Run-in Collection and 
Accountability 
 
X 
 
 
 
 
 
 
 
 
Determination/assignment of the 
study eye 
 
X 
 
 
 
 
 
 
 
 
Randomization 
 
X 
 
 
 
 
 
 
 
 
Study Drug Dispensation 
 
X 
 
 
 
Xd 
Xd 
Xd 
 
 
Study Drug Instillation 
 
X 
 
X 
X 
Xd 
Xd 
Xd 
 
 
Study Drug Collection and 
Accountability 
 
 
 
Xe 
Xe 
X 
Xd 
Xd 
Xd 
 
Fluorescein Staining Scoring 
X 
X 
 
X 
X 
X 
X 
X 
X 
 
VAS 
X 
X 
 
X 
X 
X 
X 
X 
X 
 
TFBUT 
X 
X 
 
X 
X 
X 
X 
X 
X 
 
Schirmer’s Test 
X 
X 
 
X 
X 
X 
X 
X 
X 
 


CONFIDENTIAL 
 
Kowa Research Institute, Inc. 
K-161-3.01, Study Protocol 
 
K-161 
 
 
December 7, 2022 
Page 24 of 83 
ASSESSMENTS 
PERFORMED 
STUDY PERIOD 
Screening 
/Run-in 
Period 
Days of Dosing and Assessments 
Post-dose 
Assessments 
52-week Overall Period 
12-week Primary Period 
40-week Extension Period 
Visit 1 
Day -14 
(Day -21 
to -12) 
Visit 2 
Day 1 
(Baseline) 
Visit 3 
Day 15 
± 2 
(Remote)a 
Visit 4 
Day 29 
± 2 
Visit 5 
Day 57 
± 7 
Visit 6 
Day 85 
± 7 
Visit 7b 
Day 169 
± 7 
Visit 8b 
Day 253 
± 7 
Visit 9b 
Day 365 
± 7 
Visit 6.5b  
Day 99 ± 7c  
or 
Visit 10b 
Day 379 
± 7c 
Adverse Event Collection 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Systemic Clinical Evaluation  
 
X 
 
 
 
X 
 
 
X 
 
Clinical Laboratory 
Measurement 
X 
 
 
 
 
X 
 
 
X 
 
Exit Patient from Study 
 
 
 
 
 
 
 
 
 
X 
 
 HIPAA=Health Insurance 
Portability and Accountability Act; OSDI=Ocular Surface Disease Index; TFBUT=tear film break-up time; VAS=Visual analog scale. 
Note: The visit schedule will always be calculated from randomization visit date (Visit 2). 
a. 
Visit 3 will be a remote visit. 
b. Only first 120 patients of each arm, approximate total 240 patients, will proceed to Visit 7 (Day 169) and following visits. Other patients will proceed to 
Visit 6.5 (Day 99) for post-dose assessments. 
c. 
Post-dose assessments will be performed at least 14 days after the last dose of study medication. 
d. Only patients in the Extension Period will be dispensed and instilled with the study drugs and will be examined for 
 












CONFIDENTIAL 
 
Kowa Research Institute, Inc. 
K-161-3.01, Study Protocol 
 
K-161 
 
 
December 7, 2022 
Page 30 of 83 
a. Study medication should be stopped if the patient develops severe 
ocular/periocular infection disease. In case of a mild or moderate 
infectious event, the study medication can be continued at the 
Investigator’s discretion.  
3. Violation of the protocol inclusion or exclusion criteria is discovered, and if, in 
the opinion of the Investigator or the sponsor, the violation will significantly 
compromise data interpretation or safety 
4. The patient undergoes rescue ophthalmic surgery (Section 8.3) 
5. The female patient becomes pregnant during the study (Section 9.3) 
6. Lack of efficacy, as judged by the Investigator 
7. Lost to follow-up 
8. Site termination of the study by the site itself 
9. Sponsor termination of study 
10. Other 
Although a patient is not obligated to give his/her reason for discontinuing study drug, 
the Investigator will make a reasonable effort to obtain the reason while fully respecting 
the patient’s rights. The reason for discontinuation of study drug must be documented in 
the electronic case report form (eCRF). The clinical study report will include the 
reason(s) for discontinuation of study drug. 
4.4 
Withdrawal Criteria 
The patient has the right to withdraw from the study at any time and for any reason 
without prejudice to the patient’s future medical care. Nevertheless, every attempt will be 
made to prevent missing data and to obtain complete follow-up of all patients. 
Patients who meet study drug discontinuation criteria described in Section 4.3 will be 
discontinued from study drug; however, are not required to withdraw from the study 
unless the patient withdraws consent completely. As such, these patients will be 
encouraged to remain in the study and asked to attend all of the remaining study visits 
through Visit 6 (for the patients who are assigned into the 12-week Primary Period) or 
Visit 9 (for the patients who are assigned into the 52-week Overall Period) (Table 1). 
Patients who choose to withdraw from the study will be asked if they are prepared to 
complete a last visit. In this case, the same evaluations as the End of Treatment Period 
(Visit 6 or 9), or at least, the same evaluations as the Post-dose Assessment Visit (Visit 
6.5 or 10) should be performed. If a patient fails to actively maintain contact with the 
Investigator, reasonable efforts (telephone calls to family members or friends, email 
contacts, etc.) will be made in order to encourage the patient to complete the study visits. 
If the patient withdraws from the study, the reason should be captured. 
The patient will be withdrawn from the study if: 
1. The patient withdraws consent to attend the remaining study visits 


CONFIDENTIAL 
 
Kowa Research Institute, Inc. 
K-161-3.01, Study Protocol 
 
K-161 
 
 
December 7, 2022 
Page 31 of 83 
2. Lost to follow-up 
3. Site termination of the study by the site itself 
4. Sponsor termination of study 
5. Other 
Although a patient is not obligated to give his/her reason for withdrawing from the study, 
the Investigator will make a reasonable effort to obtain the reason while fully respecting 
the patient’s rights. Unless revoked, further contact in the case of withdrawal from the 
study will occur consistent with methods listed in the informed consent form (ICF). The 
reason for withdrawal from the study must be documented in the eCRF. The clinical 
study report will include the reason(s) for withdrawal from the study. 
If a patient withdraws from the study due to an AE, the patient will be asked to return to 
the clinic for, at a minimum, the evaluations scheduled for post-dose assessments. If the 
AE has still not resolved, additional follow-up will be performed, as appropriate. Every 
effort will be made by the Investigator or delegate to contact the patient until the AE is 
resolved or stabilized, or the medical monitor and Investigator agree that further follow-
up is not necessary. If patients are lost to follow-up, the Investigator will make 3 
reasonable attempts to contact the patient via telephone, US postal service, or certified 
mail. All attempts to contact them must be made and documented in the study records.  
4.5 
Replacement, Rescreening, and Retesting 
 Replacement 
Patients who are screened for the study may be replaced if they never are randomly 
assigned study drug or are withdrawn from the study before they administer any study 
drug after randomization. The replacement patients will receive a new randomly assigned 
treatment and not the treatment assignment of the replaced patient. Patients who self-
administer any study drug after randomization and subsequently are withdrawn early 
from the study will not be replaced. 
 Rescreening 
Patients who fail to satisfy inclusion and exclusion criteria at screening (Visit 1 or 
Visit 2) may be rescreened 1 additional time at the discretion of the sponsor. Screen 
failures due to inclusion and/or exclusion criteria that could transiently change and do not 
compromise the patient’s safety as judged by the Investigator can be rescreened once. 
Patients who were re-screen failures under the previous version of this protocol 
(Amendment No. 1) can be re-screened one additional time for this amended protocol 
(Amendment No. 2), only if the eligibility criteria determining the original screen failures 
have been revised in this amendment (i.e. corneal sum fluorescein staining score and/or 
Schirmer score). All eligibility assessments will be repeated regardless of the reason for 
the screen failure(s) and new subject number will be assigned. Rescreening decision must 
be confirmed by the sponsor’s medical monitor. 


CONFIDENTIAL 
 
Kowa Research Institute, Inc. 
K-161-3.01, Study Protocol 
 
K-161 
 
 
December 7, 2022 
Page 32 of 83 
 Retesting 
Clinical labs with clinically significant abnormalities (per the principal Investigator’s [PI] 
assessment) can be retested 1 time if there is a reasonable expectation that abnormality 
will resolve within the Screening Period (21 days at maximum). Unscheduled visits 
should be allowed within Screening Period. 
























CONFIDENTIAL 
 
Kowa Research Institute, Inc. 
K-161-3.01, Study Protocol 
 
K-161 
 
 
December 7, 2022 
Page 44 of 83 
 
 
 
























CONFIDENTIAL 
 
Kowa Research Institute, Inc. 
K-161-3.01, Study Protocol 
 
K-161 
 
 
December 7, 2022 
Page 56 of 83 
5.4 
Data Monitoring Committee 
No data monitoring committee is planned for this study. 


CONFIDENTIAL 
 
Kowa Research Institute, Inc. 
K-161-3.01, Study Protocol 
 
K-161 
 
 
December 7, 2022 
Page 57 of 83 
 
CONDUCT OF STUDY 
6.1 
Study Masking and Randomization 
All arms will be double-masked. The run-in drops will be single-masked for patients.  
Before the initiation of study run-in at Visit 1, each patient who provides written 
informed consent will be assigned a subject code. All subject codes will be assigned in 
strict numerical sequence at a site and no numbers will skipped or omitted. If a patient is 
retested on clinical labs, the same subject code will be used (Section 4.5.3). If a patient is 
rescreened, the patient will be assigned with a new subject code (Section 4.5.2). 
Patients who have signed informed consent and subsequently fail to satisfy inclusion and 
exclusion criteria are defined as screen failures. For all screen failures, the reason(s) for 
screen failure will be recorded on the patient’s source document and eCRF. 
Each patient who meets all the inclusion and none of the exclusion criteria at Visit 1 and 
Visit 2 will be randomized at the end of Visit 2 by using the IWRS. 
Subject codes and kit numbers will be assigned automatically to each patient as they are 
entered into the IWRS. All patients will be randomized into either vehicle or active 
treatment group at Visit 2 (Day 1) in a 1:1 ratio. 
 
The first approximately 240 (120/arm) randomized patients will be 
assigned into the 52-week Overall Period and the rest of study population (approximately 
380 [190/arm] patients) will be assigned into the 12-week Primary Period. 
The site staff will dispense the required kit(s). Both the subject codes and the dispensed 
study drug kit number(s) will be recorded on the patient’s source document and eCRF. 
Patients, sponsor, CRO, and site personnel will be masked to treatment assignment. 
After Visit 6 (Day 85), patients who are randomized to enter the 40-week Extension 
Period will proceed to Visit 7 (Day 169) until Visit 10 (Day 379). Other patients, who are 
randomized to enter the 12-week Primary Period only, will proceed to Visit 6.5 (Day 99) 
for post-dose assessments and will complete the study. 
Planned analyses at Day 85 including the primary analyses will be performed by an 
unmasked team not involved in the conduct of the study once all patient data until Day 85 
are obtained in a fashion to protect the masking of all patients who will be followed in the 
40-week Extension Period. The masked team will have access only to a summary of the 
results comparing the two arms so the same study team can continue to be masked while 
conducting the remaining part of the trial until the end of the 52-week Overall Period. 
The investigational sites will not be unmasked and will not have access to the summary 
of the results comparing the two arms. 
6.2 
Study Visits 
For each patient, a maximum of 10 scheduled visits will be performed: 
• Visit 1 at Day -14 (Day -21 to -12): Screening: The screening examination to 
determine patient eligibility can take place anytime within this time period. 


CONFIDENTIAL 
 
Kowa Research Institute, Inc. 
K-161-3.01, Study Protocol 
 
K-161 
 
 
December 7, 2022 
Page 58 of 83 
• Visit 2 at Day 1: Baseline (12-21 days after Visit 1) 
• Visit 3 at Day 15 ± 2 days 
• Visit 4 at Day 29 ± 2 days 
• Visit 5 at Day 57 ± 7 days 
• Visit 6 at Day 85 ± 7 days 
For the patients who are assigned into the 12-week Primary Period 
• Visit 6.5 (post-dose) at Day 99 ± 7 days (at least 14 days after the last dose of 
study medication) 
For the patients who are assigned into the 52-week Overall Period (with the 40-week 
Extension Period): 
• Visit 7 at Day 169 ± 7 days 
• Visit 8 at Day 253 ± 7 days 
• Visit 9 at Day 365 ± 7 days 
• Visit 10 (post-dose) at Day 379 ± 7 days (at least 14 days after the last dose of 
study medication) 
The procedures and assessments to be performed at each visit are indicated in Table 1. 
6.3 
Compliance with The Protocol 
The Investigator must agree to implement the study protocol as written and adhere to the 
guidelines given in the Investigator’s Statement, which will be signed prior to the start of 
the study. The study will be performed in accordance with HIPAA, Declaration of 
Helsinki, International Council for Harmonisation (ICH) Good Clinical Practice (GCP) 
guidelines, local laws, FDA GCP regulations (21 Code of Federal Regulations [CFR] 
Parts 11, 50, 54, 56, and 312), and other applicable guidance documents. 
If the Investigator considers enrolling a patient that does not meet all inclusion or 
exclusion criteria, an exemption must be requested from the sponsor’s medical monitor 
prior to patient enrollment. The justification for the exemption must be document by the 
Investigator. The approval or rejection of the exemption must be documented by the 
sponsor’s medical monitor prior to the patient’s enrollment or screen failure. 
Protocol non-compliance must be reported to the sponsor or its representatives. Each 
deviation and the reason for its occurrence must be documented. The sponsor retains the 
right to require the withdrawal of any patient who violates the protocol. 
6.4 
Termination of the Study 
If, in the opinion of the Investigator, the clinical observations in the study suggest that it 
may be unwise to continue, the study may be terminated after consultation with the 
sponsor. A written statement fully documenting the reason(s) for the termination will be 
provided to the sponsor. In addition, the sponsor may terminate the study at any time. 


CONFIDENTIAL 
 
Kowa Research Institute, Inc. 
K-161-3.01, Study Protocol 
 
K-161 
 
 
December 7, 2022 
Page 59 of 83 
If it becomes apparent that patient enrollment is unsatisfactory with respect to quality or 
quantity, or data recording is inaccurate or incomplete on a chronic basis, the sponsor has 
the right to terminate the study and remove all study materials from the investigational 
site. A written statement will be provided to the Investigator, the Institutional Review 
Board/Independent Ethics Committee/Research Ethics Committee (IRB/IEC/REC), and 
regulatory authorities, if required. In the event of any serious or non-serious AEs having 
occurred at a site, all documentation relating to the event(s) must be obtained. 






CONFIDENTIAL 
 
Kowa Research Institute, Inc. 
K-161-3.01, Study Protocol 
 
K-161 
 
 
December 7, 2022 
Page 62 of 83 
7.7 
Drug Accountability 
The study drug is to only be dispensed by the PI or his/her named sub-Investigator(s), and 
is to only be used in accordance with this protocol. The study drug must only be 
distributed to patients properly qualified as described in this protocol to receive study 
drug. 
The Investigator must keep an accurate account of the study drug received from the 
supplier. This includes the amount of study drug dispensed to patients, amount of study 
drug returned to the Investigator by the patients, and the amount returned or disposed 
upon the completion of the study. A detailed inventory must be completed for the study 
drug. 
7.8 
Procedure for Unmasking 
As needed, the randomization code may be broken by the Investigator to manage an 
urgent medical safety event. If possible, the medical monitor should be contacted to 
discuss the case before the code is broken. 
If it becomes necessary to unmask treatment information during the study, the reason for 
unmasking must be documented in the eCRF. If the medical monitor cannot be notified 
prior to unmasking, the Investigator must contact the medical monitor promptly and 
explain the reason for the premature unmasking (e.g., unmasking due to an SAE). 
Planned analyses at Day 85 including the primary analyses will be performed by 
unmasked team not involved in the conduct of the study once all patient data until Day 85 
are obtained in a fashion to protect the masking of the patients who will be followed in 
the 40-week Extension Period. 
 


CONFIDENTIAL 
 
Kowa Research Institute, Inc. 
K-161-3.01, Study Protocol 
 
K-161 
 
 
December 7, 2022 
Page 63 of 83 
 
CONCOMITANT MEDICATION 
The Investigator must record the use of all concomitant medications and any historical 
use of 
 before Visit 1, both dispensed and OTC, in the eCRF along with the 
reason the medication was taken. This includes drugs used on a chronic and as-needed 
basis. Patients must be discouraged from starting any new medication, both dispensed 
and OTC, without consulting the Investigator, unless the new medication is required for 
emergency use. 
8.1 
General Considerations 
Concurrent enrollment in another investigational drug or medical device study is not 
permitted. 
8.2 
Prohibited Medication 
Disallowed medications/treatments during the study are outlined in the exclusion criteria 
(Section 4.2). 
8.3 
Permitted Medication and Rescue Therapy 
Contact lenses are allowed only during the 40-week Extension Period (except for study 
visit days before all visit assessments are completed). Contact lenses should be removed 
prior to the administration of study drug and may be reinserted at least 15 minutes 
following administration. If a patient is using another prescription eye drop in 
combination with the study medication, the concomitant use of contact lenses is not 
recommended for the duration of such combination therapy. 
The following medications are permitted as long as the dosage is stable: 
• Systemic tetracycline compounds (e.g., tetracycline, doxycycline, or 
minocycline), macrolides (e.g., azithromycin): for at least 30 days prior to Visit 1 
and dose will remain stable until the end of the 12-week Primary Period 
• Any medication (topical and systemic) known to cause ocular drying, such as 
systemic anticholinergic medications (e.g., atropine, homatropine), 
antidepressants and antipsychotic agents, statins, diuretics, beta-blockers, 
NSAIDs: for at least 30 days prior to Visit 1 and dose will remain stable until the 
end of the 12-week Primary Period 
o Episodic use of anticholinergic drops for eye examination and episodic use 
of systemic NSAIDs are allowed during the study except for within 2 days 
prior to any study visit.  
• Omega-3 fatty acid supplements in doses above 3000 mg/day, oral hormonal 
contraceptives, hormone replacement therapy for menopause: for 12 weeks prior 
to Visit 1 and dose will remain stable until the end of the 12-week Primary Period. 
Omega-3 fatty acid supplements in doses equal to or below 3000 mg/day are 
permitted. 


CONFIDENTIAL 
 
Kowa Research Institute, Inc. 
K-161-3.01, Study Protocol 
 
K-161 
 
 
December 7, 2022 
Page 64 of 83 
Any prohibited and restricted medications, devices, and procedures indicated for dry eye 
disease are permitted as “rescue therapy” after all assessments are completed at Visit 6  
(except for study visit days before all visit assessments are completed) (Table 1). 
Especially, 
 will be summarized as described in 
Section 5.2.10. All other prohibited medications, other than isotretinoin, systemic 
 
, and restricted medications, devices, and procedures are permitted as 
“permitted therapy” after all assessments are completed at Visit 6 (except for study visit 
days before all visit assessments are completed). If more than one topical ophthalmic 
medicinal product is being used, the medicinal products must be administered at least 15 
minutes apart. 
Any non-emergent ocular surgical procedure is prohibited until the end of the 12-week 
Primary Period. However, if the patient’s condition necessitates a surgical ocular 
procedure during the study, the patient may undergo rescue ophthalmic surgery. In this 
case, the use of study medication should be interrupted in the eye undergoing the 
procedure until resolution or stabilization of this condition and full recovery after surgery 
as determined by the Investigator. The decision to interrupt or restart the study 
medication for a specific ocular procedure/condition should be based on the best clinical 
judgment of the Investigator and preferably after consultation with the medical monitor. 


CONFIDENTIAL 
 
Kowa Research Institute, Inc. 
K-161-3.01, Study Protocol 
 
K-161 
 
 
December 7, 2022 
Page 65 of 83 
 
AEs AND SAEs 
9.1 
AEs 
 AE Definition 
An AE is any untoward medical occurrence in a patient administered a pharmaceutical 
product and which does not necessarily have a causal relationship with the 
pharmaceutical product. An AE can, therefore, be any unfavorable and unintended sign, 
symptom, or disease temporally associated with the use of a medicinal product, whether 
or not related to the medicinal product. Any worsening of the patient’s disease under 
study or other medical conditions will also be considered to be an AE, unless it is within 
the normal range of disease fluctuation for that patient. 
Clinically meaningful (for a given patient) changes in physical examination findings and 
abnormal objective test findings (e.g., clinical laboratory tests) are also recorded as AEs. 
The criteria for determining whether an abnormal objective test finding should be 
reported as an AE are as follows: 
1. Test result is associated with accompanying symptoms, and/or; 
2. Test result requires additional diagnostic testing or medical/surgical intervention, 
and/or; 
3. Test result leads to a change in study dosing or withdrawal from the study, 
significant additional concomitant drug treatment or other therapy, and/or; 
4. Test result leads to any of the outcomes included in the definition of an SAE 
(Section 9.2). 
Merely repeating a test, in the absence of any of the above conditions, does not meet 
condition number 2 above for reporting as an AE. 
Any abnormal test result that is determined to be an error does not require reporting as an 
AE. 
A treatment-emergent AE (TEAE) is defined as an AE that begins after the start of the 
double-masked study treatment or an event that begins before the start of the double-
masked study treatment and worsens in intensity after starting double-masked study 
treatment. 
 Reporting of AEs 
At each evaluation, the Investigator will determine whether any AEs have occurred. The 
patient will be questioned in a general way and no specific symptoms will be suggested. 
If any AEs have occurred, they will be recorded on the AE pages of the eCRF and in the 
patient’s medical record. If known, the diagnosis will be recorded, in preference to the 
listing of individual signs and symptoms. 
AE reporting begins when informed consent is obtained and ends at the conclusion of the 
study, unless an unresolved AE is still being followed. 


CONFIDENTIAL 
 
Kowa Research Institute, Inc. 
K-161-3.01, Study Protocol 
 
K-161 
 
 
December 7, 2022 
Page 66 of 83 
The severity of the AE will be graded as follows: 
Mild 
The AE is easily tolerated and does not interfere with normal daily 
activities. 
Moderate 
The AE causes some interference with daily activities. 
Severe  
The AE causes all normal daily activities to be completely halted. 
 
The relationship of each AE to the study drug will be determined by the Investigator 
using these explanations: 
• Related: A reasonable possibility exists that the study drug caused the AE. A 
related AE can be further defined as follows: 
o Occurs within a reasonable temporal sequence to administration of study 
drug 
o Cannot be explained by concurrent disease or other drugs or chemicals 
o Improves or disappears on stopping or reducing study drug (de-challenge) 
o Reappears on repeated exposure to study drug (re-challenge) 
o Is an unusual event that is known to be associated with the drug or this 
class of compound, and cannot be explained by other therapy or the 
participant’s physical condition 
o Unlikely to be attributed to concurrent disease or other drugs or a 
clinically reasonable response on withdrawal (de-challenge) 
• Not Related: A reasonable possibility does not exist that the study drug caused 
the AE. A not related AE can be further defined as follows: 
o Occurs with a temporal relationship to administration of study drug which 
makes a causal relationship improbable 
o Other drugs, chemicals or underlying disease provide plausible 
explanations of causality 
o Is known to be associated with the participant’s clinical condition, or with 
other medication taken by the participant 
 
The Investigator will record each action taken and outcome for each AE according to the 
following: 
Action taken 
• None 
• Treatment required 
• Hospitalization 
• Study drug interrupted 


CONFIDENTIAL 
 
Kowa Research Institute, Inc. 
K-161-3.01, Study Protocol 
 
K-161 
 
 
December 7, 2022 
Page 67 of 83 
• Study drug discontinued 
• Patient withdrawn 
• Other (specify) 
Outcome 
• Recovered 
• Recovered with sequelae 
• Recovering 
• Ongoing 
• Death 
• Lost to follow-up 
Whether each AE is ocular or non-ocular will be determined by the Investigator for each 
AE and it will be recorded on the AE pages of the eCRF. 
 Follow-up of AEs 
If any AEs are present when a patient completes the study, or if a patient is withdrawn 
from the study, the patient will be re-evaluated. At the Investigator’s discretion, minor 
AEs can be re-evaluated via telephone and documented. If the AE is still not resolved, 
additional follow-up will be performed as appropriate. Every effort will be made by the 
Investigator or delegate to contact the patient until the AE is resolved or stabilized, or the 
medical monitor and Investigator agree that further follow-up is not necessary. The 
follow-up of AEs after post-dose assessments at Visits 6.5 or 10 will be documented in 
the patient’s medical records. 
9.2 
SAEs 
 SAE Definition 
An SAE is any untoward medical occurrence that at any dose: 
• Results in death 
• Is life-threatening 
• Requires patient hospitalization or prolongation of existing hospitalization 
• Results in persistent or significant disability/incapacity 
• Is a congenital anomaly/birth defect 
Medical and scientific judgment will be exercised in deciding whether expedited 
reporting is appropriate in other situations, such as important medical events that may not 
be immediately life-threatening or result in death or hospitalization but may jeopardize 
the patient or may require intervention to prevent one of the other outcomes listed in the 


CONFIDENTIAL 
 
Kowa Research Institute, Inc. 
K-161-3.01, Study Protocol 
 
K-161 
 
 
December 7, 2022 
Page 68 of 83 
definition above. Events that require expedited reporting will also be considered to be 
SAEs. 
 
Life-Threatening AEs 
The term life-threatening in the definition of serious refers to an event in which the 
patient 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. 
 
Hospitalization 
Hospitalization is defined as the patient being hospitalized overnight, or the patient’s 
hospital stay being prolonged for at least an additional overnight stay. Pre-planned 
hospital stays or hospital stays for non-medical social reasons are not applicable. Twenty-
three-hour hospitalizations for observation will be discussed with the medical monitor to 
determine whether they are appropriate for SAE reporting. 
 Reporting of SAEs 
All SAEs occurring from the time of informed consent until Visit 6.5 (patients enrolled in 
the Primary Period only) or Visit 10 (all other patients) must be reported to the CRO 
safety personnel within 24 hours of the knowledge of the occurrence (this refers to any 
AE that meets any of the aforementioned serious criteria). All SAEs that the Investigator 
considers related to study drug occurring after post-dose assessments at Visits 6.5 or 10 
must be reported to the CRO or the sponsor/designee. 
To report the SAE, the site staff will complete the SAE form electronically in the 
electronic data capture (EDC) system for the study. When the form is completed, the 
CRO safety personnel will be notified electronically and will retrieve the form. If the 
event meets serious criteria and it is not possible to access the EDC system, site staff will 
send a completed paper SAE form to
 within 24 hours of 
awareness. When the EDC system becomes available, the SAE information must be 
entered within 24 hours. 
 
 
  
 
  
 
  
 
 
The Investigator must continue to follow-up with the patient until the SAE has subsided 
or until the condition becomes chronic in nature, stabilizes (in the case of persistent 
impairment), or the patient dies. 
Within 24 hours of receipt of follow-up information, the Investigator must update the 
SAE form electronically in the EDC system for the study and submit any supporting 


CONFIDENTIAL 
 
Kowa Research Institute, Inc. 
K-161-3.01, Study Protocol 
 
K-161 
 
 
December 7, 2022 
Page 69 of 83 
documentation (e.g., patient discharge summary or autopsy reports) to 
. If it is not possible to access the EDC system, refer to the 
procedures outlined above for initial reporting of SAEs. Written confirmation that any 
serious, unexpected, and related AEs have been submitted to the IRB/IEC/REC must be 
forwarded to the sponsor and kept in the Investigator files. 
 Serious Unexpected Suspected Adverse Reactions 
According to FDA CFR 312.32(a) and FDA Guidance “Safety Reporting Requirements 
for Investigational New Drugs (INDs) and BA/BE (Bioavailability/Bioequivalence) 
Studies” finalized December 2012, suspected adverse reaction means any AE for which 
there is a reasonable possibility that the medicinal product caused the AE. The phrase 
reasonable possibility means there is evidence to suggest a causal relationship between 
the AE and the medicinal product. 
The following are examples of types of evidence that would suggest a causal relationship 
between the drug and the AE (i.e., reasonable possibility): 
• A single occurrence of an event that is uncommon and known to be strongly 
associated with drug exposure (e.g., angioedema, hepatic injury, Stevens-Johnson 
syndrome) 
• One or more occurrences of an event that is not commonly associated with drug 
exposure, but is otherwise uncommon in the population exposed to the drug 
(e.g., tendon rupture) 
Suspected adverse reactions are the subset of all AEs for which there is a reasonable 
possibility that the drug caused the event. The Investigator will initially classify the 
relatedness of an AE, but the final classification is subject to the medical monitor’s 
determination unless revised by the sponsor, which has the ultimate responsibility for 
judging relatedness. 
A suspected adverse reaction is considered unexpected if it is not listed in the Reference 
Safety Information in Section 6 of the K-161 Investigator’s Brochure or is not listed at 
the specificity or severity that has been described in the K-161 Investigator’s Brochure. 
An AE or suspected adverse reaction is considered serious if, in the view of either the 
Investigator or sponsor, it results in any of the following outcomes: Death, a 
life-threatening AE, inpatient hospitalization or prolongation of existing hospitalization, a 
persistent or significant incapacity or substantial disruption of the ability to conduct 
normal life functions, or a congenital anomaly/birth defect (Section 9.2.1). Important 
medical events that may not result in death, be life-threatening, or require hospitalization 
may be considered serious when, based upon appropriate medical judgment, they may 
jeopardize the patient or patient and may require medical or surgical intervention to 
prevent one of the outcomes listed in this definition. 
Any AE meeting the definitions of suspected adverse reaction, unexpected, and serious is 
considered a serious unexpected suspected adverse reaction (SUSAR). In accordance 
with the FDA Guidance “Safety Reporting Requirements for INDs and BA/BE Studies” 
finalized December 2012, the sponsor will unmask the study data for patients 




CONFIDENTIAL 
 
Kowa Research Institute, Inc. 
K-161-3.01, Study Protocol 
 
K-161 
 
 
December 7, 2022 
Page 71 of 83 
 STATISTICAL METHODS AND DATA ANALYSIS 
10.1 
Sample Size Justification 
The parameters to be needed for the calculation of sample size were estimated from the 
previous Phase 2 study (K-161-2.01US). In order to take intercurrent events (ICEs) into 
account, 4 different patient patterns are considered: (1) patients who were assigned to 
K-161 
 and had an ICE, (2) patients who were assigned to K-161 
 
and did not have an ICE, (3) patients who were assigned to vehicle and had an ICE, and 
(4) patients who were assigned to vehicle and did not have an ICE. 
Regarding EDS (VAS), a population mean in each pattern is assumed as follows: 
Assigned Treatment 
Intercurrent Event 
Not Occurred 
Occurred 
K-161 
 
(1) -10.0 
(2)   -3.6 
Vehicle 
(3)   -3.6 
(4)   -3.6 
 
A common variance, 431.2, and a common ICE occurrence rate, 8%, are assumed among 
the patterns. In order for EDS (VAS) to have at least 90% power when Holm’s method is 
applied, i.e., in order to have 90% probability that EDS (VAS) is statistically significant 
when an alpha is set to 0.025 (two-sided), 310 patients/arm will be needed. 
10.2 
Targeted Estimand 
The summary of the targeted estimand is as follows: 
Treatment Condition 
Treatment condition based on the assigned treatment group. 
Population 
DED patients based on the Inclusion and Exclusion criteria of the study. 
Variable 
Change from baseline to Day 85 in conjunctival sum fluorescein staining score and 
EDS (VAS) including measurements after intercurrent events (i.e., treatment policy 
strategy). Potential intercurrent events of the study are as follows: 
 Discontinuation of the study treatment due to an adverse event 
 Discontinuation of the study treatment due to lack of efficacy 
Population-level Summary 
Difference in means between the two treatment conditions. 
 


CONFIDENTIAL 
 
Kowa Research Institute, Inc. 
K-161-3.01, Study Protocol 
 
K-161 
 
 
December 7, 2022 
Page 72 of 83 
10.3 
Study Populations 
The following analysis populations will be considered: 
Full Analysis Set (FAS) in the 12-week Primary Period: will include all randomized 
patients who received at least 1 dose of study treatment. Patients will be analyzed 
according to their randomized treatment group, regardless of whether they adhere to their 
assigned treatment. The FAS will be used as the primary efficacy analyses. 
Per Protocol Set (PPS) in the 12-week Primary Period: will include all randomized 
patients without any major protocol deviations and have valid baseline and Day 85 
primary endpoint values. Major protocol deviations will be pre-specified prior to 
unmasking the study. PPS will be used to assess robustness of the primary analysis 
results. 
Safety Population in the 12-week Primary Period: will include all randomized patients 
who have received at least 1 dose of study treatment. 
FAS in the 52-week Overall Period: will include the randomized patients who are 
assigned into the 52-week Overall Period and received at least 1 dose of study treatment. 
Patients will be analyzed according to their randomized treatment group, regardless of 
whether they adhere to their assigned treatment. 
Safety Population in the 52-week Overall Period: will include randomized patients for the 
52-week Overall Period and who had at least 1 dose of study treatment. 
10.4 
Analysis of Efficacy Parameters 
The primary efficacy endpoints are change from baseline to Day 85 in conjunctival sum 
fluorescein staining score on study eye and EDS (VAS), which are used regardless of 
whether or not the following ICEs occur: discontinuation of the study treatment due to an 
AE or lack of efficacy. Patients’ measurements will be made even after occurrence of 
those ICEs. For each of the primary endpoints, the analysis of covariance with baseline 
value, sex and treatment as covariates is used in order to make a comparison between the 
treatment groups. Least squares means will be calculated for the comparison. 
The data set to be used for the primary analyses is the FAS. 
Missing values will be imputed using the pattern mixture model (PMM) with multiple 
imputation (MI). Patterns to be used for the PMM are, as feasible, determined in each 
treatment group by whether or not patients had an ICE, or the type of ICEs if patients had 
an ICE. For example, if patients who discontinued the study treatment due to an AE had 
missing values, their missing values will be imputed from the patients who had the same 
ICE, i.e., discontinuation of the study treatment due to an AE. If enough patients to 
develop an imputation model in each pattern do not exist, the control-based mean 
imputation proposed by Mehrotra (Mehrotra 2017) will be applied instead of the PMM 
with MI. 
If the MI is applied, multiple parameter estimates will be combined using Rubin’s rule 
(Rubin 1987). 


CONFIDENTIAL 
 
Kowa Research Institute, Inc. 
K-161-3.01, Study Protocol 
 
K-161 
 
 
December 7, 2022 
Page 73 of 83 
With regard to multiplicity caused by the 2 primary endpoints, Holm’s method 
(Holm 1979) will be utilized. First, an endpoint with a smaller p-value will be tested at 
alpha=0.025 (two-sided). If the first test is significant, another endpoint will be tested at 
alpha=0.05 (two-sided). Otherwise, the second test will not be performed. 
Planned analyses at Day 85 including the primary analyses will be performed by 
unmasked team not involved in the conduct of the study once all patient data until Day 85 
are obtained in a fashion to protect the masking of the patients who will be followed in 
extension. Masked team will have access only to a summary of the results comparing the 
two arms so the same study team can continue to be masked while conducting the 
remaining part of the trial until the end of the 52-week Overall Period. The 
investigational sites will not be unmasked and will not have access to the summary of the 
results comparing the two arms.  
As a sensitivity analysis, a tipping point, at which the primary analysis result turns out to 
be not-significant, is examined in each ICE.  
Further details will be included in a separated statistical analysis plan.  
 Analysis of Secondary Efficacy Parameters 
The key secondary efficacy endpoint is change from baseline of total eye fluorescein 
staining score as assessed by expanded NEI scale for study eye will be analyzed in a 
similar manner as performed for primary endpoint. All other secondary endpoints will 
also be analyzed in a similar manner. 
The other secondary efficacy endpoints are ordered as follows: corneal sum fluorescein 
staining score as assessed by expanded NEI scale, OSDI, Schirmer’s test 
(unanesthetized), and TFBUT. 
Key secondary efficacy endpoint will be tested at alpha=0.05 (two-sided) if primary 
endpoints are both significant at alpha=0.05. 
The other secondary efficacy endpoints will be tested in order by fixed sequence method 
if the key secondary endpoint is significant. 
10.5 
Analysis of Safety Data 
AEs will be coded using the Medical Dictionary for Regulatory Activities dictionary (the 
most recent version, ver. 24.1 or later). Frequencies, percentages, severity, and 
relationship to study drug of patients with TEAEs, serious TEAEs, and TEAEs causing 
premature study withdrawal and study drug discontinuation will be provided by treatment 
group. An AE is treatment emergent if it occurs or worsens after the first dose of study 
treatment. Furthermore, frequencies of occurrence will be given of patients with TEAEs 
by system organ class; by system organ class and preferred term; by system organ class, 
preferred term, and maximal severity; by system organ class and preferred term for 
treatment-related TEAEs; and by system organ class, preferred term, and study day of 
onset. Separate summaries will be additionally performed for ocular and non-ocular AEs. 




CONFIDENTIAL 
 
Kowa Research Institute, Inc. 
K-161-3.01, Study Protocol 
 
K-161 
 
 
December 7, 2022 
Page 75 of 83 
 STUDY MANAGEMENT AND DATA COLLECTION 
11.1 
Ethical Conduct of the Trial 
The study will be performed in accordance with the ethical principles that have their 
origin in the Declaration of Helsinki, the HIPAA, and the ICH harmonised tripartite 
guideline E6(R2): GCP. The study will also be performed in compliance with the 
requirements of the US FDA as outlined in Title 21 of the CFR (Parts 11, 50, 54, 56, and 
312) and all other applicable regional or local regulatory requirements. 
11.2 
IRB/IEC/REC 
The IRB/IEC/REC must be assembled according to the applicable state and federal 
requirements of each participating location, including ICH E6(R2) guidelines, and 
US FDA 21 CFR Part 56. 
It is the responsibility of the clinical site to submit the Protocol, Investigator’s Brochure, 
patient ICF, patient recruitment materials (if applicable), and other documentation as 
required by the IRB/IEC/REC for review and approval. A copy of the written approval 
must be provided to KRI. The documentation must clearly mention the 
approval/favorable opinion of the Protocol, the patient ICF, and patient recruitment 
materials (if applicable), including respective version dates. The written approval and a 
list of the voting members, their titles or occupations, and their institutional affiliations 
must be obtained from the IRB/IEC/REC and provided to KRI before the release of 
clinical study supplies to the clinical site and commencement of the study. If any member 
of the IRB/IEC/REC has direct participation in the study, written notification regarding 
his or her abstinence from voting must also be obtained. 
The clinical site must adhere to all requirements stipulated by the IRB/IEC/REC. This 
includes notification to the IRB/IEC/REC regarding the following: protocol amendments, 
updates to the patient ICF, recruitment materials intended for viewing by patients, IND 
safety reports, serious and unexpected AEs, reports and updates regarding the ongoing 
review of the study at intervals specified by the IRB/IEC/REC, and submission of final 
study reports and summaries to the IRB/IEC/REC. 
It is the responsibility of each investigational site to submit information to the appropriate 
IRB/IEC/REC for annual review and annual re-approval. 
11.3 
Patient Informed Consent 
Written consent must be obtained from the patient prior to any study-specific procedure 
or investigation. 
Prior to the implementation of study procedures, patients and persons conducting the 
consent discussion will be required to sign and date the IRB/IEC-approved ICF, and each 
patient will be given a copy. In addition, this information will be recorded in the patient’s 
medical record (i.e., source document). 


CONFIDENTIAL 
 
Kowa Research Institute, Inc. 
K-161-3.01, Study Protocol 
 
K-161 
 
 
December 7, 2022 
Page 76 of 83 
The written consent document will embody the elements of informed consent as 
described in the HIPAA, World Medical Association Declaration of Helsinki, FDA 21 
CFR Part 50.25, ICH GCP, and in accordance with any local regulations. The 
Investigator is responsible for the preparation, content, and IRB/IEC/REC approval of the 
ICF. The ICF must be approved by the clinical site-designated IRB/IEC/REC and be 
acceptable to KRI or its designee prior to their use. 
The ICF must be written in a language fully comprehensible to the prospective patient. 
The written patient ICF will explain the objectives of the study and its potential risks and 
benefits. The information included on the ICF must be provided to the patient both 
verbally and in writing whenever possible and in a manner deemed appropriate by the 
IRB/IEC/REC. Patients must be given ample opportunity to read the information and 
inquire about details of the study. The Investigator must be satisfied that the patient has 
understood the information provided before written consent is obtained. If there is any 
doubt as to whether the patient has understood the written and verbal information, the 
patient must not be allowed to enter the study. 
If a patient agrees to participate, he or she will be asked to sign and date an ICF, the 
original copy of which will be kept by the Investigator. A copy of the signed ICF will be 
given to the patient. Information documenting the informed consent procedure will be 
recorded in the patient’s medical records (i.e., source document), and the original signed 
ICF must be made available to the study monitor for inspection. 
If informed consent is taken under special circumstances (oral informed consent), then 
the procedures to be followed must be determined by CRO and/or the sponsor and 
provided in writing by CRO and/or the sponsor prior to the consent process. 
All ICFs must be approved for use by the sponsor or designee and receive 
approval/favorable opinion from an IRB/IEC/REC prior to their use. If the ICF requires 
revision (e.g., due to a protocol amendment or significant new safety information), it is 
the PI’s responsibility to ensure that the amended form is reviewed and approved by the 
sponsor prior to submission to the governing IRB/IEC/REC and that it is read, signed, 
and dated by all patients or their designees currently and subsequently enrolled in the 
study. 
11.4 
Amendments to the Protocol 
An amendment must be agreed to in writing by the sponsor, submitted to FDA as an IND 
application amendment, and submitted to and approved by the respective IRB/IEC/REC 
for each investigational site before it is implemented. Written approval of a protocol 
amendment is not required prior to implementation for changes to the protocol, which 
eliminate immediate hazard to the patient; however, approval must be obtained as soon as 
possible thereafter. Approved amendments must also be signed by the Investigator. 
11.5 
Study Initiation 
The Investigator must not enroll any patients prior to the completion of a formal meeting 
conducted by a representative of the sponsor. This meeting will include a detailed review 
of the study protocol and eCRFs. Study drug will not be supplied to an Investigator until 


CONFIDENTIAL 
 
Kowa Research Institute, Inc. 
K-161-3.01, Study Protocol 
 
K-161 
 
 
December 7, 2022 
Page 77 of 83 
all the necessary pre-study requirements have been completed and essential signed 
documents are received by the sponsor or its representative. 
11.6 
Study Monitoring 
It is the responsibility of the Investigator to ensure that the study is conducted in 
accordance with the protocol, ICH/FDA GCPs, applicable regulatory requirements, 
HIPAA, and the current Declaration of Helsinki. Valid data are to be entered into the 
eCRFs. 
To achieve this objective, the monitor’s duties are to aid the Investigator and, at the same 
time, the sponsor in the maintenance of accurate, complete, legible, well-organized, and 
easily retrievable data. The monitor will review the protocol with the Investigator. In 
addition, the monitor will explain the Investigator’s reporting responsibilities and all 
applicable regulations concerning the clinical evaluation of the study drug. 
The Investigator will permit the representatives of the sponsor to monitor the study as 
frequently as the sponsor deems is necessary to determine that data recording and 
protocol adherence are acceptable. The eCRFs and related source documents will be 
reviewed in detail by the monitor at each visit, in accordance with relevant standard 
operating procedures, ICH GCP guidance, and FDA GCP regulations. This includes 
results of tests performed as a requirement for participation in this study and any other 
medical records required to confirm information contained in the eCRFs, such as past 
medical history and secondary diagnoses. The Investigator and staff will be expected to 
cooperate with the monitor and provide any missing information, whenever possible. 
All monitoring activities will be reported and archived. In addition, monitoring visits will 
be documented at the investigational site by signature and date on the study-specific 
monitoring log. 
11.7 
Case Report Form 
All patient data generated during the study will be recorded on the eCRF. 
The Investigator will ensure that all data are entered promptly, legibly, completely, 
accurately and conform to source documents, in accordance with specific instructions 
accompanying the eCRFs, designed specifically for this study and supplied by the 
representatives of the sponsor for each patient. 
The representatives of the sponsor will only consider the eCRFs to be complete after they 
are reviewed and signed by the Investigator, indicating his/her assurance of the accuracy 
of all recorded data. It is expected that the Investigator and staff will cooperate with the 
monitoring team and provide missing data in a timely manner. 
11.8 
Verification Procedures 
In fulfillment of their obligations to the sponsor and to verify compliance with this 
protocol, ICH GCP guidance, and FDA GCP regulations, the Investigator will permit the 
representatives of the sponsor, the IRBs/IECs/RECs, the monitor, and regulatory 
authorities to have direct access to the patient’s medical records. 


CONFIDENTIAL 
 
Kowa Research Institute, Inc. 
K-161-3.01, Study Protocol 
 
K-161 
 
 
December 7, 2022 
Page 78 of 83 
It is the Investigator’s obligation to ensure documentation of all relevant data in the 
patient’s medical record, eCRFs, and on study forms, when applicable, according to 
procedures provided in the protocol and/or supplemental instructions. 
The Investigator will maintain a Patient Identification Code List to enable unambiguous 
identification of the patients (patient names and corresponding subject codes). The 
Patient Identification Code List is an essential document and as such must be maintained 
according to the ICH GCP guidelines. 
11.9 
Retention of Records 
All documentation pertaining to the study will be retained by the sponsor in accordance 
with US FDA regulations and the ICH GCP guidance document. 
The representatives of the sponsor will provide each Investigator with a study file, which 
will be used to file the Investigator’s Brochure, protocol, drug accountability records, 
correspondence with the IRB/IEC and the sponsor, and other study-related documents. 
The Investigator agrees to keep records and those documents that include (but are not 
limited to) the identification of all participating patients, medical records, study-specific 
source documents, source worksheets, all original signed and dated ICFs, copies of all 
eCRFs, query responses, and detailed records of drug disposition, to enable evaluations 
or audits from regulatory authorities and the sponsor or its designees. 
The Investigator will retain records required to be maintained under federal regulations 
for a period of 2 years following the date a marketing application is approved for the drug 
for the indication for which it is being investigated; or, if no application is to be filed or if 
the application is not approved for such indication, until 2 years after the investigation is 
discontinued and FDA is notified. However, these documents will be retained for a 
longer period if required by the applicable regulatory requirement(s) or if needed by the 
sponsor. In addition, the Investigator must make provision for the patient’s medical 
records to be kept for the same period of time. 
Patients’ medical records and other original data will be archived in accordance with 
applicable regulations and requirements established by the investigational sites. 
11.10 Insurance and Indemnity 
The sponsor’s obligations regarding insurance and indemnification are described in other 
documents or agreements. 
11.11 Audit and Inspection 
The Investigator must permit study-related quality oversight monitoring, quality 
assurance audits, IRB/IEC/REC review, and regulatory agency inspections and provide 
direct access to source data documents. It is important that the Investigator(s) and their 
relevant personnel are available during the monitoring, audit, or inspection visits and that 
sufficient time is devoted to the process. 


CONFIDENTIAL 
 
Kowa Research Institute, Inc. 
K-161-3.01, Study Protocol 
 
K-161 
 
 
December 7, 2022 
Page 79 of 83 
It is the responsibility of KRI to perform sponsor quality oversight, as part of the quality 
assurance and quality control programs. The purpose of a quality assurance audit, which 
is independent of and separate from routine monitoring or quality control functions, is to 
evaluate trial conduct and compliance with the protocol, the principles of ICH GCP, and 
other applicable regulatory requirements. 


CONFIDENTIAL 
 
Kowa Research Institute, Inc. 
K-161-3.01, Study Protocol 
 
K-161 
 
 
December 7, 2022 
Page 80 of 83 
 USE OF INFORMATION 
12.1 
General Aspects 
All information concerning KRI, such as patent applications, formula, manufacturing 
processes, basic scientific data or formulation information supplied by KRI and not 
previously published, are considered confidential and will remain the sole property of 
KRI. The Investigator agrees to use this information only in accomplishing this study and 
will not use it for other purposes without the written consent of KRI, except for official 
representatives, such as regulatory authorities. 
It is understood by the Investigator that the information developed in this clinical study, 
in connection with the development of K-161 will be used by KRI and, therefore, may be 
disclosed by KRI as required to other clinical Investigators, other pharmaceutical 
companies and to other government agencies. In order to allow for the use of the 
information derived from clinical studies, it is understood that there is an obligation to 
provide to KRI complete test results and all data compiled in this study. 
12.2 
Patient Confidentiality and Data Protection 
KRI and its designees affirm and uphold the principle of the patient’s right to protection 
against invasion of privacy. Throughout this study, all data will be linked to the eCRF via 
a unique identification number and the patient's initials. The data will be masked 
correspondingly in all data analyses. 
However, in compliance with the guidelines and regulations of the US FDA concerning 
the acceptance of clinical studies in support of IND applications and the ICH GCP 
(whether performed in the US or elsewhere), and in fulfillment of its obligations to KRI 
to verify compliance with this protocol, KRI’s designee requires that the Investigator to 
permit its monitor, representatives from the FDA, KRI’s designated auditors, IRBs/IECs, 
and other governmental regulatory authorities to review the patient’s primary medical 
records (source data or documents) including, but not limited to laboratory test result 
reports, electrocardiogram reports, admission and discharge summaries for hospital 
admissions occurring during a patient’s study participation, and autopsy reports related to 
deaths occurring during the study. 
Should access to such medical records require a waiver or authorization separate from the 
statement of informed consent, the Investigator will obtain such permission in writing 
from the patient before the patient is entered into the study. 
12.3 
Final Report and Publication Policy 
All information regarding this study will be kept strictly confidential. All data derived 
from the study will be the property of KRI. The Investigator must undertake not to submit 
any part of the data from this study for publication without prior consent of KRI. KRI 
may disclose data derived from the study to other Investigators and drug regulatory 
authorities. 


CONFIDENTIAL 
 
Kowa Research Institute, Inc. 
K-161-3.01, Study Protocol 
 
K-161 
 
 
December 7, 2022 
Page 81 of 83 
After completion of the study, and as agreed by the Investigator and KRI, the Investigator 
may send a draft manuscript to KRI to be reviewed in order to reach an agreement 
regarding publication. The Investigator must receive written approval from KRI before 
the final version of the manuscript is submitted for publication. 
At the conclusion of the study, after the data are analyzed, KRI or its designee will 
prepare a final clinical report. 




CONFIDENTIAL 
 
Kowa Research Institute, Inc. 
K-161-3.01, Study Protocol 
 
K-161 
 
 
December 7, 2022 
Page 83 of 83 
Tauber J, Karpecki P, Latkany R, Luchs J, Martel J, Sall K, et al. Lifitegrast ophthalmic 
solution 5.0% versus placebo for treatment of dry eye disease: results of the randomized 
phase III OPUS-2 study. Ophthalmology. 2015;122(12):2423-2431.  
Tyrvaya [package insert] Oyster Point Pharma, Inc.; Nov 2021. 

SAP_003.pdf: 
NCT05403827


Kowa Research Institute, Inc. 
 Statistical Analysis Plan, Version 1.0 
K-161-3.01 
Date Issued: 2023-05-24 
 
II
SIGNATURE PAGE 


Kowa Research Institute, Inc.    
  Statistical Analysis Plan, Version 1.0 
K-161-3.01 
Date Issued: 2023-05-23 
 
III 
TABLE OF CONTENTS 
LIST OF ABBREVIATIONS ............................................................................ VI 
1.
INTRODUCTION......................................................................................8
2.
OBJECTIVES ............................................................................................9 
2.1. PRIMARY OBJECTIVES ................................................................................ 9 
2.2. SECONDARY OBJECTIVES ........................................................................... 9 
2.3. EXTENSION OBJECTIVES ............................................................................. 9 
2.4. EXPLORATORY OBJECTIVES ....................................................................... 9 
3.
INVESTIGATIONAL PLAN .................................................................10 
3.1. OVERALL STUDY DESIGN AND PLAN ........................................................ 10 
3.2. STUDY ENDPOINTS ................................................................................... 10 
3.2.1. 
Primary Efficacy Endpoints .............................................................. 10 
3.2.2. 
Key Secondary Efficacy Endpoint ..................................................... 11 
3.2.3. 
Secondary Efficacy Endpoints .......................................................... 11 
3.2.4. 
Safety Endpoints................................................................................ 11 
3.2.5. 
Extension Endpoints.......................................................................... 11 
3.2.6. 
Exploratory Endpoints ...................................................................... 11 
3.3. STUDY PROCEDURES AND BASELINE ........................................................ 12 
3.4. TREATMENTS ............................................................................................ 13 
4.
GENERAL STATISTICAL CONSIDERATIONS ..............................14 
4.1. SAMPLE SIZE ............................................................................................ 15 
4.2. TARGETED ESTIMAND .............................................................................. 15 
4.3. RANDOMIZATION, 
AND MASKING .................................. 16 
4.4. ANALYSIS SETS ........................................................................................ 16 
4.4.1. 
Full Analysis Set in the 12-week Primary Period ............................. 16 
4.4.2. 
Per Protocol Set in the 12-week Primary Period ............................. 16 
4.4.3. 
Safety Population in the 12-week Primary Period ........................... 17 
4.4.4. 
Full Analysis Set in the 52-week Overall Period .............................. 17 
4.4.5. 
Safety Population in the 52-week Overall Period............................. 17 
4.5. ASSESSMENT WINDOWS AND TIME PERIODS ............................................ 17 
4.5.1. 
Study Day .......................................................................................... 17 
4.5.2. 
Visit Windows for Analysis ............................................................... 17 
4.5.3. 
Time Periods ..................................................................................... 18 
5.
PATIENT DISPOSITION.......................................................................19 
5.1. DISPOSITION ............................................................................................. 19 
5.2. PROTOCOL DEVIATIONS ........................................................................... 20 
5.3. INTERCURRENT EVENTS ........................................................................... 20 
6.
DEMOGRAPHICS AND BASELINE CHARACTERISTICS ...........20 
6.1. DEMOGRAPHICS ........................................................................................ 20 
6.2. DRY EYE, MEDICAL, AND SURGICAL HISTORY ......................................... 21 
6.2.1. 
Dry Eye History ................................................................................ 21 




Kowa Research Institute, Inc.    
  Statistical Analysis Plan, Version 1.0 
K-161-3.01 
Date Issued: 2023-05-23 
 
V
10.
INTERIM ANALYSIS ............................................................................45 
11.
REFERENCES .........................................................................................46 
12.
APPENDIX I: TIME AND EVENT TABLE ........................................47 




Kowa Research Institute, Inc.    
  Statistical Analysis Plan, Version 1.0 
K-161-3.01 
Date Issued: 2023-05-23 
 
VII 
Q1 
quartile 1 
Q3 
quartile 3 
SAE 
serious adverse event 
SD 
standard deviation 
SOA 
schedule of study site activities 
SOC 
system organ class 
SP 
safety population 
SP12 
safety population in the 12-week primary period 
SP52 
safety population in the 52-week overall period 
TEAE 
treatment-emergent adverse event 
TESAE 
treatment-emergent serious adverse events 
TFBUT 
tear film break-up time 
 
 
US 
United States 
 
 
VAS 
visual analog scale 
WHO Drug 
World Health Organization Drug Dictionary 














Kowa Research Institute, Inc.    
  Statistical Analysis Plan, Version 1.0 
K-161-3.01 
Date Issued: 2023-05-23 
 
14 
4. General Statistical Considerations
Statistical analysis will be performed using SAS software (Version 9.4, SAS/STAT 15.2). 
Continuous variables will be summarized using the mean, the standard deviation (SD), 
median, Quartile 1 (Q1), Quartile 3 (Q3), minimum value, and maximum value. Categorical 
variables will be summarized using frequency and percentages. Unless otherwise noted, the 
denominator to determine the percentage of participants in each category will be based on 
the number of participants with available data. Selected ordinal data may be summarized 
using both descriptive statistics and frequencies and percentages of participants in each 
category, as appropriate. Data will be listed in data listings. 
All statistical tests will be 2-sided and performed using a 0.05 significance level, leading to 
95% (2-sided) Confidence Intervals (CIs). P-values less than 0.0001 will be presented as 
'<0.0001' and p-values = 1 will be presented as '>0.9999' in all tables. 
Number of patients, minimums, and maximums will be calculated to the same number of 
decimal places as the source data. Means, medians, and quartiles will be calculated to one 
more decimal place than the source data. SDs, standard errors, and CIs will be calculated to 
two more decimals than the source data. Percentages will be calculated to the nearest one 
decimal place. Zero count cells will be displayed as “0” with percentage of (0%).  
With regard to multiplicity caused by the 2 primary endpoints, Holm’s method (Holm 1979) 
will be utilized. First, an endpoint with a smaller p-value will be tested at alpha=0.025 
(two-sided). If the first test is significant, another endpoint will be tested at alpha=0.05 
(two-sided). Otherwise, the second test will not be performed. Key secondary efficacy 
endpoint will be tested at alpha=0.05 (two-sided) if primary endpoints are both significant 
at alpha=0.05. The other secondary efficacy endpoints will be tested in order by fixed 
sequence method if the key secondary endpoint is significant. 
The investigator will select the study eye, and this selection will be used in the final 
analysis even if the fellow eye is found to qualify and be worst. 
All efficacy analyses will only be presented for the study eye. 
Numeric data may be recorded at limits of detection (with a ‘<’ or ‘>’ sign, i.e. < 0.1 or > 
0.1). To summarize the data, the original value below a limit of detection will be converted 
to one half of the reported limit if it is a biological molecule, 0 otherwise. Values above a 
limit of detection will be reported at the limit. The actual values will be presented in the data 
listings. 


Kowa Research Institute, Inc.                                                                                                             Statistical Analysis Plan, Version 1.0 
K-161-3.01 
 
Date Issued: 2023-05-23 
 
 
 
 
15 
4.1. Sample Size 
The parameters to be needed for the calculation of sample size were estimated from the 
previous Phase 2 study (K-161-2.01US). In order to take intercurrent events (ICEs) into 
account, 4 different patient patterns are considered: (1) patients who were assigned to K-161 
 
 and had an ICE, (2) patients who were assigned to K-161 
 
 and did not 
have an ICE, (3) patients who were assigned to vehicle and had an ICE, and (4) patients who 
were assigned to vehicle and did not have an ICE. 
Regarding EDS (VAS), a population mean in each pattern is assumed as follows: 
Table 1: Intercurrent Event Estimates 
Assigned Treatment 
Intercurrent Event 
Not Occurred 
Occurred 
K-161 
 
 
(1) -10.0 
(2)   -3.6 
Vehicle 
(3)   -3.6 
(4)   -3.6 
A common variance, 431.2, and a common ICE occurrence rate, 8%, are assumed among 
the patterns. In order for EDS (VAS) to have at least 90% power when Holm’s method is 
applied, i.e., in order to have 90% probability that EDS (VAS) is statistically significant 
when an alpha is set to 0.025 (two-sided), 310 patients/arm will be needed. 
4.2. Targeted Estimand 
The summary of the targeted estimand is as follows: 
Treatment Condition 
Treatment condition based on the assigned treatment group. 
Population 
DED patients based on the Inclusion and Exclusion criteria of the study. 
Variable 
Change from baseline to Day 85 in conjunctival sum fluorescein staining score and 
EDS (VAS) including measurements after ICEs (i.e., treatment policy strategy). 
Potential ICEs of the study are as follows: 
• Discontinuation of the study treatment due to an AE 
• Discontinuation of the study treatment due to lack of efficacy 
Population-level Summary 
   Difference in means between the two treatment conditions. 




Kowa Research Institute, Inc.    
  Statistical Analysis Plan, Version 1.0 
K-161-3.01 
Date Issued: 2023-05-23 
 
17 
4.4.3. Safety Population in the 12-week Primary Period 
Safety Population (SP) in the 12-week Primary Period (SP12) will include all randomized 
patients who have received at least 1 dose of double-masked study treatment. Analyses 
will be presented by actual treatment received. 
4.4.4. Full Analysis Set in the 52-week Overall Period 
FAS in the 52-week Overall Period (FAS52) will include the randomized patients who are 
assigned into the 52-week Overall Period and received at least 1 dose of double-masked 
study treatment. Patients will be analysed according to their randomized treatment group, 
regardless of whether they adhere to their assigned treatment. 
4.4.5. Safety Population in the 52-week Overall Period 
SP in the 52-week Period (SP52) will include randomized patients for the 52-week Overall 
Period and who had at least 1 dose of double-masked study treatment. Analyses will be 
presented by actual treatment received. 
4.5. Assessment Windows and Time Periods 
4.5.1. Study Day 
When study day is used for display or in comparisons the following algorithm will be used: 
study day = date of assessment - Day 1 +1, if date of assessment ≥ Day 1.
study day = date of assessment - Day 1, if date of assessment < Day 1.
Note that the day before Day 1 is Day -1 (for analysis, there is no Day 0 for study day). 
4.5.2. Visit Windows for Analysis 
Visit windows will be defined for by-visit summary and analysis purposes. Summary data 
(such as AEs and concomitant medications) that are not reported by visit will not use visit 
windows.  
Scheduled, unscheduled, and early termination visits will be considered as valid assessments 
for analysis.  Visit labels will be assigned to each post-baseline record based on the windows 
for study day relative to the date of first dose of double-masked study drug. If an assessment 
at Day 1 is missing, the closest visit with non-missing assessment on or before the date of 
first dose of double-masked study drug will be used as baseline. All analyses will be based 
on the analysis visit windows in Table 2. If there are multiple valid assessments within a 
time window, the assessment which occurs closest to the target day will be used in the 


Kowa Research Institute, Inc.    
  Statistical Analysis Plan, Version 1.0 
K-161-3.01 
Date Issued: 2023-05-23 
 
18 
analysis. If there are multiple valid assessments with the same difference from the target day, 
the latest assessment will be used in the analysis.  
Table 2: Analysis Visit Windows 
Analysis Visit Window 
Analysis Visit 
12-week Primary Period
Patients / Total Patients
52-week Overall Period
Patients 
Day -14 
Nominal Visit 
Nominal Visit 
Day 1 
Nominal Visit 
Nominal Visit 
Baseline 
 Most recent measurement up 
to and including day 1 
 Most recent measurement 
up to and including day 1 
Day 15 
2 to 22 Days 
2 to 22 Days 
Day 29 
23 to 43 Days 
23 to 43 Days 
Day 57 
44 to 71 Days 
44 to 71 Days 
Day 85 
72 to 92 Days 
72 to 127 Days 
Day 99 
93 to 105 Days 
N/A 
Day 169 
N/A 
128 to 211 Days 
Day 253 
N/A 
212 to 309 Days 
Day 365 
N/A 
310 to 372 Days 
Day 379 
N/A 
373 to 385 Days 
4.5.3. Time Periods 
Data may be summarized for different time periods according to whether 12-week Primary 
Period Patients, 52-week Overall Period Patients, or Total patients are summarized. For 
data collected at the study sites for individual assessments and summarized for FAS12, 
PPS12, or SP12, data will be summarized through the Day 85 window. For FAS52 or 
SP52, data for assessments will be summarized through the Day 379 window.  
Event data will not be summarized according to the data windows above. This includes 
data for protocol deviations, concomitant medications and procedures, ICEs, and AEs. 
Data summarized for FAS12, PPS12, or SP12 will be summarized for the following period: 
•
12-week Primary Period
o
Through study day 85 for 52-week Overall Period Patients;
o
Through the end of the study for 12-week Primary Period Patients
(including data at and after Day 99 visit, if appropriate).
For FAS52 or SP52, data will be summarized according to 3 different time periods: 
•
52-week Overall Period, through the end of the study (including all
available data);


Kowa Research Institute, Inc.                                                                                                             Statistical Analysis Plan, Version 1.0 
K-161-3.01 
 
Date Issued: 2023-05-23 
 
 
 
 
19 
• 12-week Primary Period, through study day 85; 
• 40-week Extension Period, from study day 86 through the end of the study 
(including all available data). 
 
Periods for event data will be labeled for analysis populations FAS52 or SP52 in the 
analyses. The single period for event data will not be labeled beyond the labels used for 
FAS12, PPS12, or SP12. 
 
Windowing for study drug dosing and compliance is discussed in Section 7.7. 
5. Patient Disposition 
5.1. Disposition 
Enrollment by site and country will be presented for 52-week Overall Period Patients, 12-
week Primary Period Patients, and All Patients. 
Disposition will be summarized by treatment for 52-week Overall Period Patients, 12-week 
Primary Period Patients, and All Patients. The counts and percentages of patients who 
receive study treatment will be presented. The study completion status of patients will be 
presented and the reasons for withdrawal from the study will be presented for patients who 
withdraw. Study completion status for 52-week Overall Period Patients will also be 
presented by Primary and Extension Periods. Primary Period includes visits through Visit 6 
and Extension Period includes visits after Visit 6. Withdrawals will be summarized to the 
period in which they occur. Patients are assumed to be ongoing in the Primary Period if they 
did not withdraw. Patients are assumed to be ongoing unless they complete or withdraw the 
study in the Extension Period. The treatment completion status of patients will be presented 
and the reasons for study drug discontinuation will be presented for patients who do not 
complete treatment. The counts and percentages of patients who attend each study visit will 
be summarized. All percentages within the patient disposition summary will be based on the 
number of patients randomized in each treatment group within the appropriate patient 
population or overall. All percentages within the treatment disposition summary will be 
based on number of patients randomized who received at least 1 dose of double-masked 
study therapy.  For reason for study withdrawal, percentages will be based on the number of 
patients who withdrew from the study. For treatment completion status, percentages are 
based on number of patients randomized who received at least one dose of double-masked 
study therapy. For reason for study drug discontinuation, percentages are based on the 
number of patients who discontinued study drug.  
The count and percentage of patients who screen failed will be summarized out of patients 
who consented to the study. Reasons for screen failure will be presented for patients who 
screen failed.  


Kowa Research Institute, Inc.                                                                                                             Statistical Analysis Plan, Version 1.0 
K-161-3.01 
 
Date Issued: 2023-05-23 
 
 
 
 
20 
Patient and treatment disposition data will be listed. Screen failures will also be listed in the 
data listing. 
5.2. Protocol Deviations 
Protocol deviations will be tracked by the clinical team on an ongoing basis and will be 
recorded within the EDC. 
Patients with protocol deviations will be tabulated for each treatment group and overall for 
the 12-week Primary Period for FAS12 and for the 52-week Overall Period, 12-week 
Primary Period, and 40-week Extension Period for FAS52. All percentages will be based on 
the number of patients in each treatment group or overall. All deviations will be listed by 
patient. Protocol deviations will be finalized prior to database lock. 
5.3. Intercurrent Events  
Patients with protocol deviations will be tabulated for each treatment group and overall for 
the 12-week Primary Period for FAS12 and for the 52-week Overall Period, 12-week 
Primary Period, and 40-week Extension Period for FAS52. Possible ICEs include: 
• Discontinuation of the study treatment due to an AE, whether by investigator (e.g., 
“Adverse event, in the opinion of the investigator”) or the patient (e.g., “Patient 
request, Adverse event”); 
• Discontinuation of the study treatment due to lack of efficacy, whether by the 
investigator (e.g., “Lack of efficacy, as judged by the investigator”) or the patient 
(e.g., “Patient request, Lack of efficacy”). 
6. Demographics and Baseline Characteristics 
6.1. Demographics 
Demographic information and baseline characteristics collected at Screening will be 
summarized for the FAS12, PPS12, FAS52, SP12, and SP52. Continuous variables include 
age (years) will be summarized using descriptive statistics for each treatment group and 
overall. The following categorical variables will be summarized by reporting the number 
and percentage of patients in each category for each treatment group and overall.  
• Sex (Male, Female) 
• Age (<65, ≥65) and (<65, 65-84, ≥85) 
• Sex × Age (Male <65, Male ≥65, Female <65, Female ≥65) 
• Ethnicity (Hispanic, Latino/a, or Spanish origin, Not Hispanic, Latino/a, or Spanish 
origin, Not Reported, Unknown) 


Kowa Research Institute, Inc.                                                                                                             Statistical Analysis Plan, Version 1.0 
K-161-3.01 
 
Date Issued: 2023-05-23 
 
 
 
 
21 
• Hispanic, Latino/a, or Spanish Origin (Mexican, Mexican American, Chicana/o; 
Puerto Rican; Cuban; Other; Multiple) 
• Race (White, Black or African American, Asian, American Indian or Alaska Native, 
Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese, Other Asian, Native 
Hawaiian, Guamanian or Chamorro, Samoan, Other Pacific Islander, Not Reported, 
Unknown, Other, and Multiple) 
• Iris color of study eye (Brown, Blue, Hazel, Grey, Green, Black, Other) 
• Study eye [Oculus Dexter (OD) or Oculus Sinister (OS)] 
• Status of Smoking (Never, Current, Former) 
• Status of Vaping (Never, Current, Former) 
• Alcohol Use Occurrence (Never, Current, Former) 
Percentages will be based on the total number of patients in the FAS12, FAS52, SP12, and 
SP52. Percentages of individual ethnicities are out of patients of Hispanic, Latino/a, or 
Spanish Origin. 
All demographic and baseline characteristics will be listed.  
6.2. Dry Eye, Medical, and Surgical History 
6.2.1. Dry Eye History 
Dry eye history is captured in the electronic case report form (eCRF). Duration of dry eye 
years will be summarized descriptively using SP12 and SP52. The frequency and 
percentage of patients with specific features of dry eye will be summarized by treatment 
group and overall using the SP12 and SP52. 
 
Dry Eye duration will be calculated in years as (consent date – start date + 1) / 365.25. 
 
In case of a partial start date of DED: 
• If the start date is missing entirely, it will be left missing. 
• If the year is present and the month is missing, then the month will be set to January. 
• If the month and year are present and the day is missing, then the day will be set to 
the first day of month. 
6.2.2. Medical History 
Ocular and non-ocular medical histories will be captured in the eCRF.  The investigator will 
record the verbatim term, start date, and stop date (or continuing).  For ocular medical 
history, the investigator will also record the eye [right eye (OD), left eye (OS), both eyes 


Kowa Research Institute, Inc.    
  Statistical Analysis Plan, Version 1.0 
K-161-3.01 
Date Issued: 2023-05-23 
 
22 
(OU)]. Medical history will be coded using the Medical Dictionary for Regulatory Activities 
(MedDRA) Version 25.0.  
The frequency and percentage of patients with any medical history will be summarized by 
treatment group and overall using SP12 and SP52. System organ class (SOC) will be sorted 
alphabetically and preferred term (PT) within each SOC will be sorted by overall descending 
order of frequency according to the following rules in order: 
•
Descending frequency within K-161 
 
•
Descending frequency within vehicle;
•
PT in alphabetical order.
Medical history will include both the ocular and the general (non-ocular) history. Ocular 
medical history and general (non-ocular) medical histories will be summarized separately. 
Ocular and non-ocular medical histories will be identified according to whether eye is 
specified or not. Ocular medical history will be summarized for either eye. 
6.2.3. Surgical History 
Ocular and non-ocular surgical histories are captured in the eCRF.  The investigator will 
record the verbatim term and surgical date.  For ocular surgical history, the investigator will 
also record the eye (OD, OS, OU). Surgical history will be coded using the MedDRA 
Version 25.0.  
The frequency and percentage of patients with any surgical history will be summarized by 
treatment group using SP12 and SP52. SOC will be sorted alphabetically, and PT within 
each SOC will be sorted by overall descending order of frequency according to the following 
rules in order: 
•
Descending frequency within K-161 
 
•
Descending frequency within vehicle;
•
PT in alphabetical order.
Surgical history will include both the ocular and the general (non-ocular) history. Ocular 
surgical history and general (non-ocular) surgical history will be summarized separately. 
Ocular and non-ocular surgical history are identified according to whether eye is specified 
or not. Ocular surgical history will be summarized for either eye. 


Kowa Research Institute, Inc.                                                                                                             Statistical Analysis Plan, Version 1.0 
K-161-3.01 
 
Date Issued: 2023-05-23 
 
 
 
 
23 
6.3. Inclusion and Exclusion Criteria 
Inclusion and exclusion criteria deviations noted in the eCRF will be presented in a data 
listing. A summary table of inclusion and exclusion criteria that were not met will be 
presented for screen failures. 
7. Treatments and Medications 
7.1. Prior Medications and Concomitant Medications 
The investigator must record the use of all concomitant medications and any historical use 
of 
 before Visit 1, both dispensed and over-the-counter (OTC), in the eCRF 
along with the reason the medication was taken. This includes drugs used on a chronic and 
as-needed basis. Patients must be discouraged from starting any new medication, both 
dispensed and OTC, without consulting the investigator, unless the new medication is 
required for emergency use.  
Prior and concomitant medications will be coded using the World Health Organization Drug 
Dictionary (WHO Drug) (B3 WHO Drug Global Mar 2022 or later) for anatomical 
therapeutic chemical (ATC) classification and preferred drug name. 
The frequency and percentage of patients with coded medications will be summarized by 
treatment group using SP12 and SP52. Coded medications will be tabulated separately for 
the 52-week Overall Period, 12-week Primary Period, and 40-week Extension Period for 
SP52. A patient who used multiple medications will be counted only once for each ATC and 
preferred drug name. Therapeutic Subgroup will be sorted alphabetically, and preferred 
name will be sorted by descending frequency overall within each Level 3 term according to:  
 
1. Descending frequency within K-161 
 
 
2. Descending frequency within vehicle;  
3. PT in alphabetical order. 
Prior medications are defined as any medications that started and stopped prior to the first 
dose of double-masked study drug. Concomitant medications are defined as any medications 
that (1) start prior to the first dose of double-masked study drug and stop or are ongoing at 
or after the date of first dose of double-masked study drug; or (2) start at or after the first 
dose of double-masked study drug. Medications taken after a patient’s last visit or 
withdrawal from the study are not considered concomitant. 
Partial or missing medication stop dates for medications that are not ongoing will be handled 
as follows: 




Kowa Research Institute, Inc.    
  Statistical Analysis Plan, Version 1.0 
K-161-3.01 
Date Issued: 2023-05-23 
 
25 
surgery/procedure that starts at or after the first dose of double-masked study drug. Date 
imputation will be performed in a manner consistent with what was described in 7.1 Prior 
Medications and Concomitant Medications. Concomitant surgeries/procedures will be 
tabulated for each treatment group and overall for the 12-week Primary Period for SP12 
and for the 52-week Overall Period, 12-week Primary Period, and 40-week Extension 
Period for SP52.  
7.5. Rescue Surgeries/Procedures 
The subset of surgeries/procedures that are determined to be rescue surgeries/procedures 
for the signs and symptoms of DED will be summarized in a manner similar to 
surgeries/procedures. 
7.6. Concomitant Devices 
Concomitant devices will be presented in a listing. Rescue status for the signs and 
symptoms of DED will be listed. 
7.7. Study Treatments 
7.7.1. Extent of Exposure  
Descriptive statistics for the study treatment exposure (number of instillations and duration 
of treatment) and compliance will be provided by treatment group and overall and tabulated 
separately for the 12-week Primary Period for SP12 and the 52-week Overall Period, 12-
week Primary Period, and 40-week Extension Period for SP52. Duration of exposure will be 
calculated in days as the (date of last dose – date of first dose + 1). For exposure for the 12-
week Primary Period, 52-week Overall Period Patients will use the Visit 6 date – 1 as their 
last dose date if they have not already discontinued study drug. Duration for the 40-week 
Extension Period will be computed as last dose date minus Visit 6 date + 1 for 52-week 
Overall Period Patients. 
Frequency and percentages of patients in the following exposure categories will be 
summarized for SP12: 
•
<1 week
•
1 to ≤ 4 weeks
•
>4 to ≤ 8 weeks
•
>8 to ≤ 12 weeks
•
>12 weeks
•
Overall
o
1 to ≤ 12 weeks.


Kowa Research Institute, Inc.    
  Statistical Analysis Plan, Version 1.0 
K-161-3.01 
Date Issued: 2023-05-23 
 
26 
Frequency and percentages of patients in the following exposure categories will be 
summarized for SP52: 
•
<1 week
•
1 to ≤ 4 weeks
•
>4 to ≤ 8 weeks
•
>8 to ≤ 12 weeks
•
>12 to ≤ 24 weeks
•
>24 to ≤ 36 weeks
•
>36 to ≤ 52 weeks
•
>52 weeks
•
Overall
o
1 to ≤ 12 weeks
o
>12 to ≤ 52 weeks
o
1 to ≤ 52 weeks.
7.7.2. Treatment Compliance and Modifications 
Percent compliance will be calculated as: 
total assumed number of study drug instillations
planned number of instillations
× 100 
for SP12 and SP52. 
To calculate the planned number of instillations, the following scenarios are considered: 
•
For all study days, the total number of study drug instillations is the number of
dispensed vials minus the number of unused vials reported on the Study Drug
Dispensation and Accountability eCRF.
•
For all study days, the number of planned instillations will be 2 doses.
•
12-week Primary Period Patients will not be dosed on Day 85 (Visit 6). Duration of
exposure for patients who complete this phase will generally be (Visit 6 date – 1) –
Visit 2 date + 1.
•
52-week Overall Period Patients will not be dosed on Day 365 (Visit 9). Duration of
exposure for patients who complete this phase will generally be (Visit 9 date – 1) –
Visit 2 date + 1.
•
Patients who discontinue dosing early (dates do not correspond to Visit 6 or 9) will
include both doses in the planned number of doses on the last date of dosing.
•
Patients will be considered compliant with study treatment if the calculated percent
compliance is between 80% and 125%, inclusive.


Kowa Research Institute, Inc.                                                                                                             Statistical Analysis Plan, Version 1.0 
K-161-3.01 
 
Date Issued: 2023-05-23 
 
 
 
 
27 
Summaries for run-in medication will be similarly presented, except that exposure categories 
will not be included. Compliance for run-in medication will be calculated in a similar manner 
as above. Patients are expected to dose 
 daily from Visit 1 (inclusive) up to the date prior 
to Visit 2 (inclusive). Duration will generally be calculated as Visit 2 – Visit 1. 
A by-patient listing will be presented for the study treatment exposure and compliance, as 
well as drug accountability. 
8. Efficacy Analysis 
The FAS12 will be the primary analysis set for efficacy analyses. Separate efficacy analyses 
will be presented by the FAS52 if appropriate. Efficacy analyses will only be presented for 
the study eye. Primary efficacy endpoints will also be analyzed using PPS12. 
 
Summary statistics will be calculated for the observed values and change from baseline for 
the primary endpoints through Day 85 for FAS12 and through Day 365 for FAS52. The 
changes from baseline will be analyzed using MMRM models. This analysis will also be 
performed using PPS12. Imputation methods are described below. 
 
8.1. Primary Efficacy Endpoints 
8.1.1. Notation 
𝑖𝑖 
Patient (𝑖𝑖= 1, … , 𝑛𝑛𝑗𝑗) 
𝑗𝑗 
Treatment group (𝑗𝑗= 1, … , 𝐽𝐽) 
𝑘𝑘 
ICE status (𝑘𝑘= 1, … , 𝐾𝐾) 
𝑛𝑛𝑗𝑗 
The number of patients for treatment group 𝑗𝑗 
𝑡𝑡 
Time point (𝑡𝑡= 1, … , 𝑇𝑇) 
𝑦𝑦𝑖𝑖𝑖𝑖𝑖𝑖 Response variable for patient 𝑖𝑖 within treatment group 𝑗𝑗 at time point 𝑡𝑡 
𝑑𝑑𝑖𝑖𝑖𝑖𝑖𝑖 Change from baseline to time point 𝑡𝑡 for patient 𝑖𝑖 within treatment group 𝑗𝑗 
(𝑑𝑑𝑖𝑖𝑖𝑖𝑖𝑖= 𝑦𝑦𝑖𝑖𝑖𝑖𝑖𝑖−𝑦𝑦𝑖𝑖𝑖𝑖0 where 𝑦𝑦𝑖𝑖𝑖𝑖0 is baseline value) 
𝐱𝐱𝑖𝑖𝑖𝑖 Covariates (vector) for patient 𝑖𝑖 within treatment group 𝑗𝑗 
𝑅𝑅𝑖𝑖𝑖𝑖𝑖𝑖 Missingness status (𝑅𝑅𝑖𝑖𝑖𝑖𝑖𝑖= 0 if observed, 𝑅𝑅𝑖𝑖𝑖𝑖𝑖𝑖= 1 if missing) for patient 𝑖𝑖 within 
treatment group 𝑗𝑗 at time point 𝑡𝑡 
 
K-161-3.01 study has 𝐽𝐽= 2 treatments, 𝐾𝐾= 3 different ICE statuses and 𝑇𝑇= 3 time 
points as follows:  
 
Indicator 
 
Treatment Group 




Kowa Research Institute, Inc.    
  Statistical Analysis Plan, Version 1.0 
K-161-3.01 
Date Issued: 2023-05-23 
 
29 
VAR SEX BASE AVAL3 ; 
FCS ; 
RUN ; 
Note: The numbers specified in MINIMUM, MAXIMUM and ROUND options are utilized 
only for EDS (VAS). As for conjunctival sum fluorescein staining score, the following 
numbers are specified:  
MINIMUM= . . 0 MAXIMUM= . . 24 ROUND= . . 0.5 
The following is an example of datasets to be used: 
SUBJID 
TRTP 
TRTPN 
AGE 
SEX 
SEXN 
BASE 
AVAL1 
AVAL2 
AVAL3 
ICE 
ICEN 
0001 
Vehicle 
1 
48 
F 
1 
76 
51 
49 
60 
Not Occurred 
1 
0002 
K-161
2 
32 
F 
1 
70 
60 
 
 
Not Occurred 
1 
0003 
K-161
2 
39 
F 
1 
55 
58 
41 
 
LOE 
3 
0004 
Vehicle 
1 
21 
M 
0 
60 
72 
76 
55 
AE 
2 
… 
… 
… 
… 
… 
… 
… 
… 
… 
… 
… 
… 
SUBJID: Patient Identifier, TRTP: Planned Treatment, TRTPN: Planned Treatment (N), AGE: Age, SEX: Sex, SEXN: Sex (N), BASE: Baseline Value, 
AVAL1: Analysis Value at Day 29, AVAL2: Analysis Value at Day 57, AVAL3: Analysis Value at Day 85, ICE: Intercurrent Event Status, ICE: 
Intercurrent Event Status (N) 
With regard to the other ICE status (𝑘𝑘= 1), 𝑦𝑦𝑖𝑖𝑖𝑖𝑖𝑖 will be imputed under the Missing At 
Random (MAR) assumption if it is not observed. Let 𝐑𝐑𝑖𝑖𝑖𝑖= ൫𝑅𝑅𝑖𝑖𝑖𝑖1, 𝑅𝑅𝑖𝑖𝑖𝑖2, … , 𝑅𝑅𝑖𝑖𝑖𝑖𝑖𝑖൯
′. When
there is a patient whose values were observed at time points 𝑡𝑡< 𝑇𝑇 but not observed at the 
last time point 𝑡𝑡= 𝑇𝑇, for example, the MAR assumption implies that  
𝑓𝑓ቀ𝑦𝑦𝑖𝑖𝑖𝑖𝑖𝑖ቚ𝐱𝐱𝑖𝑖𝑖𝑖, 𝑗𝑗= 𝑝𝑝, 𝑦𝑦𝑖𝑖𝑖𝑖1, … , 𝑦𝑦𝑖𝑖𝑖𝑖(𝑇𝑇−1), 𝐑𝐑𝑖𝑖𝑖𝑖
′ = ൫0, … ,0, 1൯ቁ
= 𝑓𝑓ቀ𝑦𝑦𝑖𝑖𝑖𝑖𝑖𝑖ቚ𝐱𝐱𝑖𝑖𝑖𝑖, 𝑗𝑗= 𝑝𝑝, 𝑦𝑦𝑖𝑖𝑖𝑖1, … , 𝑦𝑦𝑖𝑖𝑖𝑖(𝑇𝑇−1), 𝐑𝐑𝑖𝑖𝑖𝑖
′ = ൫0, … ,0, 0൯ቁ. 
Actually, not only the last time point also but the other intermediate time points will be 
imputed in turn on the basis of the Available Case Missing Values (ACMV) restriction if 
there exists “not-observed” values. Thus, “not-observed” values will be imputed using 
SAS® MI procedure (Step 2A and 2B): 
MI Step 2A 
/*First, MCMC is used to complete input data to monotone pattern*/ 
PROC MI DATA= input1 OUT= output2 NIMPUTE= 100  
   MINIMUM= . . 0 0 0 MAXIMUM= . . 100 100 100 
       ROUND= . . 1 1 1 ; 
WHERE ICEN IN (1) ; 
BY TRTPN TRTP ; 


Kowa Research Institute, Inc.    
  Statistical Analysis Plan, Version 1.0 
K-161-3.01 
Date Issued: 2023-05-23 
 
30 
VAR SEXN BASE AVAL1 AVAL2 AVAL3 ; 
MCMC IMPUTE= MONOTONE ; 
RUN ; 
Note: The SEXN is the numeric variable for sex which was coded as 1 = female and 0 = 
male. The numbers specified in MINIMUM, MAXIMUM and ROUND options are utilized 
only for EDS (VAS). As for conjunctival sum fluorescein staining score, the following 
numbers are specified:  
  MINIMUM= . . 0 0 0 MAXIMUM= . . 24 24 24 
  ROUND= . . 0.5 0.5 0.5 
MI Step 2B 
/*Then, single imputation is performed in order for the data to be full*/ 
PROC MI DATA= output2 OUT= output3 NIMPUTE= 1  
   MINIMUM= . . 0 0 0 MAXIMUM= . . 100 100 100 
  ROUND= . . 1 1 1 ; 
BY TRTPN TRTP _Imputation_ ; 
CLASS SEX ; 
VAR SEX BASE AVAL1 AVAL2 AVAL3 ; 
MONOTONE REG ; 
RUN ; 
Note: The numbers specified in MINIMUM, MAXIMUM and ROUND options are utilized 
only for EDS (VAS). As for conjunctival sum fluorescein staining score, the following 
numbers are specified:  
 MINIMUM= . . 0 0 0 MAXIMUM= . . 24 24 24 
   ROUND= . . 0.5 0.5 0.5 
Two output datasets output1 and output3 are combined, which is named as input2, and 
then change from baseline to each time point (𝑑𝑑𝑖𝑖𝑖𝑖𝑖𝑖) is calculated, whose variable names are 
CHG1, CHG2 and CHG3, respectively. The dataset input2 is analyzed using SAS® MIXED 
procedure in each imputation after sorted by the variable _Imputation_. The following 
analysis model is assumed:  
𝑑𝑑𝑖𝑖𝑖𝑖𝑖𝑖= 𝛃𝛃′𝐱𝐱𝑖𝑖𝑖𝑖+ 𝜏𝜏𝑗𝑗+ 𝜀𝜀𝑖𝑖𝑖𝑖,   𝜀𝜀𝑖𝑖𝑖𝑖~𝑁𝑁(0, 𝜎𝜎2) 
where 𝜏𝜏𝑗𝑗 is effect of treatment group 𝑗𝑗. The estimator of interest is ൫𝜏𝜏̂2 + 𝛃𝛃෡′𝐱𝐱ത൯−
൫𝜏𝜏̂1 + 𝛃𝛃෡′𝐱𝐱ത൯= 𝜏𝜏̂2 −𝜏𝜏̂1, which is the difference of least squares means between K-161 
 
 vs. Vehicle 
 




Kowa Research Institute, Inc.                                                                                                             Statistical Analysis Plan, Version 1.0 
K-161-3.01 
 
Date Issued: 2023-05-23 
 
 
 
 
32 
Note that observed values after any of the ICEs occurred are not used in this approach, that 
is, those values are considered as “not-observed”. In this approach, first, a separate Mixed 
Model for Repeated Measures (MMRM) analysis for each treatment group is performed 
using all randomized patients under the MAR assumption:  
 
Step 1 
PROC MIXED DATA= input1 ; 
BY TRTPN TRTP ; 
CLASS SUBJID AVISIT ; 
MODEL CHG = BASE SEXN AVISIT BASE*AVISIT / DDFM= KR ; 
REPEATED AVISIT / SUBJECT= SUBJID TYPE= UN ; 
LSMEANS AVISIT / AT (BASE SEXN)= (&BASE_Mean &SEXN_Mean) ; 
ODS OUTPUT LSMeans= output1 ; 
RUN ; 
 
Note: The SEXN is the numeric variable for sex which was coded as 1 = female and 0 = 
male. The &BASE_Mean and & SEXN_Mean are an overall mean of baseline and an 
overall proportion of female patients values, respectively, in all study patients in the 
appropriate analysis population, FAS12 or PPS12. 
 
The following is an example of datasets to be used: 
 
SUBJID 
TRTP 
TRTPN 
AGE 
SEX 
SEXN 
AVISIT 
AVISITN 
BASE 
CHG 
ICE 
ICEN 
0001 
Vehicle 
1 
48 
F 
1 
Day 29 
1 
76 
-25 
Not Occurred 
1 
0001 
Vehicle 
1 
48 
F 
1 
Day 57 
2 
76 
-27 
Not Occurred 
1 
0001 
Vehicle 
1 
48 
F 
1 
Day 85 
3 
76 
-16 
Not Occurred 
1 
0002 
K-161 
2 
32 
F 
1 
Day 29 
1 
70 
-10 
Not Occurred 
1 
0002 
K-161 
2 
32 
F 
1 
Day 57 
2 
70 
 
Not Occurred 
1 
0002 
K-161 
2 
32 
F 
1 
Day 85 
3 
70 
 
Not Occurred 
1 
0003 
K-161 
2 
39 
F 
1 
Day 29 
1 
55 
3 
LOE 
3 
… 
… 
… 
… 
… 
… 
… 
… 
 
 
… 
… 
SUBJID: Patient Identifier, TRTP: Planned Treatment, TRTPN: Planned Treatment (N), AGE: Age, SEX: Sex, SEXN: Sex (N), AVISIT: Analysis Visit, 
AVISITN: Analysis Visit (N), BASE: Baseline Value, CHG: Change from Baseline, ICE: Intercurrent Event Status, ICE: Intercurrent Event Status (N) 
 
Second, the by-treatment MMRM analysis is repeated using only patients in whom any 
ICEs didn’t occur (𝑘𝑘= 1):  
 
Step 2 
PROC MIXED DATA= input1 ; 
WHERE ICEN = 1 ; 
BY TRTPN TRTP ; 
CLASS SUBJID AVISIT ; 
MODEL CHG = BASE SEXN AVISIT BASE*AVISIT / DDFM= KR ; 
REPEATED AVISIT / SUBJECT= SUBJID TYPE= UN ; 


Kowa Research Institute, Inc.                                                                                                             Statistical Analysis Plan, Version 1.0 
K-161-3.01 
 
Date Issued: 2023-05-23 
 
 
 
 
33 
LSMEANS AVISIT / AT (BASE SEXN)= (&BASE_Mean &SEXN_Mean) ; 
ODS OUTPUT LSMeans= output2; 
RUN ; 
 
When 𝜇𝜇̂𝑗𝑗,𝑀𝑀𝑀𝑀𝑀𝑀 and 𝜇𝜇̂𝑗𝑗
𝑘𝑘=1 denote LS-Means at week 12 for treatment group 𝑗𝑗 from the Step 1 
and 2, respectively, the estimator of effect for active treatment (i.e., K-161 
 
 𝑗𝑗=
2) proposed by Mehrotra et al. (2017) is as follows:  
 
𝜇𝜇̂2,𝑛𝑛𝑛𝑛𝑛𝑛[𝑐𝑐] ≡𝑓𝑓2
𝑘𝑘=1𝜇𝜇̂2
𝑘𝑘=1 + 𝑓𝑓2
𝑘𝑘≠1൫𝜇𝜇̂1,𝑀𝑀𝑀𝑀𝑀𝑀+ 𝑐𝑐൯ 
 
where 𝑓𝑓𝑗𝑗
𝑘𝑘=1 and 𝑓𝑓𝑗𝑗
𝑘𝑘≠1 are the proportions of patients with 𝑘𝑘= 1 or 𝑘𝑘≠1 in treatment 
group 𝑗𝑗, that is, 𝑓𝑓𝑗𝑗
𝑘𝑘≠1 = 1 −𝑓𝑓𝑗𝑗
𝑘𝑘=1. As for the primary analysis, suppose that 𝑐𝑐= 0, which 
implies that an average of active group’s patients in whom any of ICEs occurred is equal to 
one of vehicle group’s patients. Thus, the proposed estimator of treatment difference and 
its variance are as follows:  
 
𝛿𝛿̂𝑛𝑛𝑛𝑛𝑛𝑛[𝑐𝑐] = 𝜇𝜇̂2,𝑛𝑛𝑛𝑛𝑛𝑛[𝑐𝑐] −𝜇𝜇̂1,𝑀𝑀𝑀𝑀𝑀𝑀= 𝑓𝑓2
𝑘𝑘=1൫𝜇𝜇̂2
𝑘𝑘=1 −𝜇𝜇̂1,𝑀𝑀𝑀𝑀𝑀𝑀−𝑐𝑐൯+ 𝑐𝑐 
 
and 
𝑉𝑉෠൫𝛿𝛿̂𝑛𝑛𝑛𝑛𝑛𝑛[𝑐𝑐]൯= ቂ𝐴𝐴2 + ൫𝑓𝑓2
𝑘𝑘=1൯
2ቃ൫𝑉𝑉෠2
𝑘𝑘=1 + 𝑉𝑉෠1,𝑀𝑀𝑀𝑀𝑀𝑀൯+ ቂ𝐴𝐴2൫𝜇𝜇̂2
𝑘𝑘=1 −𝜇𝜇̂1,𝑀𝑀𝑀𝑀𝑀𝑀−𝑐𝑐൯
2ቃ 
 
where 𝐴𝐴2 = 𝑓𝑓2
𝑘𝑘=1൫1 −𝑓𝑓2
𝑘𝑘=1൯𝑛𝑛2
−1. 𝑉𝑉෠2
𝑘𝑘=1 and 𝑉𝑉෠1,𝑀𝑀𝑀𝑀𝑀𝑀 are the estimated variances of 𝜇𝜇̂2
𝑘𝑘=1 and 
𝜇𝜇̂1,𝑀𝑀𝑀𝑀𝑀𝑀, respectively, with corresponding Kenward-Roger type degrees of freedom 𝜆𝜆2
𝑘𝑘=1 
and 𝜆𝜆1,𝑀𝑀𝑀𝑀𝑀𝑀. Therefore, the statistic  
𝑡𝑡𝑛𝑛𝑛𝑛𝑛𝑛[𝑐𝑐] =
𝛿𝛿̂𝑛𝑛𝑛𝑛𝑛𝑛[𝑐𝑐]
ට𝑉𝑉෠൫𝛿𝛿̂𝑛𝑛𝑛𝑛𝑛𝑛[𝑐𝑐]൯
 
is tested using t-distribution with the degree of freedom  
𝜆𝜆[𝑐𝑐] =
ൣ𝑉𝑉෠൫𝛿𝛿̂𝑛𝑛𝑛𝑛𝑛𝑛[𝑐𝑐]൯൧
2
൫𝑉𝑉෠2
𝑘𝑘=1൯
2
𝜆𝜆2
𝑘𝑘=1
+ ൫𝑉𝑉෠1,𝑀𝑀𝑀𝑀𝑀𝑀൯
2
𝜆𝜆1,𝑀𝑀𝑀𝑀𝑀𝑀
 
 
In order to calculate the above statistics, the following values are extracted from the two 
output datasets output1 and output2, and aggregated into one dataset output3 with 
underlined variables. 
 


Kowa Research Institute, Inc.    
  Statistical Analysis Plan, Version 1.0 
K-161-3.01 
Date Issued: 2023-05-23 
 
34 
𝜇𝜇̂2
𝑘𝑘=1 
Value of variable Estimate where TRTPN = 2 AND AVISIT = ‘Day 85’ 
in dataset output2: mu2_k1. 
𝜇𝜇̂1,𝑀𝑀𝑀𝑀𝑀𝑀 Value of variable Estimate where TRTPN = 1 AND AVISIT = ‘Day 85’ 
in dataset output1: mu1 MAR. 
𝑉𝑉෠2
𝑘𝑘=1 
Squared value of variable StdErr where TRTPN = 2 AND AVISIT = ‘Day 85’ in 
dataset output2: V2 k1. 
𝑉𝑉෠1,𝑀𝑀𝑀𝑀𝑀𝑀 Squared value of variable StdErr where TRTPN = 1 AND AVISIT = ‘Day 85’ 
in dataset output1: V1_MAR. 
𝜆𝜆2
𝑘𝑘=1 
Value of variable DF where TRTPN = 2 AND AVISIT = ‘Day 85’ 
in dataset output2: lambda2_k1. 
𝜆𝜆1,𝑀𝑀𝑀𝑀𝑀𝑀 Value of variable DF where TRTPN = 1 AND AVISIT = ‘Day 85’ 
in dataset output1: lambda1 MAR. 
Besides, 𝑓𝑓2
𝑘𝑘=1 the proportion of treated group patients with 𝑘𝑘= 1 and 𝑛𝑛2 the sample size 
in study treatment group in FAS (i.e., K-161 
 
 𝑗𝑗= 2) are added to the dataset. 
With regard to the primary analysis, p-value (Probt) and two-sided 95% CI (Lower and 
Upper) are calculated as follows: 
 DATA output4 ; 
SET output3 ; 
c= 0 ; 
delta_new_c= f2_k1*(mu2_k1 - mu1_MAR - c) + c ; 
A2= f2_k1*(1 - f2_k1)/n2 ; 
V_delta_new_c= (A2 + (f2_k1)**2)*(V2_k1 + V1_MAR) 
+ (A2*(mu2_k1 + mu1_MAR - c)**2) ;
t_new_c= delta_new_c/sqrt(V_delta_new_c) ; 
lambda_c= V_delta_new_c**2/ 
         (V2_k1**2/lambda2_k1 + V1_MAR**2/lambda1_MAR) ; 
Probt= 2*(1 - cdf(‘T’, abs(t_new_c), lambda_c)) ; 
Lower= delta_new_c -  
        quantile(‘T’, .975, lambda_c)*sqrt(V_delta_new_c) ; 
Upper= delta_new_c +  
   quantile(‘T’, .975, lambda_c)*sqrt(V_delta_new_c) ; 
RUN ; 
8.1.5. Subgroup Analysis 
Week 12 observed and change from baseline for the primary endpoints will also be 
presented by the following subgroups: 


Kowa Research Institute, Inc.                                                                                                             Statistical Analysis Plan, Version 1.0 
K-161-3.01 
 
Date Issued: 2023-05-23 
 
 
 
 
35 
• Baseline EDS VAS (≤ or > median); 
• Baseline conjunctival sum fluorescein staining score (≤ or > median); 
• Baseline total eye fluorescein staining score (≤ or > median); 
• Baseline corneal sum fluorescein staining score (≤ or > median); 
• Baseline Schirmer score (≤ 5 mm or > 5 mm). 
8.1.6. Sensitivity Analysis 
A tipping point 𝑐𝑐= 𝑐𝑐𝑡𝑡, at which the primary analysis result turns out to be not-significant, 
is examined.  
 
An appropriate range of values for 𝑐𝑐𝑡𝑡 will be determined prior to database lock. 
8.2. Key Secondary Efficacy Endpoint 
The key secondary efficacy endpoint is change from baseline of total eye fluorescein 
staining score as assessed by expanded NEI scale for the study eye will be analyzed in a 
similar manner as performed for primary endpoint. 
The key secondary efficacy endpoint will be tested at alpha=0.05 (two-sided) if primary 
endpoints are both significant at alpha=0.05. 
 
Week 12 observed and change from baseline for the key secondary efficacy endpoint will 
also be presented by the subgroups defined for the primary endpoint. 
 
Summary statistics will be calculated for the observed values and change from baseline for 
the key secondary endpoint through Day 85 for FAS12 and through Day 365 for FAS52. 
Changes from baseline will also be analyzed using MMRM models. The MMRM analysis 
will also be performed using PPS12. Note that efficacy analyses using MMRM only 
summarize and analyze data that occur prior to ICEs. 
8.3. Secondary Efficacy Endpoints 
The secondary efficacy endpoints are the change from baseline to Day 85 for: 
• Corneal sum fluorescein staining score as assessed by expanded NEI scale, study 
eye; 
• OSDI© Score; 
• Schirmer’s test (unanesthetized), study eye; 
• TFBUT, study eye. 








Kowa Research Institute, Inc.    
  Statistical Analysis Plan, Version 1.0 
K-161-3.01 
Date Issued: 2023-05-23 
 
39 
SOC will be sorted alphabetically, and PT within each SOC will be sorted by overall 
descending order of frequency according to the following rules in order: 
•
Descending frequency within K-161 
 
•
Descending frequency within vehicle;
•
PT in alphabetical order.
Patients are counted only once for each SOC and PT. The percentages are calculated based 
on the number of patients in each treatment group.  
Partial dates on AE start dates will be handled as follows:  
•
If the onset date is completely missing and the AE end date is not prior to the date of
first dose of double-masked study drug, onset date will be set to the date of first dose.
•
If the year is present and the month is missing, then the month will be set to January.
If the year is the same as the year of the date of first dose of double-masked study
drug and the AE end date is not prior to the date of first dose of double-masked study
drug, then onset date will be set to the date of first dose of double-masked study drug.
•
If the month and year are present and the day is missing, then the day will be set to
the 1st day of month. If the month and year are the same as the month and year of the
date of first dose and the AE end date is not prior to the date of first dose of double-
masked study drug, then onset date will be set to the date of first dose of double-
masked study drug.
•
If the AE end date is present, then the imputed start date will be no later than the end
date.
9.1.1. Overview of Adverse Events
Overall summaries of TEAEs by treatment will include: 
•
the number of TEAEs and TESAEs reported;
•
the number of study-drug related TEAEs and TESAEs reported;
•
the number and percentage of patients who experienced any TEAE or TESAE;
•
the number and percentage of patients who experienced any study-drug related
TEAE or TESAE;
•
the number and percentage of patients with specific reasons for seriousness for
TESAE;
•
the number and percentage of patients with TEAE or TESAE leading to study drug
discontinuation;
•
the number and percentage of patients with TEAE or TESAE leading to study
withdrawal;


Kowa Research Institute, Inc.    
  Statistical Analysis Plan, Version 1.0 
K-161-3.01 
Date Issued: 2023-05-23 
 
40 
•
the number and percentage of patients with any TEAE or TESAE by worst
severity.
The above quantities will be tabulated for each treatment group and overall for the 12-
week Primary Period for SP12 and for the 52-week Overall Period, 12-week Primary 
Period, and 40-week Extension Period for SP52 for total, ocular, and non-ocular events. 
9.1.2. Incidence of Adverse Events 
Both ocular and non-ocular TEAEs will be summarized by treatment group or overall. The 
total number of TEAEs and the number and percentage of patients with at least one TEAE 
in each SOC and having each individual TEAE based on the PT will be presented. The 
number of events overall will also be presented. All AEs will be listed.  
The above analyses will be tabulated for each treatment group and overall for the 12-week 
Primary Period for SP12 and for the 52-week Overall Period, 12-week Primary Period, and 
40-week Extension Period for SP52 for ocular and non-ocular events.
9.1.3. Severity of Adverse Event 
A summary of TEAEs by maximum severity will be presented in a table by total number of 
patients with incidence of TEAE occurrence.  The severity that will be presented represents 
the most extreme severity captured on the eCRF page. The possible severities are “Mild,” 
“Moderate,” and “Severe.”  If a patient reported multiple occurrences of the same TEAE, 
only the most severe will be presented in the incidence count. TEAEs that are missing 
severity will be presented in tables as “Severe” but will be presented in the data listing with 
a missing severity. The percentages are calculated based on the number of patients in each 
treatment group and overall. The number of events overall by severity will also be presented. 
The TEAE data will be categorized and presented by SOC, PT, and severity in a manner 
similar to that described in Section 9.1.2. The above analyses will be tabulated for each 
treatment group and overall for the 12-week Primary Period for SP12 and for the 52-week 
Overall Period, 12-week Primary Period, and 40-week Extension Period for SP52 for 
ocular and non-ocular events. 
9.1.4. Adverse Events Related to Study Drug 
The relationship or association of the study drug in causing or contributing to the TEAE will 
be characterized as related or not related. A summary of TEAEs related to study drug will 
be presented in a table by total number of patients with incidence of TEAE occurrence. The 
investigator will provide an assessment of the relationship of the event to the study drug. 
TEAEs that are missing a relationship will be presented in the summary table as “Related” 
but will be presented in the data listing with a missing relationship. The percentages are 


Kowa Research Institute, Inc.    
  Statistical Analysis Plan, Version 1.0 
K-161-3.01 
Date Issued: 2023-05-23 
 
41 
calculated based on the number of patients in each treatment group or overall. The number 
of events overall will also be presented. 
The TEAE data will be categorized and presented by SOC, PT, and relationship in a manner 
similar to that described in Section 9.1.2. 
Summaries based on maximum relationship will be conducted in a manner similar to 
analyses for severity described in Section 9.1.3. 
The above analyses will be tabulated for each treatment group and overall for the 12-week 
Primary Period for SP12 and for the 52-week Overall Period, 12-week Primary Period, and 
40-week Extension Period for SP52 for ocular and non-ocular events.
9.1.5. Treatment-Emergent Adverse Events Leading to Study Drug 
Discontinuation 
TEAEs leading to study drug discontinuation will be identified as TEAEs on the AE eCRF 
page, where the action taken with study drug is “Study Drug Discontinued”.  The TEAEs 
leading to study drug discontinuation will be categorized and presented by SOC and PT in a 
manner similar to Section 9.1.2 that described in. All TEAEs leading to study drug 
discontinuation will be listed in a data listing. 
9.1.6. Treatment-Emergent Adverse Events Leading to Study Withdrawal 
TEAEs leading to study withdrawal will be identified as such if the study completion page 
lists reason for discontinuation is AE, in the opinion of the patient with the AE listed. The 
TEAEs leading to study withdrawal will be categorized and presented by SOC and PT in a 
manner similar to that described in Section 9.1.2. All TEAEs leading to study withdrawal 
will be listed in a data listing. 
9.1.7. Serious Adverse Events 
The TESAE data will be categorized and presented by SOC and PT in a manner similar to 
that described in Section 9.1.2. The TESAE data will be presented by SOC, PT, and severity 
as described in Section 9.1.3. The TESAE data will be presented by SOC, PT, and 
relationship as described in Section 9.1.4. The TESAE leading to treatment discontinuation 
and study withdrawal will be categorized and presented by SOC and PT in a manner similar 
to Sections 9.1.5 and 9.1.6. For all TESAE summaries, the number of events under each 
SOC and PT will also be presented. All SAE data will be listed in a data listing. 
The above analyses will be tabulated for each treatment group and overall for the 12-week 
Primary Period for SP12 and for the 52-week Overall Period, 12-week Primary Period, and 
40-week Extension Period for SP52 for ocular and non-ocular events.


Kowa Research Institute, Inc.    
  Statistical Analysis Plan, Version 1.0 
K-161-3.01 
Date Issued: 2023-05-23 
 
42 
9.1.8. Death 
Deaths will be identified as AEs on the AE eCRF page. Patient deaths will be identified as 
AEs where the outcome is “Death”.  All deaths will be listed in a data listing. 
9.2. Systemic Clinical Evaluation 
Systemic clinical evaluation will be conducted by investigator at baseline, Day 85, and Day 
365 and will include a review of the patient’s medical and medication history and subsequent 
evaluation of relevant body system complaints. In case of abnormal findings, full evaluation 
of the condition should be conducted by a physician in accordance with local standard of 
care. The findings will be documented in the patient’s medical records and eCRF. Clinically 
significant (CS) abnormal findings should be recorded as AEs. 
Whether these evaluations were performed will be listed. 
9.3. Clinical Laboratory Measurements 
The following clinical laboratory assessments will be conducted: 
Hematology: hematocrit, hemoglobin, mean corpuscular hemoglobin, mean corpuscular 
hemoglobin concentration, mean corpuscular volume, red cell distribution width, platelets, 
red blood cell, white blood cell, red blood cell morphology, and differentials (basophils, 
eosinophils, lymphocytes, monocytes, and neutrophils) 
Clinical chemistry: alanine aminotransferase, aspartate aminotransferase, albumin, 
calcium, chloride, alkaline phosphatase, bicarbonate, cholesterol, creatine kinase, creatinine, 
direct 
bilirubin, 
lactate 
dehydrogenase, 
magnesium, 
globulin, 
glucose, 
γ-
glutamyltransferase, indirect bilirubin, phosphorus, potassium, sodium, total bilirubin, total 
protein, triglycerides, urea nitrogen, and uric acid 
Urinalysis: bilirubin, blood, clarity, color, glucose, ketones, leukocyte esterase, nitrites, pH, 
protein, specific gravity, urobilinogen, and microscopic examination (if needed) 
Descriptive summaries of the observed test results at each scheduled visit as well as the 
change from baseline at each post-baseline visit will be presented for hematology, serum 
chemistry, and a subset of urinalysis labs (specific gravity, pH, urobilinogen). The frequency 
and percentage of the categorical shift from baseline at each post-baseline visit will be 
tabulated at each scheduled visit for labs. The frequency and percentage of patients with 
observed values for categorical urinalysis laboratory measurements will be tabulated at each 
scheduled visit. All laboratory data will be listed. 










Kowa Research Institute, Inc.    
  Statistical Analysis Plan, Version 1.0 
K-161-3.01 
Date Issued: 2023-05-23 
 
47 
12. Appendix I: Time and Event Table
Table 4: Schedule of Study Site Activities 
ASSESSMENTS 
PERFORMED 
STUDY PERIOD 
Scree
ning 
/Run-
in 
Period 
Days of Dosing and Assessments 
Post-
dose 
Assessm
ents 
52-week Overall Period
12-week Primary Period
40-week Extension
Period 
Visit 
1 
Day -
14 
(Day -
21 to -
12) 
Visit 
2 
Day 1 
(Base
line) 
Visit 
3 
Day 
15 
± 2 
(Rem
ote)a 
Visit 
4 
Day 
29 
± 2 
Visit 
5 
Day 
57 
± 7 
Visit 
6 
Day 
85 
± 7 
Visit 
7b 
Day 
169 
± 7 
Visit 
8b 
Day 
253 
± 7 
Visit 
9b 
Day 
365 
± 7 
Visit 6.5b 
Day 99 ± 7c 
or 
Visit 10b 
Day 379 
± 7c 
Informed 
Consent/HIPAA 
X 
Medical/Medication/
Ocular History and 
Demographics 
X 
Medical/Medication 
Update 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Vehicle Run-In 
Dispensation 
X 
Vehicle Run-In 
Instillation 
X 
Vehicle Run-in 
Collection and 
Accountability 
X 
Determination/assig
nment of the study 
eye 
X 
Randomization 
X 
Study Drug 
Dispensation 
X 
Xd 
Xd 
Xd 
Study Drug 
Instillation 
X 
X 
X 
Xd 
Xd 
Xd 
Study Drug 
Collection and 
Accountability 
Xe 
Xe 
X 
Xd 
Xd 
Xd 


Kowa Research Institute, Inc.    
  Statistical Analysis Plan, Version 1.0 
K-161-3.01 
Date Issued: 2023-05-23 
 
48 
ASSESSMENTS 
PERFORMED 
STUDY PERIOD 
Scree
ning 
/Run-
in 
Period 
Days of Dosing and Assessments 
Post-
dose 
Assessm
ents 
52-week Overall Period
12-week Primary Period
40-week Extension
Period 
Visit 
1 
Day -
14 
(Day -
21 to -
12) 
Visit 
2 
Day 1 
(Base
line) 
Visit 
3 
Day 
15 
± 2 
(Rem
ote)a 
Visit 
4 
Day 
29 
± 2 
Visit 
5 
Day 
57 
± 7 
Visit 
6 
Day 
85 
± 7 
Visit 
7b 
Day 
169 
± 7 
Visit 
8b 
Day 
253 
± 7 
Visit 
9b 
Day 
365 
± 7 
Visit 6.5b 
Day 99 ± 7c 
or 
Visit 10b 
Day 379 
± 7c 
Fluorescein Staining 
Scoring 
X 
X 
X 
X 
X 
X 
X 
X 
VAS 
X 
X 
X 
X 
X 
X 
X 
X 
TFBUT 
X 
X 
X 
X 
X 
X 
X 
X 
Schirmer’s Test 
X 
X 
X 
X 
X 
X 
X 
X 
Adverse Event 
Collection 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Systemic Clinical 
Evaluation  
X 
X 
X 
Clinical Laboratory 
Measurement 
X 
X 
X 



Prot_001.pdf: 
CONFIDENTIAL 
KOWA 
R.ESEAR.CH INSTITUTE, INC. 
A Phase 3, Prospective, Double-masked, Randomized, Multi-center, Vehicle-controlled, 
Parallel-group, 12-week Administration and 40-week Extension Study Confirming the 
Efficacy and Safety of K-161 Ophthalmic Solution for the Treatment of Moderate to 
Severe Dry Eye Disease 
Drug Name: 
Study Number: 
US IND Number: 
Clinical Study Protocol 
K-161
K-161-3.01
138738 
Protocol Version Date: 
Febma1y 10, 2022 
Amendment No. 1 
Protocol Version 
Name of Sponsor: 
Address: 
Kowa Research Institute, Inc. 
430 Davis Drive, Suite 200 
Monisville, NC 27560 
United States of America 
Confidentiality Statement 
This protocol contains confidential, proprieta1y info1mation of Kowa Research Institute, Inc. 
Fmther dissemination, distiibution or copying of this protocol or its contents is stiictly prohibited. 
NCT#: 
         NCT05403827


CONFIDENTIAL 
 
Kowa Research Institute, Inc. 
K-161-3.01, Study Protocol 
 
K-161 
 
 
February 10, 2022 
Page 2 of 82 
INVESTIGATOR’S STATEMENT 
I, the Investigator, understand that all information concerning the product supplied to me 
by Kowa Research Institute, Inc. (KRI) in connection with this study and not previously 
published is confidential information. This information includes the Investigator’s 
Brochure, protocol, case report forms, assay methods, technical methodology, and basic 
scientific data. 
I understand that any changes to the protocol must be approved in writing by KRI or 
representative 
and 
the 
Institutional 
Review 
Board/Independent 
Ethics 
Committee/Research Ethics Committee (IRB/IEC/REC) before implementation, except 
where necessary to eliminate apparent immediate hazards to the patients. 
I confirm that I will report all adverse events (AEs) following the regulations indicated in 
the protocol. 
I confirm that I will conduct this study in conformance with the ethical principles that have 
their origin in the Declaration of Helsinki, Health Insurance Portability and Accountability 
Act (HIPAA), as applicable, and, as applicable, the International Council for 
Harmonisation (ICH) tripartite guideline E6 (R2): Good Clinical Practice (GCP). I will 
also conduct this study, as applicable, in compliance with the requirements of the United 
States (US) Food and Drug Administration (FDA) as outlined in Title 21 of the Code of 
Federal Regulations (CFR) (Parts 11, 50, 54, 56, and 312) and all other applicable regional 
or local regulatory requirements. 
I confirm that I am informed of the need for record retention and that no data can be 
destroyed. 
By my signature below, I hereby attest that I have read, understood, and agree to abide by 
all conditions, instructions, and restrictions contained in this version of the protocol dated 
February 10, 2022. 
 
Investigator’s 
Signature: 
 
Date:  
 
 
 
 
 
mm/dd/yyyy 
Investigator’s 
Name: 
 
 
 
 
 
 
 


CONFIDENTIAL
Kowa Research Institute, Inc.
K-161-3.01, Study Protocol
K-161
February 10, 2022
Page 3 of 82
SIGNATURE PAGE
 Date  ____________________
mm/dd/yyyy
Kowa Pharma Development Company
_______________
mm/dd/yyyy
Kowa Pharma Development Company
_________________
mm/dd/yyyy
Kowa Pharma Development Company




CONFIDENTIAL 
 
Kowa Research Institute, Inc. 
K-161-3.01, Study Protocol 
 
K-161 
 
 
February 10, 2022 
Page 5 of 82 
Criteria for Evaluation: 
Primary Efficacy Endpoints: 
The primary efficacy endpoint (symptom) is: 
• 
Change in EDS (VAS) from baseline to Day 85 
The primary efficacy endpoint (sign) is: 
• 
Change in conjunctival sum fluorescein staining score from baseline to Day 85 as assessed by 
expanded NEI scale 
 
Key Secondary Efficacy Endpoint: 
Change from baseline to Day 85 in: 
• 
Total eye fluorescein staining score as assessed by expanded NEI scale 
 
Secondary Efficacy Endpoints: 
Change from baseline to Day 85 in: 
• 
Corneal sum fluorescein staining score as assessed by expanded NEI scale 
• 
OSDI 
• 
Schirmer’s test (unanesthetized) 
• 
TFBUT 
 
Safety Endpoints: 
Safety assessments from baseline up to Day 85 
• 
Adverse events (AEs) 
 
 
 
 
 
 
 
 
• 
Systemic clinical evaluation  
• 
Clinical laboratory measurement 
 
 
 
 
 
Extension Endpoints: 
• 
Safety assessments, as described for up to Day 85, from baseline up to Day 365 
• 
Change in all efficacy and exploratory endpoints from baseline to Day 365 
 
Exploratory Endpoints: 
 
 
 
 
 
 
 
 
 
 
 








CONFIDENTIAL 
 
Kowa Research Institute, Inc. 
K-161-3.01, Study Protocol 
 
K-161 
 
 
February 10, 2022 
Page 9 of 82 
 
Regarding EDS (VAS), a population mean in each pattern is assumed as follows: 
 
Assigned Treatment 
Intercurrent Event 
Not Occurred 
Occurred 
K-161 
 
(1) -10.0 
(2)   -3.6 
Vehicle 
(3)   -3.6 
(4)   -3.6 
 
A common variance, 431.2, and a common ICE occurrence rate, 8%, are assumed among the patterns. 
In order for EDS (VAS) to have at least 90% power when Holm’s method is applied, i.e., in order to have 
90% probability that EDS (VAS) is statistically significant when an alpha is set to 0.025 (two-sided), 
310 patients/arm will be needed. 
Targeted Estimand: 
The summary of the targeted estimand is as follows: 
Treatment Condition 
Treatment condition based on the assigned treatment group. 
Population 
DED patients based on the Inclusion and Exclusion criteria of the study. 
Variable 
Change from baseline to Day 85 in total eye stain score and EDS (VAS) including measurements 
after intercurrent events (i.e., treatment policy strategy). Potential intercurrent events of the study 
are as follows: 
 Discontinuation of the study treatment due to an adverse event 
 Discontinuation of the study treatment due to lack of efficacy 
 Discontinuation of the study treatment due to uncomfortable feeling of the study drug 
Population-level Summary 
Difference in means between the two treatment conditions. 
 
Primary Efficacy Analyses: 
The primary efficacy endpoints are change from baseline to Day 85 in conjunctival sum fluorescein 
staining score and EDS (VAS) on study eye, which are used regardless of whether or not the following 
ICEs occur: discontinuation of the study treatment due to an AE, lack of efficacy, or uncomfortable 
feeling of the study drug. Patients’ measurements will be made even after occurrence of those ICEs. For 
each of the primary endpoints, the Analysis of Covariance with baseline value, sex and treatment as 
covariates is used in order to make a comparison between the treatment groups. Least squares means will 
be calculated for the comparison. 
 
The data set to be used for the primary analyses is the FAS. 
 
Missing values will be imputed using the PMM with MI. Patterns to be used for the PMM are, as feasible, 
determined in each treatment group by whether or not patients had an ICE, or the type of ICEs if patients 
had an ICE. For example, if patients who discontinued the study treatment due to an AE had missing 
values, their missing values will be imputed from the patients who had the same ICE, i.e., discontinuation 
of the study treatment due to an AE. If enough patients to develop an imputation model in each pattern 
does not exist, the control-based mean imputation proposed by Mehrotra et al. (2017) will be applied 
instead of the PMM with MI. 




CONFIDENTIAL 
 
Kowa Research Institute, Inc. 
K-161-3.01, Study Protocol 
 
K-161 
 
 
February 10, 2022 
Page 11 of 82 
TABLE OF CONTENTS 
TITLE PAGE ................................................................................................................................. 1 
INVESTIGATOR’S STATEMENT ............................................................................................. 2 
SIGNATURE PAGE ...................................................................................................................... 3 
PROTOCOL SYNOPSIS .............................................................................................................. 4 
TABLE OF CONTENTS ............................................................................................................ 11 
LIST OF ABBREVIATIONS AND DEFINITION OF TERMS ............................................. 15 
 
INTRODUCTION AND RATIONALE FOR DOSE SELECTION .......................... 17 
1.1 
Background Information ................................................................................................... 17 
1.2 
Rationale for Study and Dose Selection ........................................................................... 17 
 
STUDY OBJECTIVES AND ENDPOINTS ................................................................. 19 
2.1 
Study Objectives ............................................................................................................... 19 
 
Primary Objectives ........................................................................................................... 19 
 
Secondary Objectives ....................................................................................................... 19 
 
Extension Objectives ........................................................................................................ 19 
 
Exploratory Objectives ..................................................................................................... 19 
2.2 
Study Endpoints ................................................................................................................ 20 
 
Primary Efficacy Endpoints .............................................................................................. 20 
 
Key Secondary Efficacy Endpoint .................................................................................... 20 
 
Secondary Efficacy Endpoints .......................................................................................... 20 
 
Safety Endpoints ............................................................................................................... 20 
 
Extension Endpoints ......................................................................................................... 21 
 
Exploratory Endpoints ...................................................................................................... 21 
 
STUDY DESCRIPTION ................................................................................................ 22 
3.1 
Study Design ..................................................................................................................... 22 
 
PATIENT ELIGIBILITY AND WITHDRAWAL CRITERIA ................................. 26 
4.1 
Inclusion Criteria .............................................................................................................. 26 
4.2 
Exclusion Criteria ............................................................................................................. 27 
4.3 
Study Drug Discontinuation Criteria ................................................................................ 29 
4.4 
Withdrawal Criteria .......................................................................................................... 30 
4.5 
Replacement, Rescreening, and Retesting ........................................................................ 31 
 
Replacement ...................................................................................................................... 31 
 
Rescreening ....................................................................................................................... 31 
 
Retesting ........................................................................................................................... 31 
 
PROCEDURES FOR SAFETY AND EFFICACY EVALUATIONS ....................... 32 
5.1 
Examination Procedures ................................................................................................... 32 
 
Scheduled Visits ............................................................................................................... 32 
 Visit 1 at Day –14 (Day -21 to -12): Screening ................................................................ 32 
 Visit 2: Day 1 – Baseline .................................................................................................. 33 
 Visit 3: Day 15 (± 2) – Remote Visit ................................................................................ 34 
 Visit 4: Day 29 (± 2) ......................................................................................................... 35 
 Visit 5: Day 57 (± 7) ......................................................................................................... 36 
 Visit 6: Day 85 (± 7) ......................................................................................................... 37 
 Visit 6.5: Day 99 (± 7; at least 14 days after the last dose of study medication) (Only 
Patients Who Are Assigned Into the 12-week Primary Period) ........................................ 38 




CONFIDENTIAL 
 
Kowa Research Institute, Inc. 
K-161-3.01, Study Protocol 
 
K-161 
 
 
February 10, 2022 
Page 13 of 82 
8.1 
General Considerations ..................................................................................................... 62 
8.2 
Prohibited Medication ....................................................................................................... 62 
8.3 
Permitted Medication and Rescue Therapy ...................................................................... 62 
 
AEs AND SAEs ............................................................................................................... 64 
9.1 
AEs ................................................................................................................................... 64 
 
AE Definition .................................................................................................................... 64 
 
Reporting of AEs .............................................................................................................. 64 
 
Follow-up of AEs .............................................................................................................. 66 
9.2 
SAEs ................................................................................................................................. 66 
 
SAE Definition ................................................................................................................. 66 
 Life-Threatening AEs ....................................................................................................... 67 
 Hospitalization .................................................................................................................. 67 
 
Reporting of SAEs ............................................................................................................ 67 
 
Serious Unexpected Suspected Adverse Reactions .......................................................... 68 
9.3 
 
9.4 
Patient Withdrawal and Drug Discontinuation ................................................................. 69 
 
STATISTICAL METHODS AND DATA ANALYSIS ............................................... 70 
10.1 
Sample Size Justification .................................................................................................. 70 
10.2 
Targeted Estimand ............................................................................................................ 70 
10.3 
Study Populations ............................................................................................................. 71 
10.4 
Analysis of Efficacy Parameters ....................................................................................... 71 
 Analysis of Secondary Efficacy Parameters ..................................................................... 72 
10.5 
Analysis of Safety Data .................................................................................................... 72 
10.6 
Analysis of Exploratory Endpoints ................................................................................... 73 
10.7 
Demographic/Baseline Information .................................................................................. 73 
10.8 
Interim Analysis ................................................................................................................ 73 
10.9 
Pharmacokinetic/Pharmacodynamic Analysis .................................................................. 73 
 
STUDY MANAGEMENT AND DATA COLLECTION ............................................ 74 
11.1 
Ethical Conduct of the Trial .............................................................................................. 74 
11.2 
IRB/IEC/REC ................................................................................................................... 74 
11.3 
Patient Informed Consent ................................................................................................. 74 
11.4 
Amendments to the Protocol ............................................................................................. 75 
11.5 
Study Initiation ................................................................................................................. 75 
11.6 
Study Monitoring .............................................................................................................. 76 
11.7 
Case Report Form ............................................................................................................. 76 
11.8 
Verification Procedures .................................................................................................... 76 
11.9 
Retention of Records ........................................................................................................ 77 
11.10 
Insurance and Indemnity ................................................................................................... 77 
11.11 
Audit and Inspection ......................................................................................................... 77 
 
USE OF INFORMATION ............................................................................................. 79 
12.1 
General Aspects ................................................................................................................ 79 
12.2 
Patient Confidentiality and Data Protection ..................................................................... 79 
12.3 
Final Report and Publication Policy ................................................................................. 79 
 
REFERENCES ................................................................................................................ 81 
 
 


CONFIDENTIAL 
 
Kowa Research Institute, Inc. 
K-161-3.01, Study Protocol 
 
K-161 
 
 
February 10, 2022 
Page 14 of 82 
 
List of Tables 
 
Table 1 
Clinical Evaluation Schedule ..................................................................................... 23 
 
 
List of Figures 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 




CONFIDENTIAL 
 
Kowa Research Institute, Inc. 
K-161-3.01, Study Protocol 
 
K-161 
 
 
February 10, 2022 
Page 16 of 82 
OD 
oculus dexter; right eye  
OS 
oculus sinister; left eye 
OSDI 
ocular surface disease index 
OTC 
over-the-counter 
PI 
principal Investigator 
PMM 
pattern mixture model 
PPS 
per protocol set 
REC 
Research Ethics Committee 
SAE 
serious adverse event 
SUSAR 
serious unexpected suspected adverse reaction 
TEAE 
treatment-emergent adverse event 
TFBUT 
tear film break-up time 
 
 
US 
United States 
 
 
VAS 
visual analog scale 
 














CONFIDENTIAL 
 
Kowa Research Institute, Inc. 
K-161-3.01, Study Protocol 
 
K-161 
 
 
November 22, 2021 
Page 23 of 82 
Table 1 
Clinical Evaluation Schedule 
ASSESSMENTS 
PERFORMED 
STUDY PERIOD 
Screening 
/Run-in 
Period 
Days of Dosing and Assessments 
Post-dose 
Assessments 
52-week Overall Period 
12-week Primary Period 
40-week Extension Period 
Visit 1 
Day -14 
(Day -21 
to -12) 
Visit 2 
Day 1 
(Baseline) 
Visit 3 
Day 15 
± 2 
(Remote)a 
Visit 4 
Day 29 
± 2 
Visit 5 
Day 57 
± 7 
Visit 6 
Day 85 
± 7 
Visit 7b 
Day 169 
± 7 
Visit 8b 
Day 253 
± 7 
Visit 9b 
Day 365 
± 7 
Visit 6.5b  
Day 99 ± 7c  
or 
Visit 10b 
Day 379 
± 7c 
Informed Consent/HIPAA 
X 
 
 
 
 
 
 
 
 
 
Medical/Medication/Ocular 
History and Demographics 
X 
 
 
 
 
 
 
 
 
 
Medical/Medication Update 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Vehicle Run-In Dispensation 
X 
 
 
 
 
 
 
 
 
 
Vehicle Run-In Instillation 
X 
 
 
 
 
 
 
 
 
 
Vehicle Run-in Collection and 
Accountability 
 
X 
 
 
 
 
 
 
 
 
Determination/assignment of the 
study eye 
 
X 
 
 
 
 
 
 
 
 
Randomization 
 
X 
 
 
 
 
 
 
 
 
Study Drug Dispensation 
 
X 
 
 
 
Xd 
Xd 
Xd 
 
 
Study Drug Instillation 
 
X 
 
X 
X 
Xd 
Xd 
Xd 
 
 
Study Drug Collection and 
Accountability 
 
 
 
Xe 
Xe 
X 
Xd 
Xd 
Xd 
 
Fluorescein Staining Scoring 
X 
X 
 
X 
X 
X 
X 
X 
X 
 
VAS 
X 
X 
 
X 
X 
X 
X 
X 
X 
 


CONFIDENTIAL 
 
Kowa Research Institute, Inc. 
K-161-3.01, Study Protocol 
 
K-161 
 
 
February 10, 2022 
 
Page 24 of 82 
ASSESSMENTS 
PERFORMED 
STUDY PERIOD 
Screening 
/Run-in 
Period 
Days of Dosing and Assessments 
Post-dose 
Assessments 
52-week Overall Period 
12-week Primary Period 
40-week Extension Period 
Visit 1 
Day -14 
(Day -21 
to -12) 
Visit 2 
Day 1 
(Baseline) 
Visit 3 
Day 15 
± 2 
(Remote)a 
Visit 4 
Day 29 
± 2 
Visit 5 
Day 57 
± 7 
Visit 6 
Day 85 
± 7 
Visit 7b 
Day 169 
± 7 
Visit 8b 
Day 253 
± 7 
Visit 9b 
Day 365 
± 7 
Visit 6.5b  
Day 99 ± 7c  
or 
Visit 10b 
Day 379 
± 7c 
TFBUT 
X 
X 
 
X 
X 
X 
X 
X 
X 
 
Schirmer’s Test 
X 
X 
 
X 
X 
X 
X 
X 
X 
 
Adverse Event Collection 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Systemic Clinical Evaluation  
 
X 
 
 
 
X 
 
 
X 
 
Clinical Laboratory 
Measurement 
X 
 
 
 
 
X 
 
 
X 
 
Exit Patient from Study 
 
 
 
 
 
 
 
 
 
X 
 HIPAA=Health Insurance 
Portability and Accountability Act; OSDI=Ocular Surface Disease Index; TFBUT=tear film break-up time; VAS=Visual analog scale. 
Note: The visit schedule will always be calculated from randomization visit date (Visit 2). 
a. 
Visit 3 will be a remote visit. 












CONFIDENTIAL 
 
Kowa Research Institute, Inc. 
K-161-3.01, Study Protocol 
 
K-161 
 
 
February 10, 2022 
Page 30 of 82 
infectious event, the study medication can be continued at the 
Investigator’s discretion.  
3. Violation of the protocol inclusion or exclusion criteria is discovered, and if, in 
the opinion of the Investigator or the sponsor, the violation will significantly 
compromise data interpretation or safety 
4. The patient undergoes rescue ophthalmic surgery (Section 8.3) 
5. The female patient becomes pregnant during the study (Section 9.3) 
6. In the Investigator’s judgment, it is in the patient’s best interest 
7. Lost to follow-up 
8. Sponsor termination of study 
9. Other 
Although a patient is not obligated to give his/her reason for discontinuing study drug, 
the Investigator will make a reasonable effort to obtain the reason while fully respecting 
the patient’s rights. The reason for discontinuation of study drug must be documented in 
the electronic case report form (eCRF). The clinical study report will include the 
reason(s) for discontinuation of study drug. 
4.4 
Withdrawal Criteria 
The patient has the right to withdraw from the study at any time and for any reason 
without prejudice to the patient’s future medical care. Nevertheless, every attempt will be 
made to prevent missing data and to obtain complete follow-up of all patients. 
Patients who meet study drug discontinuation criteria described in Section 4.3 will be 
discontinued from study drug; however, are not required to withdraw from the study 
unless the patient withdraws consent completely. As such, these patients will be 
encouraged to remain in the study and asked to attend all of the remaining study visits 
through Visit 6 (for the patients who are assigned into the 12-week Primary Period) or 
Visit 9 (for the patients who are assigned into the 52-week Overall Period) (Table 1). 
Patients who choose to withdraw from the study will be asked if they are prepared to 
complete a last visit. In this case, the same evaluations as the End of Treatment Period 
(Visit 6 or 9), or at least, the same evaluations as the Post-dose Assessment Visit (Visit 
6.5 or 10) should be performed. If a patient fails to actively maintain contact with the 
Investigator, reasonable efforts (telephone calls to family members or friends, email 
contacts, etc.) will be made in order to encourage the patient to complete the study visits. 
If the patient withdraws from the study, the reason should be captured. 
The patient will be withdrawn from the study if: 
1. The patient withdraws consent to attend the remaining study visits 
2. Lost to follow-up 
3. Sponsor termination of study 
4. Other 


CONFIDENTIAL 
 
Kowa Research Institute, Inc. 
K-161-3.01, Study Protocol 
 
K-161 
 
 
February 10, 2022 
Page 31 of 82 
Although a patient is not obligated to give his/her reason for withdrawing from the study, 
the Investigator will make a reasonable effort to obtain the reason while fully respecting 
the patient’s rights. Unless revoked, further contact in the case of withdrawal from the 
study will occur consistent with methods listed in the informed consent form (ICF). The 
reason for withdrawal from the study must be documented in the eCRF. The clinical 
study report will include the reason(s) for withdrawal from the study. 
If a patient withdraws from the study due to an AE, the patient will be asked to return to 
the clinic for, at a minimum, the evaluations scheduled for post-dose assessments. If the 
AE has still not resolved, additional follow-up will be performed, as appropriate. Every 
effort will be made by the Investigator or delegate to contact the patient until the AE is 
resolved or stabilized, or the medical monitor and Investigator agree that further follow-
up is not necessary. If patients are lost to follow-up, the Investigator will make 3 
reasonable attempts to contact the patient via telephone, US postal service, or certified 
mail. All attempts to contact them must be made and documented in the study records.  
4.5 
Replacement, Rescreening, and Retesting 
 Replacement 
Patients who are screened for the study may be replaced if they never are randomly 
assigned study drug or are withdrawn from the study before they administer any study 
drug after randomization. The replacement patients will receive a new randomly assigned 
treatment and not the treatment assignment of the replaced patient. Patients who self-
administer any study drug after randomization and subsequently are withdrawn early 
from the study will not be replaced. 
 Rescreening 
Patients who fail to satisfy inclusion and exclusion criteria at screening may be 
rescreened 1 additional time at the discretion of the sponsor. Screen failures due to 
inclusion and/or exclusion criteria that could transiently change and do not compromise 
the patient’s safety as judged by the Investigator can be rescreened once. All eligibility 
assessments will be repeated regardless of the reason for the initial screen failure and new 
subject number will be assigned. Rescreening decision must be confirmed by the 
sponsor’s medical monitor. 
 Retesting 
Clinical labs with clinically significant abnormalities (per the principal Investigator’s [PI] 
assessment) can be retested 1 time if there is a reasonable expectation that abnormality 
will resolve within the Screening Period (21 days at maximum). Unscheduled visits 
should be allowed within Screening Period. 


























CONFIDENTIAL 
 
Kowa Research Institute, Inc. 
K-161-3.01, Study Protocol 
 
K-161 
 
 
February 10, 2022 
Page 44 of 82 
 
 
 
 
 






CONFIDENTIAL 
 
Kowa Research Institute, Inc. 
K-161-3.01, Study Protocol 
 
K-161 
 
 
February 10, 2022 
Page 47 of 82 
 
 
 


















CONFIDENTIAL 
 
Kowa Research Institute, Inc. 
K-161-3.01, Study Protocol 
 
K-161 
 
 
February 10, 2022 
Page 56 of 82 
 
CONDUCT OF STUDY 
6.1 
Study Masking and Randomization 
All arms will be double-masked. The run-in drops will be single-masked for patients.  
Before the initiation of study run-in at Visit 1, each patient who provides written 
informed consent will be assigned a subject code. All subject codes will be assigned in 
strict numerical sequence at a site and no numbers will skipped or omitted. If a patient is 
retested on clinical labs, the same subject code will be used (Section 4.5.3). If a patient is 
rescreened, the patient will be assigned with a new subject code (Section 4.5.2). 
Patients who have signed informed consent and subsequently fail to satisfy inclusion and 
exclusion criteria are defined as screen failures. For all screen failures, the reason(s) for 
screen failure will be recorded on the patient’s source document and eCRF. 
Each patient who meets all the inclusion and none of the exclusion criteria at Visit 1 and 
Visit 2 will be randomized at the end of Visit 2 by using the IWRS. 
Subject codes and kit numbers will be assigned automatically to each patient as they are 
entered into the IWRS. All patients will be randomized into either vehicle or active 
treatment group at Visit 2 (Day 1) in a 1:1 ratio. 
 
The first 300 (150/arm) randomized patients will be assigned into the 
52-week Overall Period and the rest of study population (approximately 320 [160/arm] 
patients) will be assigned into the 12-week Primary Period. 
The site staff will dispense the required kit(s). Both the subject codes and the dispensed 
study drug kit number(s) will be recorded on the patient’s source document and eCRF. 
Patients, sponsor, CRO, and site personnel will be masked to treatment assignment. 
After Visit 6 (Day 85), patients who are randomized to enter the 40-week Extension 
Period will proceed to Visit 7 (Day 169) until Visit 10 (Day 379). Other patients, who are 
randomized to enter the 12-week Primary Period only, will proceed to Visit 6.5 (Day 99) 
for post-dose assessments and will complete the study. 
Planned analyses at Day 85 including the primary analyses will be performed by an 
unmasked team not involved in the conduct of the study once all patient data until Day 85 
are obtained in a fashion to protect the masking of all patients who will be followed in the 
40-week Extension Period. The masked team will have access only to a summary of the 
results comparing the two arms so the same study team can continue to be masked while 
conducting the remaining part of the trial until the end of the 52-week Overall Period. 
The investigational sites will not be unmasked and will not have access to the summary 
of the results comparing the two arms. 
6.2 
Study Visits 
For each patient, a maximum of 10 scheduled visits will be performed: 
• Visit 1 at Day -14 (Day -21 to -12): Screening: The screening examination to 
determine patient eligibility can take place anytime within this time period. 


CONFIDENTIAL 
 
Kowa Research Institute, Inc. 
K-161-3.01, Study Protocol 
 
K-161 
 
 
February 10, 2022 
Page 57 of 82 
• Visit 2 at Day 1: Baseline (12-21 days after Visit 1) 
• Visit 3 at Day 15 ± 2 days 
• Visit 4 at Day 29 ± 2 days 
• Visit 5 at Day 57 ± 7 days 
• Visit 6 at Day 85 ± 7 days 
For the patients who are assigned into the 12-week Primary Period 
• Visit 6.5 (post-dose) at Day 99 ± 7 days (at least 14 days after the last dose of 
study medication) 
For the patients who are assigned into the 52-week Overall Period (with the 40-week 
Extension Period): 
• Visit 7 at Day 169 ± 7 days 
• Visit 8 at Day 253 ± 7 days 
• Visit 9 at Day 365 ± 7 days 
• Visit 10 (post-dose) at Day 379 ± 7 days (at least 14 days after the last dose of 
study medication) 
The procedures and assessments to be performed at each visit are indicated in Table 1. 
6.3 
Compliance with The Protocol 
The Investigator must agree to implement the study protocol as written and adhere to the 
guidelines given in the Investigator’s Statement, which will be signed prior to the start of 
the study. The study will be performed in accordance with HIPAA, Declaration of 
Helsinki, International Council for Harmonisation (ICH) Good Clinical Practice (GCP) 
guidelines, local laws, FDA GCP regulations (21 Code of Federal Regulations [CFR] 
Parts 11, 50, 54, 56, and 312), and other applicable guidance documents. 
If the Investigator considers enrolling a patient that does not meet all inclusion or 
exclusion criteria, an exemption must be requested from the sponsor’s medical monitor 
prior to patient enrollment. The justification for the exemption must be document by the 
Investigator. The approval or rejection of the exemption must be documented by the 
sponsor’s medical monitor prior to the patient’s enrollment or screen failure. 
Protocol non-compliance must be reported to the sponsor or its representatives. Each 
deviation and the reason for its occurrence must be documented. The sponsor retains the 
right to require the withdrawal of any patient who violates the protocol. 
6.4 
Termination of the Study 
If, in the opinion of the Investigator, the clinical observations in the study suggest that it 
may be unwise to continue, the study may be terminated after consultation with the 
sponsor. A written statement fully documenting the reason(s) for the termination will be 
provided to the sponsor. In addition, the sponsor may terminate the study at any time. 


CONFIDENTIAL 
 
Kowa Research Institute, Inc. 
K-161-3.01, Study Protocol 
 
K-161 
 
 
February 10, 2022 
Page 58 of 82 
If it becomes apparent that patient enrollment is unsatisfactory with respect to quality or 
quantity, or data recording is inaccurate or incomplete on a chronic basis, the sponsor has 
the right to terminate the study and remove all study materials from the investigational 
site. A written statement will be provided to the Investigator, the Institutional Review 
Board/Independent Ethics Committee/Research Ethics Committee (IRB/IEC/REC), and 
regulatory authorities, if required. In the event of any serious or non-serious AEs having 
occurred at a site, all documentation relating to the event(s) must be obtained. 






CONFIDENTIAL 
 
Kowa Research Institute, Inc. 
K-161-3.01, Study Protocol 
 
K-161 
 
 
February 10, 2022 
Page 61 of 82 
7.7 
Drug Accountability 
The study drug is to only be dispensed by the PI or his/her named sub-Investigator(s), and 
is to only be used in accordance with this protocol. The study drug must only be 
distributed to patients properly qualified as described in this protocol to receive study 
drug. 
The Investigator must keep an accurate account of the study drug received from the 
supplier. This includes the amount of study drug dispensed to patients, amount of study 
drug returned to the Investigator by the patients, and the amount returned or disposed 
upon the completion of the study. A detailed inventory must be completed for the study 
drug. 
7.8 
Procedure for Unmasking 
As needed, the randomization code may be broken by the Investigator to manage an 
urgent medical safety event. If possible, the medical monitor should be contacted to 
discuss the case before the code is broken. 
If it becomes necessary to unmask treatment information during the study, the reason for 
unmasking must be documented in the eCRF. If the medical monitor cannot be notified 
prior to unmasking, the Investigator must contact the medical monitor promptly and 
explain the reason for the premature unmasking (e.g., unmasking due to an SAE). 
Planned analyses at Day 85 including the primary analyses will be performed by 
unmasked team not involved in the conduct of the study once all patient data until Day 85 
are obtained in a fashion to protect the masking of the patients who will be followed in 
the 40-week Extension Period. 
 


CONFIDENTIAL 
 
Kowa Research Institute, Inc. 
K-161-3.01, Study Protocol 
 
K-161 
 
 
February 10, 2022 
Page 62 of 82 
 
CONCOMITANT MEDICATION 
The Investigator must record the use of all concomitant medications and any historical 
use of 
 before Visit 1, both dispensed and OTC, in the eCRF along with the 
reason the medication was taken. This includes drugs used on a chronic and as-needed 
basis. Patients must be discouraged from starting any new medication, both dispensed 
and OTC, without consulting the Investigator, unless the new medication is required for 
emergency use. 
8.1 
General Considerations 
Concurrent enrollment in another investigational drug or medical device study is not 
permitted. 
8.2 
Prohibited Medication 
Disallowed medications/treatments during the study are outlined in the exclusion criteria 
(Section 4.2). 
8.3 
Permitted Medication and Rescue Therapy 
Contact lenses are allowed only during the 40-week Extension Period (except for study 
visit days before all visit assessments are completed). Contact lenses should be removed 
prior to the administration of study drug and may be reinserted at least 15 minutes 
following administration. If a subject is using another prescription eye drop in 
combination with the study medication, the concomitant use of contact lenses is not 
recommended for the duration of such combination therapy. 
The following medications are permitted as long as the dosage is stable: 
• Systemic tetracycline compounds (e.g., tetracycline, doxycycline, or 
minocycline), macrolides (e.g., azithromycin): for at least 30 days prior to Visit 1 
and dose will remain stable until the end of the 12-week Primary Period 
• Any medication (topical and systemic) known to cause ocular drying, such as 
systemic anticholinergic medications (e.g., atropine, homatropine), 
antidepressants and antipsychotic agents, statins, diuretics, beta-blockers, 
NSAIDs: for at least 30 days prior to Visit 1 and dose will remain stable until the 
end of the 12-week Primary Period 
o Episodic use of anticholinergic drops for eye examination and episodic use 
of systemic NSAIDs are allowed during the study except for within 2 days 
prior to any study visit. 
• Omega-3 fatty acid supplements in doses above 3000 mg/day, oral hormonal 
contraceptives, hormone replacement therapy for menopause: for 12 weeks prior 
to Visit 1 and dose will remain stable until the end of the 12-week Primary Period. 
Omega-3 fatty acid supplements in doses equal to or below 3000 mg/day are 
permitted. 




CONFIDENTIAL 
 
Kowa Research Institute, Inc. 
K-161-3.01, Study Protocol 
 
K-161 
 
 
February 10, 2022 
Page 64 of 82 
 
AEs AND SAEs 
9.1 
AEs 
 AE Definition 
An AE is any untoward medical occurrence in a patient administered a pharmaceutical 
product and which does not necessarily have a causal relationship with the 
pharmaceutical product. An AE can, therefore, be any unfavorable and unintended sign, 
symptom, or disease temporally associated with the use of a medicinal product, whether 
or not related to the medicinal product. Any worsening of the patient’s disease under 
study or other medical conditions will also be considered to be an AE, unless it is within 
the normal range of disease fluctuation for that patient. 
Clinically meaningful (for a given patient) changes in physical examination findings and 
abnormal objective test findings (e.g., clinical laboratory tests) are also recorded as AEs. 
The criteria for determining whether an abnormal objective test finding should be 
reported as an AE are as follows: 
1. Test result is associated with accompanying symptoms, and/or; 
2. Test result requires additional diagnostic testing or medical/surgical intervention, 
and/or; 
3. Test result leads to a change in study dosing or withdrawal from the study, 
significant additional concomitant drug treatment or other therapy, and/or; 
4. Test result leads to any of the outcomes included in the definition of an SAE 
(Section 9.2). 
Merely repeating a test, in the absence of any of the above conditions, does not meet 
condition number 2 above for reporting as an AE. 
Any abnormal test result that is determined to be an error does not require reporting as an 
AE. 
A treatment-emergent AE (TEAE) is defined as an AE that begins after the start of study 
drug or an event that begins before the start of the study drug and worsens in intensity 
after starting treatment. 
 Reporting of AEs 
At each evaluation, the Investigator will determine whether any AEs have occurred. The 
patient will be questioned in a general way and no specific symptoms will be suggested. 
If any AEs have occurred, they will be recorded on the AE pages of the eCRF and in the 
patient’s medical record. If known, the diagnosis will be recorded, in preference to the 
listing of individual signs and symptoms. 
AE reporting begins when informed consent is obtained and ends at the conclusion of the 
study, unless an unresolved AE is still being followed. 
The severity of the AE will be graded as follows: 


CONFIDENTIAL 
 
Kowa Research Institute, Inc. 
K-161-3.01, Study Protocol 
 
K-161 
 
 
February 10, 2022 
Page 65 of 82 
Mild 
The AE is easily tolerated and does not interfere with normal daily 
activities. 
Moderate 
The AE causes some interference with daily activities. 
Severe  
The AE causes all normal daily activities to be completely halted. 
 
The relationship of each AE to the study drug will be determined by the Investigator 
using these explanations: 
• Related: A reasonable possibility exists that the study drug caused the AE. A 
related AE can be further defined as follows: 
o Occurs within a reasonable temporal sequence to administration of study 
drug 
o Cannot be explained by concurrent disease or other drugs or chemicals 
o Improves or disappears on stopping or reducing study drug (de-challenge) 
o Reappears on repeated exposure to study drug (re-challenge) 
o Is an unusual event that is known to be associated with the drug or this 
class of compound, and cannot be explained by other therapy or the 
participant’s physical condition 
o Unlikely to be attributed to concurrent disease or other drugs or a 
clinically reasonable response on withdrawal (de-challenge) 
• Not Related: A reasonable possibility does not exist that the study drug caused 
the AE. A not related AE can be further defined as follows: 
o Occurs with a temporal relationship to administration of study drug which 
makes a causal relationship improbable 
o Other drugs, chemicals or underlying disease provide plausible 
explanations of causality 
o Is known to be associated with the participant’s clinical condition, or with 
other medication taken by the participant 
 
The Investigator will record each action taken and outcome for each AE according to the 
following: 
Action taken 
• None 
• Treatment required 
• Hospitalization 
• Study drug interrupted 
• Study drug discontinued 


CONFIDENTIAL 
 
Kowa Research Institute, Inc. 
K-161-3.01, Study Protocol 
 
K-161 
 
 
February 10, 2022 
Page 66 of 82 
• Patient withdrawn 
• Other (specify) 
Outcome 
• Recovered 
• Recovered with sequelae 
• Recovering 
• Ongoing 
• Death 
• Lost to follow-up 
Whether each AE is ocular or non-ocular will be determined by the Investigator for each 
AE and it will be recorded on the AE pages of the eCRF. 
 Follow-up of AEs 
If any AEs are present when a patient completes the study, or if a patient is withdrawn 
from the study, the patient will be re-evaluated. At the Investigator’s discretion, minor 
AEs can be re-evaluated via telephone and documented. If the AE is still not resolved, 
additional follow-up will be performed as appropriate. Every effort will be made by the 
Investigator or delegate to contact the patient until the AE is resolved or stabilized, or the 
medical monitor and Investigator agree that further follow-up is not necessary. The 
follow-up of AEs after post-dose assessments at Visits 6.5 or 10 will be documented in 
the patient’s medical records. 
9.2 
SAEs 
 SAE Definition 
An SAE is any untoward medical occurrence that at any dose: 
• Results in death 
• Is life-threatening 
• Requires patient hospitalization or prolongation of existing hospitalization 
• Results in persistent or significant disability/incapacity 
• Is a congenital anomaly/birth defect 
Medical and scientific judgment will be exercised in deciding whether expedited 
reporting is appropriate in other situations, such as important medical events that may not 
be immediately life-threatening or result in death or hospitalization but may jeopardize 
the patient or may require intervention to prevent one of the other outcomes listed in the 
definition above. Events that require expedited reporting will also be considered to be 
SAEs. 


CONFIDENTIAL 
 
Kowa Research Institute, Inc. 
K-161-3.01, Study Protocol 
 
K-161 
 
 
February 10, 2022 
Page 67 of 82 
 
Life-Threatening AEs 
The term life-threatening in the definition of serious refers to an event in which the 
patient 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. 
 
Hospitalization 
Hospitalization is defined as the patient being hospitalized overnight, or the patient’s 
hospital stay being prolonged for at least an additional overnight stay. Pre-planned 
hospital stays or hospital stays for non-medical social reasons are not applicable. Twenty-
three-hour hospitalizations for observation will be discussed with the medical monitor to 
determine whether they are appropriate for SAE reporting. 
 Reporting of SAEs 
All SAEs occurring from the time of informed consent until Visit 6.5 (patients enrolled in 
the Primary Period only) or Visit 10 (all other patients) must be reported to the CRO 
safety personnel within 24 hours of the knowledge of the occurrence (this refers to any 
AE that meets any of the aforementioned serious criteria). All SAEs that the Investigator 
considers related to study drug occurring after post-dose assessments at Visits 6.5 or 10 
must be reported to the CRO or the sponsor/designee. 
To report the SAE, the site staff will complete the SAE form electronically in the 
electronic data capture (EDC) system for the study. When the form is completed, the 
CRO safety personnel will be notified electronically and will retrieve the form. If the 
event meets serious criteria and it is not possible to access the EDC system, site staff will 
send a completed paper SAE form to 
within 24 hours of 
awareness. When the EDC system becomes available, the SAE information must be 
entered within 24 hours. 
 
 
  
 
  
 
  
 
 
The Investigator must continue to follow-up with the patient until the SAE has subsided 
or until the condition becomes chronic in nature, stabilizes (in the case of persistent 
impairment), or the patient dies. 
Within 24 hours of receipt of follow-up information, the Investigator must update the 
SAE form electronically in the EDC system for the study and submit any supporting 
documentation (e.g., patient discharge summary or autopsy reports) to 
 If it is not possible to access the EDC system, refer to the 
procedures outlined above for initial reporting of SAEs. Written confirmation that any 


CONFIDENTIAL 
 
Kowa Research Institute, Inc. 
K-161-3.01, Study Protocol 
 
K-161 
 
 
February 10, 2022 
Page 68 of 82 
serious, unexpected, and related AEs have been submitted to the IRB/IEC/REC must be 
forwarded to the sponsor and kept in the Investigator files. 
 Serious Unexpected Suspected Adverse Reactions 
According to FDA CFR 312.32(a) and FDA Guidance “Safety Reporting Requirements 
for Investigational New Drugs (INDs) and BA/BE (Bioavailability/Bioequivalence) 
Studies” finalized December 2012, suspected adverse reaction means any AE for which 
there is a reasonable possibility that the medicinal product caused the AE. The phrase 
reasonable possibility means there is evidence to suggest a causal relationship between 
the AE and the medicinal product. 
The following are examples of types of evidence that would suggest a causal relationship 
between the drug and the AE (i.e., reasonable possibility): 
• A single occurrence of an event that is uncommon and known to be strongly 
associated with drug exposure (e.g., angioedema, hepatic injury, Stevens-Johnson 
syndrome) 
• One or more occurrences of an event that is not commonly associated with drug 
exposure, but is otherwise uncommon in the population exposed to the drug 
(e.g., tendon rupture) 
Suspected adverse reactions are the subset of all AEs for which there is a reasonable 
possibility that the drug caused the event. The Investigator will initially classify the 
relatedness of an AE, but the final classification is subject to the medical monitor’s 
determination unless revised by the sponsor, which has the ultimate responsibility for 
judging relatedness. 
A suspected adverse reaction is considered unexpected if it is not listed in the Reference 
Safety Information in Section 6 of the K-161 Investigator’s Brochure or is not listed at 
the specificity or severity that has been described in the K-161 Investigator’s Brochure. 
An AE or suspected adverse reaction is considered serious if, in the view of either the 
Investigator or sponsor, it results in any of the following outcomes: Death, a 
life-threatening AE, inpatient hospitalization or prolongation of existing hospitalization, a 
persistent or significant incapacity or substantial disruption of the ability to conduct 
normal life functions, or a congenital anomaly/birth defect (Section 9.2.1). Important 
medical events that may not result in death, be life-threatening, or require hospitalization 
may be considered serious when, based upon appropriate medical judgment, they may 
jeopardize the patient or patient and may require medical or surgical intervention to 
prevent one of the outcomes listed in this definition. 
Any AE meeting the definitions of suspected adverse reaction, unexpected, and serious is 
considered a serious unexpected suspected adverse reaction (SUSAR). In accordance 
with the FDA Guidance “Safety Reporting Requirements for INDs and BA/BE Studies” 
finalized December 2012, the sponsor will unmask the study data for patients 
experiencing SUSARs and only report those for patients who are on the active K-161 
product. All such reports will be submitted to the Investigator(s), FDA, and 
IRB/IEC/REC in an expedited manner. 




CONFIDENTIAL 
 
Kowa Research Institute, Inc. 
K-161-3.01, Study Protocol 
 
K-161 
 
 
February 10, 2022 
Page 70 of 82 
 STATISTICAL METHODS AND DATA ANALYSIS 
10.1 
Sample Size Justification 
The parameters to be needed for the calculation of sample size were estimated from the 
previous Phase 2 study (K-161-2.01US). In order to take intercurrent events (ICEs) into 
account, 4 different patient patterns are considered: (1) patients who were assigned to 
K-161 
 and had an ICE, (2) patients who were assigned to K-161 
 
and did not have an ICE, (3) patients who were assigned to vehicle and had an ICE, and 
(4) patients who were assigned to vehicle and did not have an ICE. 
Regarding EDS (VAS), a population mean in each pattern is assumed as follows: 
Assigned Treatment 
Intercurrent Event 
Not Occurred 
Occurred 
K-161 
 
(1) -10.0 
(2)   -3.6 
Vehicle 
(3)   -3.6 
(4)   -3.6 
 
A common variance, 431.2, and a common ICE occurrence rate, 8%, are assumed among 
the patterns. In order for EDS (VAS) to have at least 90% power when Holm’s method is 
applied, i.e., in order to have 90% probability that EDS (VAS) is statistically significant 
when an alpha is set to 0.025 (two-sided), 310 patients/arm will be needed. 
10.2 
Targeted Estimand 
The summary of the targeted estimand is as follows: 
Treatment Condition 
Treatment condition based on the assigned treatment group. 
Population 
DED patients based on the Inclusion and Exclusion criteria of the study. 
Variable 
Change from baseline to Day 85 in total eye stain score and EDS (VAS) including 
measurements after intercurrent events (i.e., treatment policy strategy). Potential 
intercurrent events of the study are as follows: 
 Discontinuation of the study treatment due to an adverse event 
 Discontinuation of the study treatment due to lack of efficacy 
 Discontinuation of the study treatment due to uncomfortable feeling of the study 
drug 
Population-level Summary 


CONFIDENTIAL 
 
Kowa Research Institute, Inc. 
K-161-3.01, Study Protocol 
 
K-161 
 
 
February 10, 2022 
Page 71 of 82 
Difference in means between the two treatment conditions. 
 
10.3 
Study Populations 
The following analysis populations will be considered: 
Full Analysis Set (FAS) in the 12-week Primary Period: will include all randomized 
patients who received at least 1 dose of study treatment. Patients will be analyzed 
according to their randomized treatment group, regardless of whether they adhere to their 
assigned treatment. The FAS will be used as the primary efficacy analyses. 
Per Protocol Set (PPS) in the 12-week Primary Period: will include all randomized 
patients without any major protocol deviations and have valid baseline and Day 85 
primary endpoint values. Major protocol deviations will be pre-specified prior to 
unmasking the study. PPS will be used to assess robustness of the primary analysis 
results. 
Safety Population in the 12-week Primary Period: will include all randomized patients 
who have received at least 1 dose of study treatment. 
FAS in the 52-week Overall Period: will include the randomized patients who are 
assigned into the 52-week Overall Period and received at least 1 dose of study treatment. 
Patients will be analyzed according to their randomized treatment group, regardless of 
whether they adhere to their assigned treatment. 
Safety Population in the 52-week Overall Period: will include randomized patients for the 
52-week Overall Period and who had at least 1 dose of study treatment. 
10.4 
Analysis of Efficacy Parameters 
The primary efficacy endpoints are change from baseline to Day 85 in conjunctival sum 
fluorescein staining score on study eye and EDS (VAS), which are used regardless of 
whether or not the following ICEs occur: discontinuation of the study treatment due to an 
AE, lack of efficacy or uncomfortable feeling of the study drug. Patients’ measurements 
will be made even after occurrence of those ICEs. For each of the primary endpoints, the 
analysis of covariance with baseline value, sex and treatment as covariates is used in 
order to make a comparison between the treatment groups. Least squares means will be 
calculated for the comparison. 
The data set to be used for the primary analyses is the FAS. 
Missing values will be imputed using the pattern mixture model (PMM) with multiple 
imputation (MI). Patterns to be used for the PMM are, as feasible, determined in each 
treatment group by whether or not patients had an ICE, or the type of ICEs if patients had 
an ICE. For example, if patients who discontinued the study treatment due to an AE had 
missing values, their missing values will be imputed from the patients who had the same 
ICE, i.e., discontinuation of the study treatment due to an AE. If enough patients to 
develop an imputation model in each pattern do not exist, the control-based mean 


CONFIDENTIAL 
 
Kowa Research Institute, Inc. 
K-161-3.01, Study Protocol 
 
K-161 
 
 
February 10, 2022 
Page 72 of 82 
imputation proposed by Mehrotra (Mehrotra 2017) will be applied instead of the PMM 
with MI. 
If the MI is applied, multiple parameter estimates will be combined using Rubin’s rule 
(Rubin 1987). 
With regard to multiplicity caused by the 2 primary endpoints, Holm’s method 
(Holm 1979) will be utilized. First, an endpoint with a smaller p-value will be tested at 
alpha=0.025 (two-sided). If the first test is significant, another endpoint will be tested at 
alpha=0.05 (two-sided). Otherwise, the second test will not be performed. 
Planned analyses at Day 85 including the primary analyses will be performed by 
unmasked team not involved in the conduct of the study once all patient data until Day 85 
are obtained in a fashion to protect the masking of the patients who will be followed in 
extension. Masked team will have access only to a summary of the results comparing the 
two arms so the same study team can continue to be masked while conducting the 
remaining part of the trial until the end of the 52-week Overall Period. The 
investigational sites will not be unmasked and will not have access to the summary of the 
results comparing the two arms.  
As a sensitivity analysis, a tipping point, at which the primary analysis result turns out to 
be not-significant, is examined in each ICE.  
Further details will be included in a separated statistical analysis plan.  
 Analysis of Secondary Efficacy Parameters 
The key secondary efficacy endpoint is change from baseline of total eye fluorescein 
staining score as assessed by expanded NEI scale for study eye will be analyzed in a 
similar manner as performed for primary endpoint. All other secondary endpoints will 
also be analyzed in a similar manner. 
The other secondary efficacy endpoints are ordered as follows: corneal sum fluorescein 
staining score as assessed by expanded NEI scale, OSDI, Schirmer’s test 
(unanesthetized), and TFBUT. 
Key secondary efficacy endpoint will be tested at alpha=0.05 (two-sided) if primary 
endpoints are both significant at alpha=0.05. 
The other secondary efficacy endpoints will be tested in order by fixed sequence method 
if the key secondary endpoint is significant. 
10.5 
Analysis of Safety Data 
AEs will be coded using the Medical Dictionary for Regulatory Activities dictionary (the 
most recent version, ver. 24.1 or later). Frequencies, percentages, severity, and 
relationship to study drug of patients with TEAEs, serious TEAEs, and TEAEs causing 
premature study withdrawal and study drug discontinuation will be provided by treatment 
group. An AE is treatment emergent if it occurs or worsens after the first dose of study 
treatment. Furthermore, frequencies of occurrence will be given of patients with TEAEs 
by system organ class; by system organ class and preferred term; by system organ class, 




CONFIDENTIAL 
 
Kowa Research Institute, Inc. 
K-161-3.01, Study Protocol 
 
K-161 
 
 
February 10, 2022 
Page 74 of 82 
 STUDY MANAGEMENT AND DATA COLLECTION 
11.1 
Ethical Conduct of the Trial 
The study will be performed in accordance with the ethical principles that have their 
origin in the Declaration of Helsinki, the HIPAA, and the ICH harmonised tripartite 
guideline E6(R2): GCP. The study will also be performed in compliance with the 
requirements of the US FDA as outlined in Title 21 of the CFR (Parts 11, 50, 54, 56, and 
312) and all other applicable regional or local regulatory requirements. 
11.2 
IRB/IEC/REC 
The IRB/IEC/REC must be assembled according to the applicable state and federal 
requirements of each participating location, including ICH E6(R2) guidelines, and 
US FDA 21 CFR Part 56. 
It is the responsibility of the clinical site to submit the Protocol, Investigator’s Brochure, 
patient ICF, patient recruitment materials (if applicable), and other documentation as 
required by the IRB/IEC/REC for review and approval. A copy of the written approval 
must be provided to KRI. The documentation must clearly mention the 
approval/favorable opinion of the Protocol, the patient ICF, and patient recruitment 
materials (if applicable), including respective version dates. The written approval and a 
list of the voting members, their titles or occupations, and their institutional affiliations 
must be obtained from the IRB/IEC/REC and provided to KRI before the release of 
clinical study supplies to the clinical site and commencement of the study. If any member 
of the IRB/IEC/REC has direct participation in the study, written notification regarding 
his or her abstinence from voting must also be obtained. 
The clinical site must adhere to all requirements stipulated by the IRB/IEC/REC. This 
includes notification to the IRB/IEC/REC regarding the following: protocol amendments, 
updates to the patient ICF, recruitment materials intended for viewing by patients, IND 
safety reports, serious and unexpected AEs, reports and updates regarding the ongoing 
review of the study at intervals specified by the IRB/IEC/REC, and submission of final 
study reports and summaries to the IRB/IEC/REC. 
It is the responsibility of each investigational site to submit information to the appropriate 
IRB/IEC/REC for annual review and annual re-approval. 
11.3 
Patient Informed Consent 
Written consent must be obtained from the patient prior to any study-specific procedure 
or investigation. 
Prior to the implementation of study procedures, patients and persons conducting the 
consent discussion will be required to sign and date the IRB/IEC-approved ICF, and each 
patient will be given a copy. In addition, this information will be recorded in the patient’s 
medical record (i.e., source document). 


CONFIDENTIAL 
 
Kowa Research Institute, Inc. 
K-161-3.01, Study Protocol 
 
K-161 
 
 
February 10, 2022 
Page 75 of 82 
The written consent document will embody the elements of informed consent as 
described in the HIPAA, World Medical Association Declaration of Helsinki, FDA 21 
CFR Part 50.25, ICH GCP, and in accordance with any local regulations. The 
Investigator is responsible for the preparation, content, and IRB/IEC/REC approval of the 
ICF. The ICF must be approved by the clinical site-designated IRB/IEC/REC and be 
acceptable to KRI or its designee prior to their use. 
The ICF must be written in a language fully comprehensible to the prospective patient. 
The written patient ICF will explain the objectives of the study and its potential risks and 
benefits. The information included on the ICF must be provided to the patient both 
verbally and in writing whenever possible and in a manner deemed appropriate by the 
IRB/IEC/REC. Patients must be given ample opportunity to read the information and 
inquire about details of the study. The Investigator must be satisfied that the patient has 
understood the information provided before written consent is obtained. If there is any 
doubt as to whether the patient has understood the written and verbal information, the 
patient must not be allowed to enter the study. 
If a patient agrees to participate, he or she will be asked to sign and date an ICF, the 
original copy of which will be kept by the Investigator. A copy of the signed ICF will be 
given to the patient. Information documenting the informed consent procedure will be 
recorded in the patient’s medical records (i.e., source document), and the original signed 
ICF must be made available to the study monitor for inspection. 
If informed consent is taken under special circumstances (oral informed consent), then 
the procedures to be followed must be determined by CRO and/or the sponsor and 
provided in writing by CRO and/or the sponsor prior to the consent process. 
All ICFs must be approved for use by the sponsor or designee and receive 
approval/favorable opinion from an IRB/IEC/REC prior to their use. If the ICF requires 
revision (e.g., due to a protocol amendment or significant new safety information), it is 
the PI’s responsibility to ensure that the amended form is reviewed and approved by the 
sponsor prior to submission to the governing IRB/IEC/REC and that it is read, signed, 
and dated by all patients or their designees currently and subsequently enrolled in the 
study. 
11.4 
Amendments to the Protocol 
An amendment must be agreed to in writing by the sponsor, submitted to FDA as an IND 
application amendment, and submitted to and approved by the respective IRB/IEC/REC 
for each investigational site before it is implemented. Written approval of a protocol 
amendment is not required prior to implementation for changes to the protocol, which 
eliminate immediate hazard to the patient; however, approval must be obtained as soon as 
possible thereafter. Approved amendments must also be signed by the Investigator. 
11.5 
Study Initiation 
The Investigator must not enroll any patients prior to the completion of a formal meeting 
conducted by a representative of the sponsor. This meeting will include a detailed review 
of the study protocol and eCRFs. Study drug will not be supplied to an Investigator until 


CONFIDENTIAL 
 
Kowa Research Institute, Inc. 
K-161-3.01, Study Protocol 
 
K-161 
 
 
February 10, 2022 
Page 76 of 82 
all the necessary pre-study requirements have been completed and essential signed 
documents are received by the sponsor or its representative. 
11.6 
Study Monitoring 
It is the responsibility of the Investigator to ensure that the study is conducted in 
accordance with the protocol, ICH/FDA GCPs, applicable regulatory requirements, 
HIPAA, and the current Declaration of Helsinki. Valid data are to be entered into the 
eCRFs. 
To achieve this objective, the monitor’s duties are to aid the Investigator and, at the same 
time, the sponsor in the maintenance of accurate, complete, legible, well-organized, and 
easily retrievable data. The monitor will review the protocol with the Investigator. In 
addition, the monitor will explain the Investigator’s reporting responsibilities and all 
applicable regulations concerning the clinical evaluation of the study drug. 
The Investigator will permit the representatives of the sponsor to monitor the study as 
frequently as the sponsor deems is necessary to determine that data recording and 
protocol adherence are acceptable. The eCRFs and related source documents will be 
reviewed in detail by the monitor at each visit, in accordance with relevant standard 
operating procedures, ICH GCP guidance, and FDA GCP regulations. This includes 
results of tests performed as a requirement for participation in this study and any other 
medical records required to confirm information contained in the eCRFs, such as past 
medical history and secondary diagnoses. The Investigator and staff will be expected to 
cooperate with the monitor and provide any missing information, whenever possible. 
All monitoring activities will be reported and archived. In addition, monitoring visits will 
be documented at the investigational site by signature and date on the study-specific 
monitoring log. 
11.7 
Case Report Form 
All patient data generated during the study will be recorded on the eCRF. 
The Investigator will ensure that all data are entered promptly, legibly, completely, 
accurately and conform to source documents, in accordance with specific instructions 
accompanying the eCRFs, designed specifically for this study and supplied by the 
representatives of the sponsor for each patient. 
The representatives of the sponsor will only consider the eCRFs to be complete after they 
are reviewed and signed by the Investigator, indicating his/her assurance of the accuracy 
of all recorded data. It is expected that the Investigator and staff will cooperate with the 
monitoring team and provide missing data in a timely manner. 
11.8 
Verification Procedures 
In fulfillment of their obligations to the sponsor and to verify compliance with this 
protocol, ICH GCP guidance, and FDA GCP regulations, the Investigator will permit the 
representatives of the sponsor, the IRBs/IECs/RECs, the monitor, and regulatory 
authorities to have direct access to the patient’s medical records. 


CONFIDENTIAL 
 
Kowa Research Institute, Inc. 
K-161-3.01, Study Protocol 
 
K-161 
 
 
February 10, 2022 
Page 77 of 82 
It is the Investigator’s obligation to ensure documentation of all relevant data in the 
patient’s medical record, eCRFs, and on study forms, when applicable, according to 
procedures provided in the protocol and/or supplemental instructions. 
The Investigator will maintain a Patient Identification Code List to enable unambiguous 
identification of the patients (patient names and corresponding subject codes). The 
Patient Identification Code List is an essential document and as such must be maintained 
according to the ICH GCP guidelines. 
11.9 
Retention of Records 
All documentation pertaining to the study will be retained by the sponsor in accordance 
with US FDA regulations and the ICH GCP guidance document. 
The representatives of the sponsor will provide each Investigator with a study file, which 
will be used to file the Investigator’s Brochure, protocol, drug accountability records, 
correspondence with the IRB/IEC and the sponsor, and other study-related documents. 
The Investigator agrees to keep records and those documents that include (but are not 
limited to) the identification of all participating patients, medical records, study-specific 
source documents, source worksheets, all original signed and dated ICFs, copies of all 
eCRFs, query responses, and detailed records of drug disposition, to enable evaluations 
or audits from regulatory authorities and the sponsor or its designees. 
The Investigator will retain records required to be maintained under federal regulations 
for a period of 2 years following the date a marketing application is approved for the drug 
for the indication for which it is being investigated; or, if no application is to be filed or if 
the application is not approved for such indication, until 2 years after the investigation is 
discontinued and FDA is notified. However, these documents will be retained for a 
longer period if required by the applicable regulatory requirement(s) or if needed by the 
sponsor. In addition, the Investigator must make provision for the patient’s medical 
records to be kept for the same period of time. 
Patients’ medical records and other original data will be archived in accordance with 
applicable regulations and requirements established by the investigational sites. 
11.10 Insurance and Indemnity 
The sponsor’s obligations regarding insurance and indemnification are described in other 
documents or agreements. 
11.11 Audit and Inspection 
The Investigator must permit study-related quality oversight monitoring, quality 
assurance audits, IRB/IEC/REC review, and regulatory agency inspections and provide 
direct access to source data documents. It is important that the Investigator(s) and their 
relevant personnel are available during the monitoring, audit, or inspection visits and that 
sufficient time is devoted to the process. 


CONFIDENTIAL 
 
Kowa Research Institute, Inc. 
K-161-3.01, Study Protocol 
 
K-161 
 
 
February 10, 2022 
Page 78 of 82 
It is the responsibility of KRI to perform sponsor quality oversight, as part of the quality 
assurance and quality control programs. The purpose of a quality assurance audit, which 
is independent of and separate from routine monitoring or quality control functions, is to 
evaluate trial conduct and compliance with the protocol, the principles of ICH GCP, and 
other applicable regulatory requirements. 


CONFIDENTIAL 
 
Kowa Research Institute, Inc. 
K-161-3.01, Study Protocol 
 
K-161 
 
 
February 10, 2022 
Page 79 of 82 
 USE OF INFORMATION 
12.1 
General Aspects 
All information concerning KRI, such as patent applications, formula, manufacturing 
processes, basic scientific data or formulation information supplied by KRI and not 
previously published, are considered confidential and will remain the sole property of 
KRI. The Investigator agrees to use this information only in accomplishing this study and 
will not use it for other purposes without the written consent of KRI, except for official 
representatives, such as regulatory authorities. 
It is understood by the Investigator that the information developed in this clinical study, 
in connection with the development of K-161 will be used by KRI and, therefore, may be 
disclosed by KRI as required to other clinical Investigators, other pharmaceutical 
companies and to other government agencies. In order to allow for the use of the 
information derived from clinical studies, it is understood that there is an obligation to 
provide to KRI complete test results and all data compiled in this study. 
12.2 
Patient Confidentiality and Data Protection 
KRI and its designees affirm and uphold the principle of the patient’s right to protection 
against invasion of privacy. Throughout this study, all data will be linked to the eCRF via 
a unique identification number and the patient's initials. The data will be masked 
correspondingly in all data analyses. 
However, in compliance with the guidelines and regulations of the US FDA concerning 
the acceptance of clinical studies in support of IND applications and the ICH GCP 
(whether performed in the US or elsewhere), and in fulfillment of its obligations to KRI 
to verify compliance with this protocol, KRI’s designee requires that the Investigator to 
permit its monitor, representatives from the FDA, KRI’s designated auditors, IRBs/IECs, 
and other governmental regulatory authorities to review the patient’s primary medical 
records (source data or documents) including, but not limited to laboratory test result 
reports, electrocardiogram reports, admission and discharge summaries for hospital 
admissions occurring during a patient’s study participation, and autopsy reports related to 
deaths occurring during the study. 
Should access to such medical records require a waiver or authorization separate from the 
statement of informed consent, the Investigator will obtain such permission in writing 
from the patient before the patient is entered into the study. 
12.3 
Final Report and Publication Policy 
All information regarding this study will be kept strictly confidential. All data derived 
from the study will be the property of KRI. The Investigator must undertake not to submit 
any part of the data from this study for publication without prior consent of KRI. KRI 
may disclose data derived from the study to other Investigators and drug regulatory 
authorities. 


CONFIDENTIAL 
 
Kowa Research Institute, Inc. 
K-161-3.01, Study Protocol 
 
K-161 
 
 
February 10, 2022 
Page 80 of 82 
After completion of the study, and as agreed by the Investigator and KRI, the Investigator 
may send a draft manuscript to KRI to be reviewed in order to reach an agreement 
regarding publication. The Investigator must receive written approval from KRI before 
the final version of the manuscript is submitted for publication. 
At the conclusion of the study, after the data are analyzed, KRI or its designee will 
prepare a final clinical report. 




CONFIDENTIAL 
 
Kowa Research Institute, Inc. 
K-161-3.01, Study Protocol 
 
K-161 
 
 
February 10, 2022 
Page 82 of 82 
Tauber J, Karpecki P, Latkany R, Luchs J, Martel J, Sall K, et al. Lifitegrast ophthalmic 
solution 5.0% versus placebo for treatment of dry eye disease: results of the randomized 
phase III OPUS-2 study. Ophthalmology. 2015;122(12):2423-2431.  
Tyrvaya [package insert] Oyster Point Pharma, Inc.; Nov 2021. 

Prot_000.pdf: 
CONFIDENTIAL 
K-161-3.01, Study Protocol 
CONFIDENTIAL 
KOWA 
R.ESEAR.CH INSTITUTE, INC.
Kown Research I11stit11te, Jue. 
K-161
A Phase 3, Prospective, Double-masked, Randomized, Multi-center, Vehicle-controlled, 
Parallel-group, 12-week Administration and 40-week Extension Study Confirming the 
Efficacy and Safety of K-161 Ophthalmic Solution for the Treatment of Moderate to 
Severe Dry Eye Disease 
Drug Name: 
Study Number: 
US IND Number: 
Clinical Study Protocol 
K-161
K-161-3.01
138738 
Protocol Version Date: 
November 22, 2021 
Name of Sponsor: 
Address: 
Kowa Research Institute, Inc. 
430 Davis Drive, Suite 200 
Monisville, NC 27560 
United States of America 
Confidentiality Statement 
This protocol contains confidential, proprieta1y info1mation of Kowa Research Institute, Inc. 
Fmther dissemination, distiibution or copying of this protocol or its contents is stiictly prohibited. 
November 22, 2021 
Pagel o/82 
NCT #: 
         NCT05403827


CONFIDENTIAL 
 
Kowa Research Institute, Inc. 
K-161-3.01, Study Protocol 
 
K-161 
 
 
November 22, 2021 
Page 2 of 82 
 
INVESTIGATOR’S STATEMENT 
I, the Investigator, understand that all information concerning the product supplied to me 
by Kowa Research Institute, Inc. (KRI) in connection with this study and not previously 
published is confidential information. This information includes the Investigator’s 
Brochure, protocol, case report forms, assay methods, technical methodology, and basic 
scientific data. 
I understand that any changes to the protocol must be approved in writing by KRI or 
representative 
and 
the 
Institutional 
Review 
Board/Independent 
Ethics 
Committee/Research Ethics Committee (IRB/IEC/REC) before implementation, except 
where necessary to eliminate apparent immediate hazards to the patients. 
I confirm that I will report all adverse events (AEs) following the regulations indicated in 
the protocol. 
I confirm that I will conduct this study in conformance with the ethical principles that have 
their origin in the Declaration of Helsinki, Health Insurance Portability and Accountability 
Act (HIPAA), as applicable, and, as applicable, the International Council for 
Harmonisation (ICH) tripartite guideline E6 (R2): Good Clinical Practice (GCP). I will 
also conduct this study, as applicable, in compliance with the requirements of the United 
States (US) Food and Drug Administration (FDA) as outlined in Title 21 of the Code of 
Federal Regulations (CFR) (Parts 11, 50, 54, 56, and 312) and all other applicable regional 
or local regulatory requirements. 
I confirm that I am informed of the need for record retention and that no data can be 
destroyed. 
By my signature below, I hereby attest that I have read, understood, and agree to abide by 
all conditions, instructions, and restrictions contained in this version of the protocol dated 
November 22, 2021. 
 
Investigator’s 
Signature: 
 
Date:  
 
 
 
 
 
mm/dd/yyyy 
Investigator’s 
Name: 
 
 
 
 
 
 
 


CONFIDENTIAL
Kowa Research Institute, Inc.
K-161-3.01, Study Protocol
K-161
November 22, 2021
Page 3 of 82
SIGNATURE PAGE
 Date  ____________________
mm/dd/yyyy
Kowa Pharma Development Company
Date  ___________________
mm/dd/yyyy
Kowa Pharma Development Company
_________________
mm/dd/yyyy
Kowa Pharma Development Company


CONFIDENTIAL 
 
Kowa Research Institute, Inc. 
K-161-3.01, Study Protocol 
 
K-161 
 
 
November 22, 2021 
Page 4 of 82 
PROTOCOL SYNOPSIS 
Name of Sponsor Company: 
Kowa Research Institute, Inc. 
Drug Under Study: 
K-161 
Title of Protocol: 
A Phase 3, Prospective, Double-masked, Randomized, Multi-center, Vehicle-controlled, Parallel-
group, 12-week Administration and 40-week Extension Study Confirming the Efficacy and Safety of 
K-161 Ophthalmic Solution for the treatment of Moderate to Severe Dry Eye Disease 
Protocol Number: 
K-161-3.01 
Phase: 
3 
Indication: 
Dry eye disease (DED) 
Study Design: 
Prospective, double-masked, randomized, multi-center, vehicle-controlled, parallel-group study 
Primary Objectives: 
The primary objectives of this study are the following: 
• 
Symptom: To demonstrate the efficacy of K-161 
 compared to vehicle from 
baseline to Day 85 on eye dryness score (EDS) (Visual analog scale [VAS]) in patients with DED 
• 
Sign: To demonstrate the efficacy of K-161 
 compared to vehicle from baseline to Day 85 
on conjunctival sum fluorescein staining score in patients with DED as assessed by expanded 
National Eye Institute (NEI) scale 
Secondary Objectives: 
The secondary objectives of this study are the following: 
• 
To evaluate the efficacy of K-161 
 in patients with DED in the following order from 
baseline to Day 85 on: 
• 
Total eye fluorescein staining score as assessed by expanded NEI scale 
• 
Corneal sum fluorescein staining score as assessed by expanded NEI scale 
• 
Ocular Surface Disease Index Score (OSDI©) 
• 
Schirmer’s test (unanesthetized) 
• 
Tear film break-up time (TFBUT) 
• 
To evaluate the safety and tolerability of K-161 
 at Day 85 in patients with DED 
Extension Objectives: 
• 
To confirm the long-term safety and tolerability of K-161 
 compared to vehicle at Day 365 
in patients with DED 
• 
To evaluate the long-term efficacy of K-161 
 from baseline to Day 365 on all efficacy and 
exploratory endpoints in patients with DED 
Exploratory Objectives 
• 
 
Patient Population: 
Patients with DED  
Number of Patients: 
Total 620 (310 per arm) 
1) 300 (150 per arm) for 52 weeks 
2) 320 (160 per arm) for 12 weeks 
Number of Centers: 
Approximately 45 sites 
Dose Levels: 
 ophthalmic solution 
 
Route of Administration: 
Eye drop 
Duration of Treatment: 
12 weeks plus 40-week extension (total 52 weeks) 


CONFIDENTIAL 
 
Kowa Research Institute, Inc. 
K-161-3.01, Study Protocol 
 
K-161 
 
 
November 22, 2021 
Page 5 of 82 
Criteria for Evaluation: 
Primary Efficacy Endpoints: 
The primary efficacy endpoint (symptom) is: 
• 
Change in EDS (VAS) from baseline to Day 85 
The primary efficacy endpoint (sign) is: 
• 
Change in conjunctival sum fluorescein staining score from baseline to Day 85 as assessed by 
expanded NEI scale 
 
Key Secondary Efficacy Endpoint: 
Change from baseline to Day 85 in: 
• 
Total eye fluorescein staining score as assessed by expanded NEI scale 
 
Secondary Efficacy Endpoints: 
Change from baseline to Day 85 in: 
• 
Corneal sum fluorescein staining score as assessed by expanded NEI scale 
• 
OSDI 
• 
Schirmer’s test (unanesthetized) 
• 
TFBUT 
 
Safety Endpoints: 
Safety assessments from baseline up to Day 85 
• 
Adverse events (AEs) 
 
 
 
 
 
 
 
 
• 
Systemic clinical evaluation (abbreviated physical exams) 
• 
Clinical laboratory measurement 
 
 
 
 
 
Extension Endpoints: 
• 
Safety assessments, as described for up to Day 85, from baseline up to Day 365 
• 
Change in all efficacy and exploratory endpoints from baseline to Day 365 
 
Exploratory Endpoints: 
 
 
 
 
 
 
 
 
 
 
 








CONFIDENTIAL 
 
Kowa Research Institute, Inc. 
K-161-3.01, Study Protocol 
 
K-161 
 
 
November 22, 2021 
Page 9 of 82 
 
Assigned Treatment 
Intercurrent Event 
Not Occurred 
Occurred 
K-161 
 
(1) -10.0 
(2)   -3.6 
Vehicle 
(3)   -3.6 
(4)   -3.6 
 
A common variance, 431.2, and a common ICE occurrence rate, 8%, are assumed among the patterns. 
In order for EDS (VAS) to have at least 90% power when Holm’s method is applied, i.e., in order to have 
90% probability that EDS (VAS) is statistically significant when an alpha is set to 0.025 (two-sided), 
310 patients/arm will be needed. 
Targeted Estimand: 
The summary of the targeted estimand is as follows: 
Treatment Condition 
Treatment condition based on the assigned treatment group. 
Population 
DED patients based on the Inclusion and Exclusion criteria of the study. 
Variable 
Change from baseline to Day 85 in total eye stain score and EDS (VAS) including measurements 
after intercurrent events (i.e., treatment policy strategy). Potential intercurrent events of the study 
are as follows: 
 Discontinuation of the study treatment due to an adverse event 
 Discontinuation of the study treatment due to lack of efficacy 
 Discontinuation of the study treatment due to uncomfortable feeling of the study drug 
Population-level Summary 
Difference in means between the two treatment conditions. 
 
Primary Efficacy Analyses: 
The primary efficacy endpoints are change from baseline to Day 85 in conjunctival sum fluorescein 
staining score and EDS (VAS) on study eye, which are used regardless of whether or not the following 
ICEs occur: discontinuation of the study treatment due to an AE, lack of efficacy, or uncomfortable 
feeling of the study drug. Patients’ measurements will be made even after occurrence of those ICEs. For 
each of the primary endpoints, the Analysis of Covariance with baseline value, sex and treatment as 
covariates is used in order to make a comparison between the treatment groups. Least squares means will 
be calculated for the comparison. 
 
The data set to be used for the primary analyses is the FAS. 
 
Missing values will be imputed using the PMM with MI. Patterns to be used for the PMM are, as feasible, 
determined in each treatment group by whether or not patients had an ICE, or the type of ICEs if patients 
had an ICE. For example, if patients who discontinued the study treatment due to an AE had missing 
values, their missing values will be imputed from the patients who had the same ICE, i.e., discontinuation 
of the study treatment due to an AE. If enough patients to develop an imputation model in each pattern 
does not exist, the control-based mean imputation proposed by Mehrotra et al. (2017) will be applied 
instead of the PMM with MI. 
 
 










CONFIDENTIAL 
Kowa Research Institute, Inc. 
K-161-3.01, Study Protocol 
K-161 
November 22, 2021 
Page 14 of 82 
List of Tables 
Table 1 
Clinical Evaluation Schedule ..................................................................................... 23 
 
 
List of Figures 
 
 
 
 
 
 
 
 
 
 
 
 
 


CONFIDENTIAL 
 
Kowa Research Institute, Inc. 
K-161-3.01, Study Protocol 
 
K-161 
 
 
November 22, 2021 
Page 15 of 82 
LIST OF ABBREVIATIONS AND DEFINITION OF TERMS 
AE(s) 
adverse event(s) 
BA/BE 
bioavailability/bioequivalence 
 
 
CFR 
Code of Federal Regulations 
COVID-19 
Coronavirus disease 2019 
CPAP 
continuous positive airway pressure 
CRO 
clinical research organization 
DED 
dry eye disease 
eCRF 
electronic case report form 
EDC 
electronic data capture 
EDS 
eye dryness score 
 
 
 
 
FAS 
full analysis set 
FDA 
Food and Drug Administration 
GCP 
Good Clinical Practice 
HAV IgM 
anti-hepatitis A virus immunoglobulin isotype M 
 
 
 
 
HIPAA 
Health Insurance Portability and Accountability Act 
 
 
ICE(s) 
intercurrent event(s) 
ICF 
informed consent form 
ICH 
International Council for Harmonisation 
IEC 
Independent Ethics Committee 
 
 
IND 
Investigational New Drug 
 
 
IRB 
Institutional Review Board 
IWRS 
interactive web response system 
 
 
KRI 
Kowa Research Institute, Inc. 
LASIK 
laser in situ keratomileusis 
LFA-1 
lymphocyte function-associated antigen-1 
 
 
MI 
multiple imputation 
 
 
NCS 
not clinically significant 
NEI 
National Eye Institute 
NSAIDs 
non-steroidal anti-inflammatory drugs 


CONFIDENTIAL 
 
Kowa Research Institute, Inc. 
K-161-3.01, Study Protocol 
 
K-161 
 
 
November 22, 2021 
Page 16 of 82 
OD 
oculus dexter; right eye  
OS 
oculus sinister; left eye 
OSDI 
ocular surface disease index 
OTC 
over-the-counter 
PI 
principal Investigator 
PMM 
pattern mixture model 
PPS 
per protocol set 
REC 
Research Ethics Committee 
SAE 
serious adverse event 
SUSAR 
serious unexpected suspected adverse reaction 
TEAE 
treatment-emergent adverse event 
TFBUT 
tear film break-up time 
 
 
US 
United States 
 
 
VAS 
visual analog scale 
 












CONFIDENTIAL 
 
Kowa Research Institute, Inc. 
K-161-3.01, Study Protocol 
 
K-161 
 
 
November 22, 2021 
Page 22 of 82 
 
STUDY DESCRIPTION 
3.1 
Study Design 
This is a Phase 3, multicenter, randomized, double-masked, vehicle-controlled, 
parallel-group study. Patients will be randomized to one of the following treatment 
groups at Visit 2: 
• 
 K-161; 
 
• Placebo Ophthalmic Solution (vehicle); 
 
Patients who qualify after the initial Screening Visit will enter the Run-in Period, where 
they will self-administer vehicle 
 for approximately 14 days. Those who qualify at 
Visit 2 (Day 1) will administer either 
 K-161 or vehicle 
 in a double-masked 
fashion during the 12-week Primary Period. At Visit 6 (Day 85), patients entering the 
40-week Extension Period will be dispensed study drug. The 52-week Overall Period will 
comprise the 12-week Primary Period and 40-week Extension Period. 
A total of 620 patients (310 per arm) will be randomized for the study. 
 
 The first 300 randomized patients (150/arm) 
will be assigned into the 52-week Overall Period and the rest of study population 
(approximately 320 [160/arm] patients) will be assigned into 12-week Primary Period. 
The patients who are assigned into the 12-week Primary Period will proceed to Visit 6.5 
(Day 99) for post-dose assessments and complete the study. Patients, sponsor, clinical 
research organization (CRO), and site personnel will be masked to treatment assignment. 
Patients will be instructed not to discuss their assigned dosing regimen or perceived 
treatment effects with other study participants. 
The schedule of required assessments is provided in Table 1. The timing of patient visits 
and examinations will be consistent throughout the study. For the order of assessments 
refer to Section 5.1. 
 


CONFIDENTIAL 
Kowa Research Institute, Inc. 
K-161-3.01, Study Protocol 
K-161 
Page 23 of 82
Table 1 
Clinical Evaluation Schedule 
ASSESSMENTS 
PERFORMED 
STUDY PERIOD 
Screening 
/Run-in 
Period 
Days of Dosing and Assessments 
Post-dose 
Assessments 
52-week Overall Period
12-week Primary Period
40-week Extension Period
Visit 1 
Day -14 
(Day -21 
to -12) 
Visit 2 
Day 1 
(Baseline) 
Visit 3 
Day 15 
± 2 
(Remote)a 
Visit 4 
Day 29 
± 2 
Visit 5 
Day 57 
± 7 
Visit 6 
Day 85 
± 7 
Visit 7b 
Day 169 
± 7 
Visit 8b 
Day 253 
± 7 
Visit 9b 
Day 365 
± 7 
Visit 6.5b 
Day 99 ± 7c  
or 
Visit 10b 
Day 379 
± 7c 
Informed Consent/HIPAA 
X 
Medical/Medication/Ocular 
History and Demographics 
X 
Medical/Medication Update 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Vehicle Run-In Dispensation 
X 
Vehicle Run-In Instillation 
X 
Vehicle Run-in Collection and 
Accountability 
X 
Determination/assignment of the 
study eye 
X 
Randomization 
X 
Study Drug Dispensation 
X 
Xd 
Xd 
Xd 
Study Drug Instillation 
X 
X 
X 
Xd 
Xd 
Xd 
Study Drug Collection and 
Accountability 
Xe 
Xe 
X 
Xd 
Xd 
Xd 
Fluorescein Staining Scoring 
X 
X 
X 
X 
X 
X 
X 
X 
VAS 
X 
X 
X 
X 
X 
X 
X 
X 
November 22, 2021 


CONFIDENTIAL 
Kowa Research Institute, Inc. 
K-161-3.01, Study Protocol 
K-161 
November 22, 2021 
Page 24 of 82 
ASSESSMENTS 
PERFORMED 
STUDY PERIOD 
Screening 
/Run-in 
Period 
Days of Dosing and Assessments 
Post-dose 
Assessments 
52-week Overall Period
12-week Primary Period
40-week Extension Period
Visit 1 
Day -14 
(Day -21 
to -12) 
Visit 2 
Day 1 
(Baseline) 
Visit 3 
Day 15 
± 2 
(Remote)a 
Visit 4 
Day 29 
± 2 
Visit 5 
Day 57 
± 7 
Visit 6 
Day 85 
± 7 
Visit 7b 
Day 169 
± 7 
Visit 8b 
Day 253 
± 7 
Visit 9b 
Day 365 
± 7 
Visit 6.5b
Day 99 ± 7c  
or 
Visit 10b 
Day 379 
± 7c 
TFBUT 
X 
X 
X 
X 
X 
X 
X 
X 
Schirmer’s Test 
X 
X 
X 
X 
X 
X 
X 
X 
Adverse Event Collection 
X 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Systemic Clinical Evaluation
(abbreviated physical exams) 
X 
X 
X 
Clinical Laboratory 
Measurement 
X 
X 
X 
Exit Patient from Study 
X 
 HIPAA=Health Insurance 
Portability and Accountability Act; OSDI=Ocular Surface Disease Index; TFBUT=tear film break-up time; VAS=Visual analog scale. 
Note: The visit schedule will always be calculated from randomization visit date (Visit 2). 
a.
Visit 3 will be a remote visit.












CONFIDENTIAL 
Kowa Research Institute, Inc. 
K-161-3.01, Study Protocol 
K-161 
November 22, 2021 
Page 30 of 82 
infectious event, the study medication can be continued at the 
Investigator’s discretion.  
3. Violation of the protocol inclusion or exclusion criteria is discovered, and if, in
the opinion of the Investigator or the sponsor, the violation will significantly
compromise data interpretation or safety
4. The patient undergoes rescue ophthalmic surgery (Section 8.3)
5. The female patient becomes pregnant during the study (Section 9.3)
6. In the Investigator’s judgment, it is in the patient’s best interest
7. Lost to follow-up
8. Sponsor termination of study
9. Other
Although a patient is not obligated to give his/her reason for discontinuing study drug, 
the Investigator will make a reasonable effort to obtain the reason while fully respecting 
the patient’s rights. The reason for discontinuation of study drug must be documented in 
the electronic case report form (eCRF). The clinical study report will include the 
reason(s) for discontinuation of study drug. 
4.4 
Withdrawal Criteria 
The patient has the right to withdraw from the study at any time and for any reason 
without prejudice to the patient’s future medical care. Nevertheless, every attempt will be 
made to prevent missing data and to obtain complete follow-up of all patients. 
Patients who meet study drug discontinuation criteria described in Section 4.3 will be 
discontinued from study drug; however, are not required to withdraw from the study 
unless the patient withdraws consent completely. As such, these patients will be 
encouraged to remain in the study and asked to attend all of the remaining study visits 
through Visit 6 (for the patients who are assigned into the 12-week Primary Period) or 
Visit 9 (for the patients who are assigned into the 52-week Overall Period) (Table 1). 
Patients who choose to withdraw from the study will be asked if they are prepared to 
complete a last visit. In this case, the same evaluations as the End of Treatment Period 
(Visit 6 or 9), or at least, the same evaluations as the Post-dose Assessment Visit (Visit 
6.5 or 10) should be performed. If a patient fails to actively maintain contact with the 
Investigator, reasonable efforts (telephone calls to family members or friends, email 
contacts, etc.) will be made in order to encourage the patient to complete the study visits. 
If the patient withdraws from the study, the reason should be captured. 
The patient will be withdrawn from the study if: 
1. The patient withdraws consent to attend the remaining study visits
2. Lost to follow-up
3. Sponsor termination of study
4. Other


CONFIDENTIAL 
Kowa Research Institute, Inc. 
K-161-3.01, Study Protocol 
K-161 
November 22, 2021 
Page 31 of 82 
Although a patient is not obligated to give his/her reason for withdrawing from the study, 
the Investigator will make a reasonable effort to obtain the reason while fully respecting 
the patient’s rights. Unless revoked, further contact in the case of withdrawal from the 
study will occur consistent with methods listed in the informed consent form (ICF). The 
reason for withdrawal from the study must be documented in the eCRF. The clinical 
study report will include the reason(s) for withdrawal from the study. 
If a patient withdraws from the study due to an AE, the patient will be asked to return to 
the clinic for, at a minimum, the evaluations scheduled for post-dose assessments. If the 
AE has still not resolved, additional follow-up will be performed, as appropriate. Every 
effort will be made by the Investigator or delegate to contact the patient until the AE is 
resolved or stabilized, or the medical monitor and Investigator agree that further follow-
up is not necessary. If patients are lost to follow-up, the Investigator will make 3 
reasonable attempts to contact the patient via telephone, US postal service, or certified 
mail. All attempts to contact them must be made and documented in the study records.  
4.5 
Replacement, Rescreening, and Retesting 
 Replacement 
Patients who are screened for the study may be replaced if they never are randomly 
assigned study drug or are withdrawn from the study before they administer any study 
drug after randomization. The replacement patients will receive a new randomly assigned 
treatment and not the treatment assignment of the replaced patient. Patients who self-
administer any study drug after randomization and subsequently are withdrawn early 
from the study will not be replaced. 
 Rescreening 
Patients who fail to satisfy inclusion and exclusion criteria at screening may be 
rescreened 1 additional time at the discretion of the sponsor. Screen failures due to 
inclusion and/or exclusion criteria that could transiently change and do not compromise 
the patient’s safety as judged by the Investigator can be rescreened once. All eligibility 
assessments will be repeated regardless of the reason for the initial screen failure and new 
subject number will be assigned. Rescreening decision must be confirmed by the 
sponsor’s medical monitor. 
 Retesting 
Clinical labs with clinically significant abnormalities (per the principal Investigator’s [PI] 
assessment) can be retested 1 time if there is a reasonable expectation that abnormality 
will resolve within the Screening Period (21 days at maximum). Unscheduled visits 
should be allowed within Screening Period. 


























CONFIDENTIAL 
 
Kowa Research Institute, Inc. 
K-161-3.01, Study Protocol 
 
K-161 
 
 
November 22, 2021 
Page 44 of 82 






CONFIDENTIAL 
 
Kowa Research Institute, Inc. 
K-161-3.01, Study Protocol 
 
K-161 
 
 
November 22, 2021 
Page 47 of 82 
 
 
 


















CONFIDENTIAL 
 
Kowa Research Institute, Inc. 
K-161-3.01, Study Protocol 
 
K-161 
 
 
November 22, 2021 
Page 56 of 82 
 
CONDUCT OF STUDY 
6.1 
Study Masking and Randomization 
All arms will be double-masked. 
Before the initiation of study run-in at Visit 1, each patient who provides written 
informed consent will be assigned a subject code. All subject codes will be assigned in 
strict numerical sequence at a site and no numbers will skipped or omitted. If a patient is 
retested on clinical labs, the same subject code will be used (Section 4.5.3). If a patient is 
rescreened, the patient will be assigned with a new subject code (Section 4.5.2). 
Patients who have signed informed consent and subsequently fail to satisfy inclusion and 
exclusion criteria are defined as screen failures. For all screen failures, the reason(s) for 
screen failure will be recorded on the patient’s source document and eCRF. 
Each patient who meets all the inclusion and none of the exclusion criteria at Visit 1 and 
Visit 2 will be randomized at the end of Visit 2 by using the IWRS. 
Subject codes and kit numbers will be assigned automatically to each patient as they are 
entered into the IWRS. All patients will be randomized into either vehicle or active 
treatment group at Visit 2 (Day 1) in a 1:1 ratio. 
 
 The first 300 (150/arm) randomized patients will be assigned into the 
52-week Overall Period and the rest of study population (approximately 320 [160/arm] 
patients) will be assigned into the 12-week Primary Period. 
The site staff will dispense the required kit(s). Both the subject codes and the dispensed 
study drug kit number(s) will be recorded on the patient’s source document and eCRF. 
Patients, sponsor, CRO, and site personnel will be masked to treatment assignment. 
After Visit 6 (Day 85), patients who are randomized to enter the 40-week Extension 
Period will proceed to Visit 7 (Day 169) until Visit 10 (Day 379). Other patients, who are 
randomized to enter the 12-week Primary Period only, will proceed to Visit 6.5 (Day 99) 
for post-dose assessments and will complete the study. 
Planned analyses at Day 85 including the primary analyses will be performed by an 
unmasked team not involved in the conduct of the study once all patient data until Day 85 
are obtained in a fashion to protect the masking of all patients who will be followed in the 
40-week Extension Period. The masked team will have access only to a summary of the 
results comparing the two arms so the same study team can continue to be masked while 
conducting the remaining part of the trial until the end of the 52-week Overall Period. 
The investigational sites will not be unmasked and will not have access to the summary 
of the results comparing the two arms. 
6.2 
Study Visits 
For each patient, a maximum of 10 scheduled visits will be performed: 
• Visit 1 at Day -14 (Day -21 to -12): Screening: The screening examination to 
determine patient eligibility can take place anytime within this time period. 


CONFIDENTIAL 
 
Kowa Research Institute, Inc. 
K-161-3.01, Study Protocol 
 
K-161 
 
 
November 22, 2021 
Page 57 of 82 
• Visit 2 at Day 1: Baseline (12-21 days after Visit 1) 
• Visit 3 at Day 15 ± 2 days 
• Visit 4 at Day 29 ± 2 days 
• Visit 5 at Day 57 ± 7 days 
• Visit 6 at Day 85 ± 7 days 
For the patients who are assigned into the 12-week Primary Period 
• Visit 6.5 (post-dose) at Day 99 ± 7 days (at least 14 days after the last dose of 
study medication) 
For the patients who are assigned into the 52-week Overall Period (with the 40-week 
Extension Period): 
• Visit 7 at Day 169 ± 7 days 
• Visit 8 at Day 253 ± 7 days 
• Visit 9 at Day 365 ± 7 days 
• Visit 10 (post-dose) at Day 379 ± 7 days (at least 14 days after the last dose of 
study medication) 
The procedures and assessments to be performed at each visit are indicated in Table 1. 
6.3 
Compliance with The Protocol 
The Investigator must agree to implement the study protocol as written and adhere to the 
guidelines given in the Investigator’s Statement, which will be signed prior to the start of 
the study. The study will be performed in accordance with HIPAA, Declaration of 
Helsinki, International Council for Harmonisation (ICH) Good Clinical Practice (GCP) 
guidelines, local laws, FDA GCP regulations (21 Code of Federal Regulations [CFR] 
Parts 11, 50, 54, 56, and 312), and other applicable guidance documents. 
If the Investigator considers enrolling a patient that does not meet all inclusion or 
exclusion criteria, an exemption must be requested from the sponsor’s medical monitor 
prior to patient enrollment. The justification for the exemption must be document by the 
Investigator. The approval or rejection of the exemption must be documented by the 
sponsor’s medical monitor prior to the patient’s enrollment or screen failure. 
Protocol non-compliance must be reported to the sponsor or its representatives. Each 
deviation and the reason for its occurrence must be documented. The sponsor retains the 
right to require the withdrawal of any patient who violates the protocol. 
6.4 
Termination of the Study 
If, in the opinion of the Investigator, the clinical observations in the study suggest that it 
may be unwise to continue, the study may be terminated after consultation with the 
sponsor. A written statement fully documenting the reason(s) for the termination will be 
provided to the sponsor. In addition, the sponsor may terminate the study at any time. 


CONFIDENTIAL 
 
Kowa Research Institute, Inc. 
K-161-3.01, Study Protocol 
 
K-161 
 
 
November 22, 2021 
Page 58 of 82 
If it becomes apparent that patient enrollment is unsatisfactory with respect to quality or 
quantity, or data recording is inaccurate or incomplete on a chronic basis, the sponsor has 
the right to terminate the study and remove all study materials from the investigational 
site. A written statement will be provided to the Investigator, the Institutional Review 
Board/Independent Ethics Committee/Research Ethics Committee (IRB/IEC/REC), and 
regulatory authorities, if required. In the event of any serious or non-serious AEs having 
occurred at a site, all documentation relating to the event(s) must be obtained. 






CONFIDENTIAL 
 
Kowa Research Institute, Inc. 
K-161-3.01, Study Protocol 
 
K-161 
 
 
November 22, 2021 
Page 61 of 82 
The Investigator must keep an accurate account of the study drug received from the 
supplier. This includes the amount of study drug dispensed to patients, amount of study 
drug returned to the Investigator by the patients, and the amount returned or disposed 
upon the completion of the study. A detailed inventory must be completed for the study 
drug. 
7.8 
Procedure for Unmasking 
As needed, the randomization code may be broken by the Investigator to manage an 
urgent medical safety event. If possible, the medical monitor should be contacted to 
discuss the case before the code is broken. 
If it becomes necessary to unmask treatment information during the study, the reason for 
unmasking must be documented in the eCRF. If the medical monitor cannot be notified 
prior to unmasking, the Investigator must contact the medical monitor promptly and 
explain the reason for the premature unmasking (e.g., unmasking due to an SAE). 
Planned analyses at Day 85 including the primary analyses will be performed by 
unmasked team not involved in the conduct of the study once all patient data until Day 85 
are obtained in a fashion to protect the masking of the patients who will be followed in 
the 40-week Extension Period. 
 


CONFIDENTIAL 
 
Kowa Research Institute, Inc. 
K-161-3.01, Study Protocol 
 
K-161 
 
 
November 22, 2021 
Page 62 of 82 
 
CONCOMITANT MEDICATION 
The Investigator must record the use of all concomitant medications and any historical 
use of 
 before Visit 1, both dispensed and OTC, in the eCRF along with the 
reason the medication was taken. This includes drugs used on a chronic and as-needed 
basis. Patients must be discouraged from starting any new medication, both dispensed 
and OTC, without consulting the Investigator, unless the new medication is required for 
emergency use. 
8.1 
General Considerations 
Concurrent enrollment in another investigational drug or medical device study is not 
permitted. 
8.2 
Prohibited Medication 
Disallowed medications/treatments during the study are outlined in the exclusion criteria 
(Section 4.2). 
8.3 
Permitted Medication and Rescue Therapy 
Contact lenses are allowed only during the 40-week Extension Period. Contact lenses 
should be removed prior to the administration of study drug and may be reinserted at 
least 15 minutes following administration. If a subject is using another prescription eye 
drop in combination with the study medication, the concomitant use of contact lenses is 
not recommended for the duration of such combination therapy. 
The following medications are permitted as long as the dosage is stable: 
• Systemic tetracycline compounds (e.g., tetracycline, doxycycline, or 
minocycline), macrolides (e.g., azithromycin): for at least 30 days prior to Visit 1 
and dose will remain stable until the end of the 12-week Primary Period 
• Any medication (topical and systemic) known to cause ocular drying, such as 
systemic anticholinergic medications (e.g., atropine, homatropine), 
antidepressants and antipsychotic agents, statins, diuretics, beta-blockers, 
NSAIDs: for at least 30 days prior to Visit 1 and dose will remain stable until the 
end of the 12-week Primary Period 
o Episodic use of anticholinergic drops for eye examination and episodic use 
of systemic NSAIDs are allowed during the study except for within 2 days 
prior to any study visit. 
• Omega-3 fatty acid supplements in doses above 3000 mg/day, oral hormonal 
contraceptives, hormone replacement therapy for menopause: for 12 weeks prior 
to Visit 1 and dose will remain stable until the end of the 12-week Primary Period. 
Omega-3 fatty acid supplements in doses equal to or below 3000 mg/day are 
permitted. 
Any prohibited and restricted medications, devices, and procedures indicated for dry eye 
disease are permitted as “rescue therapy” after all assessments are completed at Visit 6 


CONFIDENTIAL 
 
Kowa Research Institute, Inc. 
K-161-3.01, Study Protocol 
 
K-161 
 
 
November 22, 2021 
Page 63 of 82 
(Table 1). Especially, 
 will be summarized as described in 
Section 5.2.10. All other prohibited medications, other than isotretinoin, systemic 
 
, and restricted medications, devices, and procedures are permitted as 
“permitted therapy” after all assessments are completed at Visit 6. If more than one 
topical ophthalmic medicinal product is being used, the medicinal products must be 
administered at least 15 minutes apart. 
Any non-emergent ocular surgical procedure is prohibited until the end of the 12-week 
Primary Period. However, if the patient’s condition necessitates a surgical ocular 
procedure during the study, the patient may undergo rescue ophthalmic surgery. In this 
case, the use of study medication should be interrupted in the eye undergoing the 
procedure until resolution or stabilization of this condition and full recovery after surgery 
as determined by the Investigator. The decision to interrupt or restart the study 
medication for a specific ocular procedure/condition should be based on the best clinical 
judgment of the Investigator and preferably after consultation with the medical monitor. 


CONFIDENTIAL 
 
Kowa Research Institute, Inc. 
K-161-3.01, Study Protocol 
 
K-161 
 
 
November 22, 2021 
Page 64 of 82 
 
AEs AND SAEs 
9.1 
AEs 
 AE Definition 
An AE is any untoward medical occurrence in a patient administered a pharmaceutical 
product and which does not necessarily have a causal relationship with the 
pharmaceutical product. An AE can, therefore, be any unfavorable and unintended sign, 
symptom, or disease temporally associated with the use of a medicinal product, whether 
or not related to the medicinal product. Any worsening of the patient’s disease under 
study or other medical conditions will also be considered to be an AE, unless it is within 
the normal range of disease fluctuation for that patient. 
Clinically meaningful (for a given patient) changes in physical examination findings and 
abnormal objective test findings (e.g., clinical laboratory tests) are also recorded as AEs. 
The criteria for determining whether an abnormal objective test finding should be 
reported as an AE are as follows: 
1. Test result is associated with accompanying symptoms, and/or; 
2. Test result requires additional diagnostic testing or medical/surgical intervention, 
and/or; 
3. Test result leads to a change in study dosing or withdrawal from the study, 
significant additional concomitant drug treatment or other therapy, and/or; 
4. Test result leads to any of the outcomes included in the definition of an SAE 
(Section 9.2). 
Merely repeating a test, in the absence of any of the above conditions, does not meet 
condition number 2 above for reporting as an AE. 
Any abnormal test result that is determined to be an error does not require reporting as an 
AE. 
A treatment-emergent AE (TEAE) is defined as an AE that begins after the start of study 
drug or an event that begins before the start of the study drug and worsens in intensity 
after starting treatment. 
 Reporting of AEs 
At each evaluation, the Investigator will determine whether any AEs have occurred. The 
patient will be questioned in a general way and no specific symptoms will be suggested. 
If any AEs have occurred, they will be recorded on the AE pages of the eCRF and in the 
patient’s medical record. If known, the diagnosis will be recorded, in preference to the 
listing of individual signs and symptoms. 
AE reporting begins when informed consent is obtained and ends at the conclusion of the 
study, unless an unresolved AE is still being followed. 
The severity of the AE will be graded as follows: 


CONFIDENTIAL 
 
Kowa Research Institute, Inc. 
K-161-3.01, Study Protocol 
 
K-161 
 
 
November 22, 2021 
Page 65 of 82 
Mild 
The AE is easily tolerated and does not interfere with normal daily 
activities. 
Moderate 
The AE causes some interference with daily activities. 
Severe  
The AE causes all normal daily activities to be completely halted. 
 
The relationship of each AE to the study drug will be determined by the Investigator 
using these explanations: 
• Related: A reasonable possibility exists that the study drug caused the AE. A 
related AE can be further defined as follows: 
o Occurs within a reasonable temporal sequence to administration of study 
drug 
o Cannot be explained by concurrent disease or other drugs or chemicals 
o Improves or disappears on stopping or reducing study drug (de-challenge) 
o Reappears on repeated exposure to study drug (re-challenge) 
o Is an unusual event that is known to be associated with the drug or this 
class of compound, and cannot be explained by other therapy or the 
participant’s physical condition 
o Unlikely to be attributed to concurrent disease or other drugs or a 
clinically reasonable response on withdrawal (de-challenge) 
• Not Related: A reasonable possibility does not exist that the study drug caused 
the AE. A not related AE can be further defined as follows: 
o Occurs with a temporal relationship to administration of study drug which 
makes a causal relationship improbable 
o Other drugs, chemicals or underlying disease provide plausible 
explanations of causality 
o Is known to be associated with the participant’s clinical condition, or with 
other medication taken by the participant 
 
The Investigator will record each action taken and outcome for each AE according to the 
following: 
Action taken 
• None 
• Treatment required 
• Hospitalization 
• Study drug interrupted 
• Study drug discontinued 


CONFIDENTIAL 
 
Kowa Research Institute, Inc. 
K-161-3.01, Study Protocol 
 
K-161 
 
 
November 22, 2021 
Page 66 of 82 
• Patient withdrawn 
• Other (specify) 
Outcome 
• Recovered 
• Recovered with sequelae 
• Recovering 
• Ongoing 
• Death 
• Lost to follow-up 
Whether each AE is ocular or non-ocular will be determined by the Investigator for each 
AE and it will be recorded on the AE pages of the eCRF. 
 Follow-up of AEs 
If any AEs are present when a patient completes the study, or if a patient is withdrawn 
from the study, the patient will be re-evaluated. At the Investigator’s discretion, minor 
AEs can be re-evaluated via telephone and documented. If the AE is still not resolved, 
additional follow-up will be performed as appropriate. Every effort will be made by the 
Investigator or delegate to contact the patient until the AE is resolved or stabilized, or the 
medical monitor and Investigator agree that further follow-up is not necessary. The 
follow-up of AEs after post-dose assessments at Visits 6.5 or 10 will be documented in 
the patient’s medical records. 
9.2 
SAEs 
 SAE Definition 
An SAE is any untoward medical occurrence that at any dose: 
• Results in death 
• Is life-threatening 
• Requires patient hospitalization or prolongation of existing hospitalization 
• Results in persistent or significant disability/incapacity 
• Is a congenital anomaly/birth defect 
Medical and scientific judgment will be exercised in deciding whether expedited 
reporting is appropriate in other situations, such as important medical events that may not 
be immediately life-threatening or result in death or hospitalization but may jeopardize 
the patient or may require intervention to prevent one of the other outcomes listed in the 
definition above. Events that require expedited reporting will also be considered to be 
SAEs. 


CONFIDENTIAL 
 
Kowa Research Institute, Inc. 
K-161-3.01, Study Protocol 
 
K-161 
 
 
November 22, 2021 
Page 67 of 82 
 
Life-Threatening AEs 
The term life-threatening in the definition of serious refers to an event in which the 
patient 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. 
 
Hospitalization 
Hospitalization is defined as the patient being hospitalized overnight, or the patient’s 
hospital stay being prolonged for at least an additional overnight stay. Pre-planned 
hospital stays or hospital stays for non-medical social reasons are not applicable. Twenty-
three-hour hospitalizations for observation will be discussed with the medical monitor to 
determine whether they are appropriate for SAE reporting. 
 Reporting of SAEs 
All SAEs occurring from the time of informed consent until Visit 6.5 (patients enrolled in 
the Primary Period only) or Visit 10 (all other patients) must be reported to the CRO 
safety personnel within 24 hours of the knowledge of the occurrence (this refers to any 
AE that meets any of the aforementioned serious criteria). All SAEs that the Investigator 
considers related to study drug occurring after post-dose assessments at Visits 6.5 or 10 
must be reported to the CRO or the sponsor/designee. 
To report the SAE, the site staff will complete the SAE form electronically in the 
electronic data capture (EDC) system for the study. When the form is completed, the 
CRO safety personnel will be notified electronically and will retrieve the form. If the 
event meets serious criteria and it is not possible to access the EDC system, site staff will 
send a completed paper SAE form to 
within 24 hours of 
awareness. When the EDC system becomes available, the SAE information must be 
entered within 24 hours. 
 
 
  
 
  
 
  
 
 
The Investigator must continue to follow-up with the patient until the SAE has subsided 
or until the condition becomes chronic in nature, stabilizes (in the case of persistent 
impairment), or the patient dies. 
Within 24 hours of receipt of follow-up information, the Investigator must update the 
SAE form electronically in the EDC system for the study and submit any supporting 
documentation (e.g., patient discharge summary or autopsy reports) to 
 If it is not possible to access the EDC system, refer to the 
procedures outlined above for initial reporting of SAEs. Written confirmation that any 
serious, unexpected, and related AEs have been submitted to the IRB/IEC/REC must be 
forwarded to the sponsor and kept in the Investigator files. 


CONFIDENTIAL 
 
Kowa Research Institute, Inc. 
K-161-3.01, Study Protocol 
 
K-161 
 
 
November 22, 2021 
Page 68 of 82 
 Serious Unexpected Suspected Adverse Reactions 
According to FDA CFR 312.32(a) and FDA Guidance “Safety Reporting Requirements 
for Investigational New Drugs (INDs) and BA/BE (Bioavailability/Bioequivalence) 
Studies” finalized December 2012, suspected adverse reaction means any AE for which 
there is a reasonable possibility that the medicinal product caused the AE. The phrase 
reasonable possibility means there is evidence to suggest a causal relationship between 
the AE and the medicinal product. 
The following are examples of types of evidence that would suggest a causal relationship 
between the drug and the AE (i.e., reasonable possibility): 
• A single occurrence of an event that is uncommon and known to be strongly 
associated with drug exposure (e.g., angioedema, hepatic injury, Stevens-Johnson 
syndrome) 
• One or more occurrences of an event that is not commonly associated with drug 
exposure, but is otherwise uncommon in the population exposed to the drug 
(e.g., tendon rupture) 
Suspected adverse reactions are the subset of all AEs for which there is a reasonable 
possibility that the drug caused the event. The Investigator will initially classify the 
relatedness of an AE, but the final classification is subject to the medical monitor’s 
determination unless revised by the sponsor, which has the ultimate responsibility for 
judging relatedness. 
A suspected adverse reaction is considered unexpected if it is not listed in the Reference 
Safety Information in Section 6 of the K-161 Investigator’s Brochure or is not listed at 
the specificity or severity that has been described in the K-161 Investigator’s Brochure. 
An AE or suspected adverse reaction is considered serious if, in the view of either the 
Investigator or sponsor, it results in any of the following outcomes: Death, a 
life-threatening AE, inpatient hospitalization or prolongation of existing hospitalization, a 
persistent or significant incapacity or substantial disruption of the ability to conduct 
normal life functions, or a congenital anomaly/birth defect (Section 9.2.1). Important 
medical events that may not result in death, be life-threatening, or require hospitalization 
may be considered serious when, based upon appropriate medical judgment, they may 
jeopardize the patient or patient and may require medical or surgical intervention to 
prevent one of the outcomes listed in this definition. 
Any AE meeting the definitions of suspected adverse reaction, unexpected, and serious is 
considered a serious unexpected suspected adverse reaction (SUSAR). In accordance 
with the FDA Guidance “Safety Reporting Requirements for INDs and BA/BE Studies” 
finalized December 2012, the sponsor will unmask the study data for patients 
experiencing SUSARs and only report those for patients who are on the active K-161 
product. All such reports will be submitted to the Investigator(s), FDA, and 
IRB/IEC/REC in an expedited manner. 




CONFIDENTIAL 
 
Kowa Research Institute, Inc. 
K-161-3.01, Study Protocol 
 
K-161 
 
 
November 22, 2021 
Page 70 of 82 
 STATISTICAL METHODS AND DATA ANALYSIS 
10.1 
Sample Size Justification 
The parameters to be needed for the calculation of sample size were estimated from the 
previous Phase 2 study (K-161-2.01US). In order to take intercurrent events (ICEs) into 
account, 4 different patient patterns are considered: (1) patients who were assigned to 
K-161 
 and had an ICE, (2) patients who were assigned to K-161 
 
and did not have an ICE, (3) patients who were assigned to vehicle and had an ICE, and 
(4) patients who were assigned to vehicle and did not have an ICE. 
Regarding EDS (VAS), a population mean in each pattern is assumed as follows: 
Assigned Treatment 
Intercurrent Event 
Not Occurred 
Occurred 
K-161 
 
(1) -10.0 
(2)   -3.6 
Vehicle 
(3)   -3.6 
(4)   -3.6 
 
A common variance, 431.2, and a common ICE occurrence rate, 8%, are assumed among 
the patterns. In order for EDS (VAS) to have at least 90% power when Holm’s method is 
applied, i.e., in order to have 90% probability that EDS (VAS) is statistically significant 
when an alpha is set to 0.025 (two-sided), 310 patients/arm will be needed. 
10.2 
Targeted Estimand 
The summary of the targeted estimand is as follows: 
Treatment Condition 
Treatment condition based on the assigned treatment group. 
Population 
DED patients based on the Inclusion and Exclusion criteria of the study. 
Variable 
Change from baseline to Day 85 in total eye stain score and EDS (VAS) including 
measurements after intercurrent events (i.e., treatment policy strategy). Potential 
intercurrent events of the study are as follows: 
 Discontinuation of the study treatment due to an adverse event 
 Discontinuation of the study treatment due to lack of efficacy 
 Discontinuation of the study treatment due to uncomfortable feeling of the study 
drug 
Population-level Summary 


CONFIDENTIAL 
 
Kowa Research Institute, Inc. 
K-161-3.01, Study Protocol 
 
K-161 
 
 
November 22, 2021 
Page 71 of 82 
Difference in means between the two treatment conditions. 
 
10.3 
Study Populations 
The following analysis populations will be considered: 
Full Analysis Set (FAS) in the 12-week Primary Period: will include all randomized 
patients who received at least 1 dose of study treatment. Patients will be analyzed 
according to their randomized treatment group, regardless of whether they adhere to their 
assigned treatment. The FAS will be used as the primary efficacy analyses. 
Per Protocol Set (PPS) in the 12-week Primary Period: will include all randomized 
patients without any major protocol deviations and have valid baseline and Day 85 
primary endpoint values. Major protocol deviations will be pre-specified prior to 
unmasking the study. PPS will be used to assess robustness of the primary analysis 
results. 
Safety Population in the 12-week Primary Period: will include all randomized patients 
who have received at least 1 dose of study treatment. 
FAS in the 52-week Overall Period: will include the randomized patients who are 
assigned into the 52-week Overall Period and received at least 1 dose of study treatment. 
Patients will be analyzed according to their randomized treatment group, regardless of 
whether they adhere to their assigned treatment. 
Safety Population in the 52-week Overall Period: will include randomized patients for the 
52-week Overall Period and who had at least 1 dose of study treatment. 
10.4 
Analysis of Efficacy Parameters 
The primary efficacy endpoints are change from baseline to Day 85 in conjunctival sum 
fluorescein staining score on study eye and EDS (VAS), which are used regardless of 
whether or not the following ICEs occur: discontinuation of the study treatment due to an 
AE, lack of efficacy or uncomfortable feeling of the study drug. Patients’ measurements 
will be made even after occurrence of those ICEs. For each of the primary endpoints, the 
analysis of covariance with baseline value, sex and treatment as covariates is used in 
order to make a comparison between the treatment groups. Least squares means will be 
calculated for the comparison. 
The data set to be used for the primary analyses is the FAS. 
Missing values will be imputed using the pattern mixture model (PMM) with multiple 
imputation (MI). Patterns to be used for the PMM are, as feasible, determined in each 
treatment group by whether or not patients had an ICE, or the type of ICEs if patients had 
an ICE. For example, if patients who discontinued the study treatment due to an AE had 
missing values, their missing values will be imputed from the patients who had the same 
ICE, i.e., discontinuation of the study treatment due to an AE. If enough patients to 
develop an imputation model in each pattern do not exist, the control-based mean 


CONFIDENTIAL 
 
Kowa Research Institute, Inc. 
K-161-3.01, Study Protocol 
 
K-161 
 
 
November 22, 2021 
Page 72 of 82 
imputation proposed by Mehrotra (Mehrotra 2017) will be applied instead of the PMM 
with MI. 
If the MI is applied, multiple parameter estimates will be combined using Rubin’s rule 
(Rubin 1987). 
With regard to multiplicity caused by the 2 primary endpoints, Holm’s method 
(Holm 1979) will be utilized. First, an endpoint with a smaller p-value will be tested at 
alpha=0.025 (two-sided). If the first test is significant, another endpoint will be tested at 
alpha=0.05 (two-sided). Otherwise, the second test will not be performed. 
Planned analyses at Day 85 including the primary analyses will be performed by 
unmasked team not involved in the conduct of the study once all patient data until Day 85 
are obtained in a fashion to protect the masking of the patients who will be followed in 
extension. Masked team will have access only to a summary of the results comparing the 
two arms so the same study team can continue to be masked while conducting the 
remaining part of the trial until the end of the 52-week Overall Period. The 
investigational sites will not be unmasked and will not have access to the summary of the 
results comparing the two arms.  
As a sensitivity analysis, a tipping point, at which the primary analysis result turns out to 
be not-significant, is examined in each ICE.  
Further details will be included in a separated statistical analysis plan.  
 Analysis of Secondary Efficacy Parameters 
The key secondary efficacy endpoint is change from baseline of total eye fluorescein 
staining score as assessed by expanded NEI scale for study eye will be analyzed in a 
similar manner as performed for primary endpoint. All other secondary endpoints will 
also be analyzed in a similar manner. 
The other secondary efficacy endpoints are ordered as follows: corneal sum fluorescein 
staining score as assessed by expanded NEI scale, OSDI, Schirmer’s test 
(unanesthetized), and TFBUT. 
Key secondary efficacy endpoint will be tested at alpha=0.05 (two-sided) if primary 
endpoints are both significant at alpha=0.05. 
The other secondary efficacy endpoints will be tested in order by fixed sequence method 
if the key secondary endpoint is significant. 
10.5 
Analysis of Safety Data 
AEs will be coded using the Medical Dictionary for Regulatory Activities dictionary (the 
most recent version, ver. 24.1 or later). Frequencies, percentages, severity, and 
relationship to study drug of patients with TEAEs, serious TEAEs, and TEAEs causing 
premature study withdrawal and study drug discontinuation will be provided by treatment 
group. An AE is treatment emergent if it occurs or worsens after the first dose of study 
treatment. Furthermore, frequencies of occurrence will be given of patients with TEAEs 
by system organ class; by system organ class and preferred term; by system organ class, 
preferred term, and maximal severity; by system organ class and preferred term for 




CONFIDENTIAL 
 
Kowa Research Institute, Inc. 
K-161-3.01, Study Protocol 
 
K-161 
 
 
November 22, 2021 
Page 74 of 82 
 STUDY MANAGEMENT AND DATA COLLECTION 
11.1 
Ethical Conduct of the Trial 
The study will be performed in accordance with the ethical principles that have their 
origin in the Declaration of Helsinki, the HIPAA, and the ICH harmonised tripartite 
guideline E6(R2): GCP. The study will also be performed in compliance with the 
requirements of the US FDA as outlined in Title 21 of the CFR (Parts 11, 50, 54, 56, and 
312) and all other applicable regional or local regulatory requirements. 
11.2 
IRB/IEC/REC 
The IRB/IEC/REC must be assembled according to the applicable state and federal 
requirements of each participating location, including ICH E6(R2) guidelines, and 
US FDA 21 CFR Part 56. 
It is the responsibility of the clinical site to submit the Protocol, Investigator’s Brochure, 
patient ICF, patient recruitment materials (if applicable), and other documentation as 
required by the IRB/IEC/REC for review and approval. A copy of the written approval 
must be provided to KRI. The documentation must clearly mention the 
approval/favorable opinion of the Protocol, the patient ICF, and patient recruitment 
materials (if applicable), including respective version dates. The written approval and a 
list of the voting members, their titles or occupations, and their institutional affiliations 
must be obtained from the IRB/IEC/REC and provided to KRI before the release of 
clinical study supplies to the clinical site and commencement of the study. If any member 
of the IRB/IEC/REC has direct participation in the study, written notification regarding 
his or her abstinence from voting must also be obtained. 
The clinical site must adhere to all requirements stipulated by the IRB/IEC/REC. This 
includes notification to the IRB/IEC/REC regarding the following: protocol amendments, 
updates to the patient ICF, recruitment materials intended for viewing by patients, IND 
safety reports, serious and unexpected AEs, reports and updates regarding the ongoing 
review of the study at intervals specified by the IRB/IEC/REC, and submission of final 
study reports and summaries to the IRB/IEC/REC. 
It is the responsibility of each investigational site to submit information to the appropriate 
IRB/IEC/REC for annual review and annual re-approval. 
11.3 
Patient Informed Consent 
Written consent must be obtained from the patient prior to any study-specific procedure 
or investigation. 
Prior to the implementation of study procedures, patients and persons conducting the 
consent discussion will be required to sign and date the IRB/IEC-approved ICF, and each 
patient will be given a copy. In addition, this information will be recorded in the patient’s 
medical record (i.e., source document). 


CONFIDENTIAL 
 
Kowa Research Institute, Inc. 
K-161-3.01, Study Protocol 
 
K-161 
 
 
November 22, 2021 
Page 75 of 82 
The written consent document will embody the elements of informed consent as 
described in the HIPAA, World Medical Association Declaration of Helsinki, FDA 21 
CFR Part 50.25, ICH GCP, and in accordance with any local regulations. The 
Investigator is responsible for the preparation, content, and IRB/IEC/REC approval of the 
ICF. The ICF must be approved by the clinical site-designated IRB/IEC/REC and be 
acceptable to KRI or its designee prior to their use. 
The ICF must be written in a language fully comprehensible to the prospective patient. 
The written patient ICF will explain the objectives of the study and its potential risks and 
benefits. The information included on the ICF must be provided to the patient both 
verbally and in writing whenever possible and in a manner deemed appropriate by the 
IRB/IEC/REC. Patients must be given ample opportunity to read the information and 
inquire about details of the study. The Investigator must be satisfied that the patient has 
understood the information provided before written consent is obtained. If there is any 
doubt as to whether the patient has understood the written and verbal information, the 
patient must not be allowed to enter the study. 
If a patient agrees to participate, he or she will be asked to sign and date an ICF, the 
original copy of which will be kept by the Investigator. A copy of the signed ICF will be 
given to the patient. Information documenting the informed consent procedure will be 
recorded in the patient’s medical records (i.e., source document), and the original signed 
ICF must be made available to the study monitor for inspection. 
If informed consent is taken under special circumstances (oral informed consent), then 
the procedures to be followed must be determined by CRO and/or the sponsor and 
provided in writing by CRO and/or the sponsor prior to the consent process. 
All ICFs must be approved for use by the sponsor or designee and receive 
approval/favorable opinion from an IRB/IEC/REC prior to their use. If the ICF requires 
revision (e.g., due to a protocol amendment or significant new safety information), it is 
the PI’s responsibility to ensure that the amended form is reviewed and approved by the 
sponsor prior to submission to the governing IRB/IEC/REC and that it is read, signed, 
and dated by all patients or their designees currently and subsequently enrolled in the 
study. 
11.4 
Amendments to the Protocol 
An amendment must be agreed to in writing by the sponsor, submitted to FDA as an IND 
application amendment, and submitted to and approved by the respective IRB/IEC/REC 
for each investigational site before it is implemented. Written approval of a protocol 
amendment is not required prior to implementation for changes to the protocol, which 
eliminate immediate hazard to the patient; however, approval must be obtained as soon as 
possible thereafter. Approved amendments must also be signed by the Investigator. 
11.5 
Study Initiation 
The Investigator must not enroll any patients prior to the completion of a formal meeting 
conducted by a representative of the sponsor. This meeting will include a detailed review 
of the study protocol and eCRFs. Study drug will not be supplied to an Investigator until 


CONFIDENTIAL 
 
Kowa Research Institute, Inc. 
K-161-3.01, Study Protocol 
 
K-161 
 
 
November 22, 2021 
Page 76 of 82 
all the necessary pre-study requirements have been completed and essential signed 
documents are received by the sponsor or its representative. 
11.6 
Study Monitoring 
It is the responsibility of the Investigator to ensure that the study is conducted in 
accordance with the protocol, ICH/FDA GCPs, applicable regulatory requirements, 
HIPAA, and the current Declaration of Helsinki. Valid data are to be entered into the 
eCRFs. 
To achieve this objective, the monitor’s duties are to aid the Investigator and, at the same 
time, the sponsor in the maintenance of accurate, complete, legible, well-organized, and 
easily retrievable data. The monitor will review the protocol with the Investigator. In 
addition, the monitor will explain the Investigator’s reporting responsibilities and all 
applicable regulations concerning the clinical evaluation of the study drug. 
The Investigator will permit the representatives of the sponsor to monitor the study as 
frequently as the sponsor deems is necessary to determine that data recording and 
protocol adherence are acceptable. The eCRFs and related source documents will be 
reviewed in detail by the monitor at each visit, in accordance with relevant standard 
operating procedures, ICH GCP guidance, and FDA GCP regulations. This includes 
results of tests performed as a requirement for participation in this study and any other 
medical records required to confirm information contained in the eCRFs, such as past 
medical history and secondary diagnoses. The Investigator and staff will be expected to 
cooperate with the monitor and provide any missing information, whenever possible. 
All monitoring activities will be reported and archived. In addition, monitoring visits will 
be documented at the investigational site by signature and date on the study-specific 
monitoring log. 
11.7 
Case Report Form 
All patient data generated during the study will be recorded on the eCRF. 
The Investigator will ensure that all data are entered promptly, legibly, completely, 
accurately and conform to source documents, in accordance with specific instructions 
accompanying the eCRFs, designed specifically for this study and supplied by the 
representatives of the sponsor for each patient. 
The representatives of the sponsor will only consider the eCRFs to be complete after they 
are reviewed and signed by the Investigator, indicating his/her assurance of the accuracy 
of all recorded data. It is expected that the Investigator and staff will cooperate with the 
monitoring team and provide missing data in a timely manner. 
11.8 
Verification Procedures 
In fulfillment of their obligations to the sponsor and to verify compliance with this 
protocol, ICH GCP guidance, and FDA GCP regulations, the Investigator will permit the 
representatives of the sponsor, the IRBs/IECs/RECs, the monitor, and regulatory 
authorities to have direct access to the patient’s medical records. 


CONFIDENTIAL 
 
Kowa Research Institute, Inc. 
K-161-3.01, Study Protocol 
 
K-161 
 
 
November 22, 2021 
Page 77 of 82 
It is the Investigator’s obligation to ensure documentation of all relevant data in the 
patient’s medical record, eCRFs, and on study forms, when applicable, according to 
procedures provided in the protocol and/or supplemental instructions. 
The Investigator will maintain a Patient Identification Code List to enable unambiguous 
identification of the patients (patient names and corresponding subject codes). The 
Patient Identification Code List is an essential document and as such must be maintained 
according to the ICH GCP guidelines. 
11.9 
Retention of Records 
All documentation pertaining to the study will be retained by the sponsor in accordance 
with US FDA regulations and the ICH GCP guidance document. 
The representatives of the sponsor will provide each Investigator with a study file, which 
will be used to file the Investigator’s Brochure, protocol, drug accountability records, 
correspondence with the IRB/IEC and the sponsor, and other study-related documents. 
The Investigator agrees to keep records and those documents that include (but are not 
limited to) the identification of all participating patients, medical records, study-specific 
source documents, source worksheets, all original signed and dated ICFs, copies of all 
eCRFs, query responses, and detailed records of drug disposition, to enable evaluations 
or audits from regulatory authorities and the sponsor or its designees. 
The Investigator will retain records required to be maintained under federal regulations 
for a period of 2 years following the date a marketing application is approved for the drug 
for the indication for which it is being investigated; or, if no application is to be filed or if 
the application is not approved for such indication, until 2 years after the investigation is 
discontinued and FDA is notified. However, these documents will be retained for a 
longer period if required by the applicable regulatory requirement(s) or if needed by the 
sponsor. In addition, the Investigator must make provision for the patient’s medical 
records to be kept for the same period of time. 
Patients’ medical records and other original data will be archived in accordance with 
applicable regulations and requirements established by the investigational sites. 
11.10 Insurance and Indemnity 
The sponsor’s obligations regarding insurance and indemnification are described in other 
documents or agreements. 
11.11 Audit and Inspection 
The Investigator must permit study-related quality oversight monitoring, quality 
assurance audits, IRB/IEC/REC review, and regulatory agency inspections and provide 
direct access to source data documents. It is important that the Investigator(s) and their 
relevant personnel are available during the monitoring, audit, or inspection visits and that 
sufficient time is devoted to the process. 


CONFIDENTIAL 
 
Kowa Research Institute, Inc. 
K-161-3.01, Study Protocol 
 
K-161 
 
 
November 22, 2021 
Page 78 of 82 
It is the responsibility of KRI to perform sponsor quality oversight, as part of the quality 
assurance and quality control programs. The purpose of a quality assurance audit, which 
is independent of and separate from routine monitoring or quality control functions, is to 
evaluate trial conduct and compliance with the protocol, the principles of ICH GCP, and 
other applicable regulatory requirements. 


CONFIDENTIAL 
 
Kowa Research Institute, Inc. 
K-161-3.01, Study Protocol 
 
K-161 
 
 
November 22, 2021 
Page 79 of 82 
 USE OF INFORMATION 
12.1 
General Aspects 
All information concerning KRI, such as patent applications, formula, manufacturing 
processes, basic scientific data or formulation information supplied by KRI and not 
previously published, are considered confidential and will remain the sole property of 
KRI. The Investigator agrees to use this information only in accomplishing this study and 
will not use it for other purposes without the written consent of KRI, except for official 
representatives, such as regulatory authorities. 
It is understood by the Investigator that the information developed in this clinical study, 
in connection with the development of K-161 will be used by KRI and, therefore, may be 
disclosed by KRI as required to other clinical Investigators, other pharmaceutical 
companies and to other government agencies. In order to allow for the use of the 
information derived from clinical studies, it is understood that there is an obligation to 
provide to KRI complete test results and all data compiled in this study. 
12.2 
Patient Confidentiality and Data Protection 
KRI and its designees affirm and uphold the principle of the patient’s right to protection 
against invasion of privacy. Throughout this study, all data will be linked to the eCRF via 
a unique identification number and the patient's initials. The data will be masked 
correspondingly in all data analyses. 
However, in compliance with the guidelines and regulations of the US FDA concerning 
the acceptance of clinical studies in support of IND applications and the ICH GCP 
(whether performed in the US or elsewhere), and in fulfillment of its obligations to KRI 
to verify compliance with this protocol, KRI’s designee requires that the Investigator to 
permit its monitor, representatives from the FDA, KRI’s designated auditors, IRBs/IECs, 
and other governmental regulatory authorities to review the patient’s primary medical 
records (source data or documents) including, but not limited to laboratory test result 
reports, electrocardiogram reports, admission and discharge summaries for hospital 
admissions occurring during a patient’s study participation, and autopsy reports related to 
deaths occurring during the study. 
Should access to such medical records require a waiver or authorization separate from the 
statement of informed consent, the Investigator will obtain such permission in writing 
from the patient before the patient is entered into the study. 
12.3 
Final Report and Publication Policy 
All information regarding this study will be kept strictly confidential. All data derived 
from the study will be the property of KRI. The Investigator must undertake not to submit 
any part of the data from this study for publication without prior consent of KRI. KRI 
may disclose data derived from the study to other Investigators and drug regulatory 
authorities. 


CONFIDENTIAL 
 
Kowa Research Institute, Inc. 
K-161-3.01, Study Protocol 
 
K-161 
 
 
November 22, 2021 
Page 80 of 82 
After completion of the study, and as agreed by the Investigator and KRI, the Investigator 
may send a draft manuscript to KRI to be reviewed in order to reach an agreement 
regarding publication. The Investigator must receive written approval from KRI before 
the final version of the manuscript is submitted for publication. 
At the conclusion of the study, after the data are analyzed, KRI or its designee will 
prepare a final clinical report. 




CONFIDENTIAL 
 
Kowa Research Institute, Inc. 
K-161-3.01, Study Protocol 
 
K-161 
 
 
November 22, 2021 
Page 82 of 82 
Tauber J, Karpecki P, Latkany R, Luchs J, Martel J, Sall K, et al. Lifitegrast ophthalmic 
solution 5.0% versus placebo for treatment of dry eye disease: results of the randomized 
phase III OPUS-2 study. Ophthalmology. 2015;122(12):2423-2431.  
Tyrvaya [package insert] Oyster Point Pharma, Inc.; Nov 2021.