Clinical trial NCT04084483
Conditions: Dry Eye Disease
Sponsor: Kowa Research Institute, Inc.
Start date: 2019-08-04; Completion date: 2020-01-09
Enrollment: 238 participants; Allocation: RANDOMIZED; Intervention model: PARALLEL

Brief summary:
The objective of the study is to assess the safety, efficacy, optimum dosage, and dosing regimen of K-161 in adult subjects with moderate to severe dry eye disease.

Detailed description:

Arms: arm 1: K-161 Ophthalmic Solution Dose A. arm 2: K-161 Ophthalmic Solution Dose B. arm 3: K-161 Ophthalmic Solution Dose C. arm 4: Vehicle Solution Dose.
Interventions: intervention 1: K-161 intervention 2: Placebo (Vehicle)
Intervention descriptions: intervention 1: K-161 alternate dosage intervention 2: Placebo solution

Protocol documents:
Prot_002.pdf: 
K-161-2.01US 
 
 
A Phase 2, Prospective, Double-Masked, Randomized, Multi-Center, Vehicle-Controlled, 
Parallel-group, 4-week Administration Study Assessing the Safety, Efficacy, and 
Optimum Dosage of K-161 in non-Japanese and Japanese Adult Subjects with Moderate 
to Severe Dry Eye Disease Both in Environmental and Controlled Adverse Environmental 
(CAE®) Settings 
 
NCT #: 04084483 
Clinical Trial Protocol 
Amendment 2 
 26 July 2019 
 


K-161 
Sponsor: Kowa Research Institute (KRI) 
Clinical Trial Protocol No.: K-161-2.01US 
Amendment 2 26Jul2019 
Clinical Trial Protocol: K-161-2.01US 
Protocol Title: 
A Phase 2, Prospective, Double-Masked, 
Randomized, Multi-Center, Vehicle-Controlled, 
Parallel-group, 4-week Administration Study 
Assessing the Safety, Efficacy, and Optimum 
Dosage of K-161 in non-Japanese and Japanese 
Adult Subjects with Moderate to Severe Dry Eye 
Disease Both in Environmental and Controlled 
Adverse Environmental (CAE®) Settings 
Protocol Number: 
K-161-2.01US / 
 
Study Phase: 
2 
Investigational Product 
Name: 
K-161 
IND/IDE/PMA Number: 
138738 
Indication: 
Dry eye disease 
Investigators: 
Multi-Center 
Sponsor: 
Kowa Research Institute, Inc. (KRI) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Date 
Original Protocol: 14 September 2018 
Amendment 1: 
13 June 2019 
Amendment 2: 
26 July 2019 
 
 
Confidentiality Statement 
 
This protocol contains confidential, proprietary information of 
 and/or Kowa 
Research Institute, Inc. Further dissemination, distribution or copying of this protocol 
or its contents is strictly prohibited. 
 


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SPONSOR PERSONNEL 
 
 
MEDICAL MONITOR 
 
 


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SYNOPSIS 
Protocol Title: 
A Phase 2, Prospective, Double-Masked, 
Randomized, Multi-Center, Vehicle-Controlled, 
Parallel-group, 4-week Administration Study 
Assessing the Safety, Efficacy, and Optimum 
Dosage of K-161 in non-Japanese and Japanese 
Adult Subjects with Moderate to Severe Dry Eye 
Disease Both in Environmental and Controlled 
Adverse Environmental (CAE) Settings 
Protocol Number: 
K-161-2.01US / 
 
Investigational Product: 
1. K-161 Ophthalmic Solution 
2. Placebo Ophthalmic Solution (Vehicle) 
Study Phase: 
2 
Objective(s): 
The objective of the study is to assess the safety, 
efficacy, optimum dosage, and dosing regimen 
of K-161 compared to its vehicle from Day 1 
(baseline) to Day 29 in non-Japanese and 
Japanese adult subjects with moderate to severe 
dry eye disease both in environmental and CAE 
settings. 
Overall Study Design: 
Structure: 
Prospective, double-masked, randomized, multi-
center, vehicle-controlled, parallel-group study 
Duration: 
An individual subject’s participation is estimated 
to be approximately 6 weeks (42 days) with a 
follow-up phone call. 
Controls: 
Placebo Ophthalmic Solution (Vehicle) 
Dosage/Dose Regimen/ 
Instillation/Application/Use: 
Subjects eligible to be randomized will receive 
one of the following treatments to be 
administered bilaterally for 28 days (from Visit 2 
to Visit 5). 
1) 
 K-161 Ophthalmic Solution; 
 
 
 
2) 
 K-161 Ophthalmic Solution; 
 
 
 
3) 
 K-161 Ophthalmic Solution; 
 
 
 
  
4) Placebo Ophthalmic Solution (Vehicle);  
 
 
 
During a 14-day study run-in period (for the 
purpose of subject selection) prior to 
randomization, all subjects will receive Placebo 


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Ophthalmic Solution (Vehicle) 
 
 
 
 
Summary of Visit Schedule: 
5 visits over the course of approximately 6 
weeks with a follow-up phone call. 
 Visit 1 = Day -14 ± 2, CAE Screening  
 Visit 2 = Day 1, CAE Confirmation/ Baseline 
 Visit 3 = Day 8 ± 1 
 Visit 4 = Day 15 ± 2 
 Visit 5 = Day 29 ± 2 
 Follow-up Phone Call = Day 36 ± 2  
Measures Taken to Reduce 
Bias: 
This is a double-masked, randomized treatment 
assignment study. 
Study Population Characteristics: 
Number of Subjects: 
Approximately 600 subjects will be screened to 
enroll approximately 240 (60 per treatment 
arm*) subjects 
 
Condition/Disease: 
Dry Eye Disease (DED) 
Inclusion Criteria: 
Subjects who meet all of the following criteria will be eligible to participate in the 
study. 
Subjects must: 


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1. Be at least 18 years of age at the time of informed consent visit 
2. Have a reported history of dry eye disease in both eyes 
 
and a history of eye drop use for dry eye 
symptoms 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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Exclusion Criteria: 
Subjects who meet any of the following criteria will not be eligible to participate in 
the study. 
Subjects must not: 
1. Have any clinically significant ocular condition 
 
 
 
 
 
 
2. Have a history of 
 
corneal refractive surgery, and/or any other ocular surgical 
procedure 
 within 12 months 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  


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. 


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Evaluation Criteria: 
 
Efficacy Measures and 
Endpoints: 
Primary Efficacy Endpoints: 
The primary efficacy endpoint (sign) is: 
 Change in inferior corneal staining score 
from Day 1 (baseline) to Day 29 by 
comparing 
 K-161 
 to its 
vehicle 
 in CAE setting 
The primary efficacy endpoint (symptom) is: 
 Change in Ora Calibra® ODS from Day 1 
(baseline) to Day 29 by comparing 
 
K-161 
 to its vehicle 
 
 in CAE setting 
Important Secondary Efficacy Endpoints: 
The important secondary efficacy endpoints are: 
 Change in Schirmer’s Test value 
(unanesthetized) from Day 1 (baseline) to 
Day 29 by comparing 
 K-161 
 
 to its vehicle 
 in 
environmental setting 
 Change in TFBUT from Day 1 (baseline) 
to Day 29 by comparing 
 K-161 
 to its vehicle 
 in 
CAE setting 
Secondary Efficacy Endpoints: 
The secondary efficacy endpoints are 
comparisons of the following associated with 
taking the vehicle 
 and K-161 
 (i.e., 
 K-161 
 and 
 K-161 
 for: 
 Fluorescein staining by region: central, 
superior, inferior, temporal, nasal and 
corneal sum as assessed by the Ora 
Calibra® Corneal and Conjunctival 
Staining Scale 
 Lissamine green staining by region: 
central, superior, inferior, temporal, 
nasal, and conjunctival sum as assessed 
by the Ora Calibra® Corneal and 
Conjunctival Staining Scale 
 Conjunctival Redness as assessed by the 
Ora Calibra® Scale 
 TFBUT  


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 Tear Osmolarity 
 Schirmer’s Test (unanesthetized) 
 Blink Rate 
 Ora Calibra® Ocular Discomfort Scale  
 Ora Calibra® Ocular Discomfort and 4-
Symptom Questionnaire  
 Visual Analog Scale (VAS)   
 Burning/ Stinging 
 Itching 
 Foreign Body Sensation 
 Blurred Vision 
 Eye Dryness 
 Photophobia 
 Pain 
 OSDI©  
Safety Measures: 
 
 
  
 
  
 Adverse event query  
 
  
 
 
 
 
 
 


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 Maximum dose tolerability by comparing 
the 
 K-161 
 arm to the 
 
and 
 K-161 
 arms 
Other: 
Analysis Populations 
 Intent-to-Treat Population – The intent-to-treat (ITT) population includes 
all randomized subjects. The primary analysis will be performed on the 
ITT population. Subjects in the ITT population will be analyzed as 
randomized. 
 Per Protocol Population – The per protocol (PP) population includes 
subjects in the ITT population who do not have significant protocol 
deviations and who complete the study. Protocol deviations will be 
assessed prior to database lock and unmasking. Subjects in the PP 
population will be analyzed as treated. 
 Safety Population – The safety population includes all subjects who have 
received at least one dose of the investigational product. The safety 
population will be analyzed for all safety assessments. Subjects in the 
Safety population will be analyzed as treated.  
Sample Size 
This study is expected to enroll 240 subjects in a 1:1:1:1 ratio across four 
treatment arms, or 60 subjects per treatment arm. In addition, randomization will 
be stratified such that 
 will be randomized in each treatment 
arm.  
The standard deviation for change from baseline in post-CAE inferior corneal 
fluorescein staining ranges between 0.68 and 0.81 units. Assuming a common 
standard deviation of 0.77, a sample size of 60 subjects per group will have 
approximately 90% power to detect a difference of 0.46 units between the active 
treatment group and the vehicle group using a two-sample t-test at a two-sided 
significance level of 0.05. Again, it is assumed that adjusting for baseline and site 
will further reduce variability and provide >90% power. 
Likewise, the standard deviation for change from baseline scores in the post-CAE 
ODS at Day 29 is assumed a common standard deviation of 0.82, a sample size of 
60 subjects per group will have approximately 90% power to detect a difference of 
0.49 units between the active treatment group and the vehicle group using a two-
sample t-test at a two-sided significance level of 0.05. It is assumed that adjusting 
for baseline and site will further reduce variability and provide >90% power. 
Multiplicity Consideration: 


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Common factors for multiplicity are multiple arms and multiple endpoints. 
1) Multiple arms 
The primary treatment comparison will be between the 
 K-161 
 treatment 
arm and the vehicle 
 treatment arm. Other treatment comparisons will be 
considered secondary or exploratory.  
2) Multiple endpoints 
The primary and important secondary endpoints will be tested hierarchically to 
maintain the study-wise Type I error rate of 0.05. First, change from baseline in 
inferior corneal fluorescein staining will be tested at an alpha level of 0.05. The 
test for change from baseline scores in the ODS will be conducted at an alpha 
level of 0.05 only if the previous test demonstrates significance. The test for 
change from baseline in Schirmer’s test will be conducted at an alpha level of 0.05 
only if the previous test demonstrates significance. The test for change from 
baseline in TFBUT will be conducted at an alpha level of 0.05 only if the previous 
test demonstrates significance. All other secondary and exploratory endpoints and 
treatment comparisons will be considered exploratory. 
The hierarchical testing order will be as follows: 
Primary comparisons: 
1. Comparison of the change from baseline in post-CAE inferior corneal 
staining at Day 29 (
 K-161 
 vs vehicle) 
2. Comparison of the change from baseline in post-CAE ocular discomfort at 
Day 29 (
 K-161 
 vs vehicle) 
Important Secondary comparisons: 
3. Comparison of the change from baseline in pre-CAE Schirmer’s test value 
at Day 29 (
 K-161 
 vs vehicle) 
4. Comparison of the change from baseline in post-CAE TFBUT at Day 29 
(
 K-161 
 vs vehicle) 
Thus, the study-wise Type I error rate will be maintained at 0.05 by considering 
only one dose of K-161 as the primary treatment comparison and using a 
hierarchical testing procedure. 
Primary Efficacy Analyses:  
The primary comparisons of change from baseline in post-CAE inferior corneal 
staining and ocular discomfort between the 
 K-161 
 group and the 
vehicle group at Day 29, will be performed using analysis of covariance 
(ANCOVA) models. The respective baseline post-CAE score will be included as a 
covariate in each model and site will be included as a fixed effect. Treatment by 
baseline and treatment by site interactions will be explored in separate models 
and, if significant, analyses will be performed by baseline stratification and/or site, 
respectively, to further examine significant interactions. The primary analyses will 
use the ITT population. 
For the primary endpoints multiple imputation with a control-based pattern 
mixture model will be used.  


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Secondary Efficacy Analyses 
Secondary and exploratory efficacy endpoints will be analyzed similarly to the 
primary analyses on the ITT population. Continuous and ordinal variables 
collected at each visit will be summarized descriptively (n, mean, standard 
deviation, median, minimum and maximum), and analyzed with ANCOVA 
models each K-161 
 group to the vehicle group. All visit-based data will be 
analyzed by visit and for each timepoint, if applicable, as well as the change from 
baseline.  
Data collected pre- and post-CAE will also be analyzed for the change from pre- 
to post-CAE within each visit. Data collected during the CAE will also be 
analyzed using repeated measures models including all of the time points from a 
CAE exposure.  
For the two important secondary endpoints, other secondary, and exploratory 
endpoints, multiple imputation with a control-based pattern mixture model will be 
used.   
 
 
 
 
Safety Variables 
Adverse events (AEs) will be coded using the MedDRA dictionary. Frequencies 
and percentages of subjects with treatment-emergent adverse events (TEAEs), 
serious TEAEs, and TEAEs causing premature 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 will be given of subjects 
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 performed for 
ocular and non-ocular AEs.  
 
 
 
 
 
 
 
 
 
  
 
 
 
 


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Other analyses may be conducted and the details will be included in a separate 
statistical analysis plan. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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TABLE OF CONTENTS 
SYNOPSIS............................................................................................................ 3 
TABLE OF CONTENTS.................................................................................... 14 
LIST OF ABBREVIATIONS ...................................................................................... 18 
1 
INTRODUCTION .............................................................................................. 20 
 
Drug Profile from Non-clinical Studies ................................................... 20 
2 
STUDY OBJECTIVES ....................................................................................... 21 
3 
CLINICAL HYPOTHESES ............................................................................... 21 
4 
OVERALL STUDY DESIGN ............................................................................ 21 
5 
STUDY POPULATION ..................................................................................... 22 
 
Number of Subjects (approximate) .......................................................... 22 
 
Study Population Characteristics .............................................................. 22 
 
Inclusion Criteria ...................................................................................... 22 
 
Exclusion Criteria ..................................................................................... 24 
 
Withdrawal Criteria (if applicable) .......................................................... 25 
6 
STUDY PARAMETERS .................................................................................... 26 
 
Efficacy Endpoints ................................................................................... 26 
6.1.1 
Primary Efficacy Endpoints .................................................. 26 
6.1.2 
Important Secondary Efficacy Endpoints ............................. 26 
6.1.3 
Secondary Efficacy Endpoints .............................................. 26 
6.1.4 
Exploratory Efficacy Endpoints ............................................ 27 
 
Safety Measures ....................................................................................... 27 
 
Other Measures ......................................................................................... 27 
 
Clinical Laboratory Measurements .......................................................... 29 
7 
STUDY MATERIALS ....................................................................................... 29 
 
Study Treatments ...................................................................................... 29 
7.1.1 
Masking................................................................................. 29 
7.1.2 
Description of and Justification for the Route of 
Administration, Dosage, Dosage Regimen, and Treatment 
Period. ................................................................................... 29 
7.1.3 
Instructions for Use and Administration ............................... 30 
 
Labeling, Packaging, Storage, Accountability, and Return or Disposal of 
Investigational Product ............................................................................. 30 


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7.2.1 
Labeling/Packaging............................................................... 30 
7.2.2 
Storage of Investigational Product ........................................ 30 
7.2.3 
Accountability of Investigational Product ............................ 30 
7.2.4 
Return or Disposal of Investigational Product ...................... 31 
 
Other Study Supplies ................................................................................ 31 
8 
STUDY METHODS AND PROCEDURES ...................................................... 31 
 
Subject Entry Procedures ......................................................................... 31 
8.1.1 
Overview ............................................................................... 31 
8.1.2 
Informed Consent.................................................................. 31 
8.1.3 
Washout Intervals ................................................................. 31 
8.1.4 
Procedures for Final Study Entry .......................................... 31 
8.1.5 
Methods for Assignment to Treatment Groups: ................... 31 
 
Concurrent Therapies ............................................................................... 32 
8.2.1 
Prohibited Medications/Treatments ...................................... 32 
8.2.2 
Escape Medications .............................................................. 32 
8.2.3 
Special Diet or Activities ...................................................... 32 
 
Schedule of Visits, Measurements and Dosing ........................................ 40 
8.4.1 
Scheduled Visits.................................................................... 40 
8.4.2 
Unscheduled Visits ............................................................... 40 
 
Compliance with Protocol ........................................................................ 41 
 
Subject Disposition ................................................................................... 41 
8.6.1 
Completed Subjects .............................................................. 41 
8.6.2 
Discontinued Subjects ........................................................... 41 
 
Study Termination .................................................................................... 41 
 
Study Duration ......................................................................................... 42 
 
Monitoring and Quality Assurance .......................................................... 42 


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9 
ADVERSE EVENTS .......................................................................................... 42 
 
Adverse Event .......................................................................................... 42 
9.1.1 
Severity ................................................................................. 43 
9.1.2 
Relationship to Investigational Product ................................ 43 
9.1.3 
Expectedness ......................................................................... 44 
 
Serious Adverse Events ............................................................................ 44 
 
Procedures for Reporting Serious Adverse Events .................................. 45 
9.3.1 
Reporting a Serious Unexpected Suspected Adverse 
Reaction ................................................................................ 45 
9.3.2 
Reporting a Serious Adverse Event ...................................... 45 
 
Procedures for Unmasking (if applicable) ................................................ 46 
 
Type and Duration of the Follow-up of Subjects after Adverse Events .. 46 
10 
STATISTICAL HYPOTHESES AND METHODS OF ANALYSES ............... 47 
 Analysis Populations ................................................................................ 47 
 Statistical Hypotheses ............................................................................... 47 
 Sample Size .............................................................................................. 48 
 Statistical Analysis ................................................................................... 48 
10.4.1 General Considerations ......................................................... 48 
10.4.2 Unit of Analysis .................................................................... 48 
10.4.3 Missing Data ......................................................................... 49 
10.4.4 Multiplicity Consideration .................................................... 49 
10.4.5 Efficacy Analyses ................................................................. 50 
10.4.6 Safety Variables .................................................................... 50 
10.4.7 Exploratory Safety Analyses................................................. 51 
 
 
 
 
 
10.4.11 Interim Analyses ................................................................... 51 
11 
COMPLIANCE WITH GOOD CLINICAL PRACTICES, ETHICAL 
CONSIDERATIONS, AND ADMINISTRATIVE ISSUES .............................. 52 
 Protection of Human Subjects .................................................................. 52 
11.1.1 Subject Informed Consent..................................................... 52 
11.1.2 Institutional Review Board (IRB) Approval ......................... 52 
 Ethical Conduct of the Study .................................................................... 52 
 Subject Confidentiality ............................................................................. 52 
 Documentation ......................................................................................... 53 


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11.4.1 Retention of Documentation ................................................. 53 
 Recording of Data on Source Documents and Case Reports Forms 
(CRFs) ...................................................................................................... 53 
 Publications .............................................................................................. 53 
12 
REFERENCES ................................................................................................... 54 
13 
APPENDICES .................................................................................................... 55 
Appendix 1: Schedule of Visits and Measurements .................................................... 55 
Appendix 2: Examination Procedures, Tests, & Evaluations ...................................... 57 
Appendix 3: Protocol Amendment Summary .............................................................. 71 
 
Appendix 5: Investigator’s Signature .......................................................................... 73 
 
 


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LIST OF ABBREVIATIONS 
AE 
Adverse event 
CAE 
Controlled adverse environment 
CFR 
Code of Federal Regulations 
CRF 
Case report form 
CRO 
Contract research organization 
DED 
dry eye disease 
eCRF 
electronic case report form 
FDA 
Food and Drug Administration 
GCP 
Good Clinical Practice 
GLP 
Good Laboratory Practice 
HIPAA 
Health Insurance Portability and Accountability Act 
IB 
Investigator’s brochure 
ICF 
informed consent form 
ICH 
International Conference on Harmonisation 
IEC 
Independent Ethics Committee 
IND 
Investigational New Drug Application 
IP 
Investigational product 
IRB 
Institutional Review Board 
ITT 
Intent to treat 
IWRS 
Interactive web response system 
LASIK 
Laser in situ keratomileusis 
LOCF 
Last observation carried forward 


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MedDRA 
Medical Dictionary for Regulatory Activities 
NCS 
Not clinically significant 
ODS 
Ocular Discomfort Score 
OSDI 
Ocular Surface Disease Index 
OTC 
Over the counter 
PP 
Per protocol 
SAE 
Serious adverse event 
SOP 
Standard operating procedure 
TFBUT 
Tear film break-up time 
WHO 
World Health Organization 
 
 


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1 INTRODUCTION 
Dry eye disease (DED) is a multifactorial, progressive disorder of the ocular surface 
resulting from insufficient tear coverage of the surface of the eye in combination with 
ocular surface inflammation. Patients with DED often experience severe pain, visual 
impairment, tear film hyperosmolarity and instability, inflammation, and corneal 
wounding. While the prevalence of DED is difficult to report due to varying 
definitions and diagnostic criteria, the global prevalence of DED is estimated to be 
between 5% and 50%, and increases with age (Bron et al. 2017). In the United States, 
it is estimated that as many as 3.2 million women and 1.7 million men over the age of 
50 have DED, with a projected 40% increase in number of patients affected by 2030 
(Schaumberg et al. 2002, Schaumberg et al. 2003, Schaumberg et al. 2009). 
Current treatment and management of DED consists primarily of tear supplementation 
with lubricants (artificial tears). While artificial tears improve symptoms associated 
with DED, they have no effect on resolving the underlying conditions that lead to 
inflammation of the ocular surface. Three currently available options for treating 
inflammation at the ocular surface are Restasis® (cyclosporine ophthalmic emulsion) 
CEQUA™ (cyclosporine ophthalmic solution), and Xiidra® (lifitegrast ophthalmic 
solution). It has been shown that only 15% of patients respond to Restasis® after 6 
months of treatment, as measured by Schirmer’s test, and many more report ocular 
side-effects such as burning and stinging (Mah et al. 2012). Xiidra® has also been 
shown to be associated with ocular adverse events (AEs); in a clinical study of 
Xiidra® for subjects with DED, subjects reported increased ocular irritation upon 
instillation with Xiidra® compared to placebo (7.8% compared to 1.4% in the placebo 
group) (Tauber et al. 2015). Similarly, common adverse reactions reported after use of 
CEQUA include instillation site pain and conjunctival hyperemia (CEQUA 2018). 
Thus, there remains a medical need for more efficacious treatment options with a 
more favorable safety and comfort profile for patients with DED.  
 Drug Profile from Non-clinical Studies 
a tyrosine kinase involved in 
cytokine signaling and activation of lymphocytes. 
 have been shown 
to have potent anti-inflammatory activity both in vitro and in vivo (
 
). Tofacitinib, a 
 
, was shown to suppress ocular 
surface inflammation and corneal injury in a mouse model of dry eye disease 
(
). Because inflammation is a key component of DED, targeting 
the inflammatory pathway via 
 to reduce cytokine production and/or 
immune cell infiltration at the ocular surface may reduce the signs and symptoms of 
DED. 
 
 
 
 
 
 
 
This will be the first clinical study of K-161 Ophthalmic Solution. 


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2 STUDY OBJECTIVES 
Prior to any changes in a subject’s medical treatment and/or study visit procedures, 
the study will be discussed with each subject and subjects wishing to participate must 
give written informed consent (and/or assent) and sign a Health Insurance Portability 
and Accountability Act (HIPAA) form.  
The objectives of the study are to assess the safety, efficacy, optimum dosage, and 
dosing regimen of K-161 compared to its vehicle from Day 1 (baseline) to Day 29 in 
non-Japanese and Japanese adult subjects with moderate to severe dry eye disease 
both in environmental and Controlled Adverse Environment (CAE) settings. 
3 CLINICAL HYPOTHESES 
The clinical hypotheses for this study is that 
 K-161 Ophthalmic Solution 
 
is superior to its vehicle (
 for the primary endpoints of signs and 
symptoms of dry eye, as follows:  
 Sign: Post-CAE inferior corneal fluorescein staining score on the Ora Calibra® 
scale, measured by mean change from baseline (Visit 2) to Visit 5 
 Symptom: Post-CAE ocular discomfort scale on the Ora Calibra® scale, 
measured by mean change from baseline (Visit 2) to Visit 5 
4 OVERALL STUDY DESIGN 
This is a Phase 2, multicenter, randomized, double-masked, vehicle-controlled, 
parallel-group design with block enrollment. Subjects will be randomized to one of 
the following treatment groups at Visit 2:  
 
 K-161; 
 (N=~60) 
 
 K-161; 
 (N=~60) 
 
 K-161; 
 (N=~60)  
 Placebo Ophthalmic Solution (Vehicle); 
 (N=~60) 
 
Approximately 240 subjects will be randomly assigned to one of the four treatment 
groups (1:1:1:1). 
 
 Subjects, Sponsor, Contract 
research organization (CRO), and site personnel will be masked to treatment 
assignment. To ensure masking, a dedicated unmasked staff member/technician will 
be delegated to dispense and observe instillation of randomized study drug and collect 
randomized study drug from a subject for drug accountability. This person cannot 
perform any other study-related procedures. Additionally, the informed consent form 
(ICF) will not indicate any relationship between dosing regimen and treatment. 
Subjects will be instructed not to discuss their assigned dosing regimen or perceived 
treatment effects with other study participants. 
During the screening period, two 90-minute exposures to the CAE will be conducted 
to ascertain eligibility to enter the study. Subjects who qualify after the initial 
screening visit will enter the run-in phase, where they will self-administer vehicle 
 for approximately 14 days. Those who qualify at Visit 2 (Day 1) will be 
randomized to receive study drug in a double-masked fashion for 28 days. 
Randomization will be stratified on Visit 2 Post-CAE inferior fluorescein staining and 


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Post-CAE ocular discomfort on the Ora Calibra® scale. Subjects will self-administer 
drops either 
 or 
 
At Visit 4 (Day 15) and Visit 5 (Day 29), CAE exposure will occur, with pre-CAE, 
during CAE (symptoms only) and post-CAE assessments of ocular signs and 
symptoms. At Visit 3, no CAE exposure will occur but signs and symptoms will be 
assessed. Study drug will be discontinued at Visit 5. Subjects will exit from the study 
at this visit. The follow-up phone call will occur about 7 days after the final day of 
randomized study drug treatment. 
The timing of subject visits and examinations will be consistent throughout the study. 
5 STUDY POPULATION 
 Number of Subjects (approximate) 
It is estimated that approximately 600 subjects will be screened to enroll 
approximately 240 randomized subjects (60 in each group). 
 
 
 
 
Subjects will be randomized in a 1:1:1:1 ratio of  
 
 K-161; 
 
 
 K-161; 
 
 
 K-161; 
     
 Placebo Ophthalmic Solution (Vehicle); 
  
 Study Population Characteristics 
All subjects must be at least 18 years of age, of either gender, and of any race, and 
must meet all inclusion criteria and none of the exclusion criteria. 
 Inclusion Criteria 
Each subject must: 
1. Be at least 18 years of age at the time of informed consent visit 
2. Have a reported history of dry eye disease in both eyes 
 
 and have a history of eye drop use for dry eye symptoms 
 
 
 
 
 
 
 
 
 
 
 
 
                                                 
 
 
 


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 Exclusion Criteria 
Each subject must not: 
1. Have any clinically significant ocular condition 
 
 
 
 
 
 
2. Have a history of 
 
corneal refractive surgery, and/or any other ocular surgical procedure 
 
 within 12 months 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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 Withdrawal Criteria (if applicable) 
If at any time during the study the investigator determines that a subject’s safety has 
been compromised, the subject may be withdrawn from the study. 
Subjects may withdraw consent from the study at any time. 
Sponsor and/or investigator may discontinue any subject for non-compliance or any 
valid medical reason (see Section 8.6.2). 
The subject has the right to withdraw from the study at any time. Nevertheless, in this 
study, every attempt will be made to prevent missing data and to obtain complete 
follow up of all subjects during the study period. Investigators will be trained to 
minimize full withdrawals from the study period wherever possible. Subjects who 
discontinue study drug during the study period are not required to withdraw from the 
study. These subjects will be encouraged to remain in the study and asked to conduct 
the remaining study visits as outlined in the protocol through Visit 5. If a subject fails 
to actively maintain contact with the Investigator, reasonable efforts (telephone calls 
to family members or friends, e-mail contacts, etc.) will be made in order to 
encourage the subject to complete the study visits. 


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6 STUDY PARAMETERS 
 Efficacy Endpoints 
6.1.1 Primary Efficacy Endpoints 
The primary efficacy endpoint (sign) is: 
 Change in inferior corneal staining score from Day 1 (baseline) to Day 29 by 
comparing 
 K-161 
 to its vehicle 
 in CAE setting 
The primary efficacy endpoint (symptom) is: 
 Change in Ora Calibra® ODS from Day 1 (baseline) to Day 29 by comparing 
 K-161 
 to its vehicle 
 in CAE setting 
6.1.2 Important Secondary Efficacy Endpoints 
The important secondary endpoints are: 
 Change in Schirmer’s Test value (unanesthetized) from Day 1 (baseline) to 
Day 29 by comparing 
 K-161 
 to its vehicle 
 in 
environmental setting 
 Change in TFBUT from Day 1 (baseline) to Day 29 by comparing 
 K-
161 
 to its vehicle 
 in CAE setting 
6.1.3 Secondary Efficacy Endpoints 
The secondary efficacy endpoints are comparisons of the following associated with 
taking the vehicle 
 and K-161 
 (i.e., 
 K-161 
 and 
 K-161 
 for: 
 Fluorescein staining by region: central, superior, inferior, temporal, nasal and 
corneal sum as assessed by the Ora Calibra® Corneal and Conjunctival 
Staining Scale 
 Lissamine green staining by region: central, superior, inferior, temporal, nasal, 
and conjunctival sum as assessed by the Ora Calibra® Corneal and 
Conjunctival Staining Scale 
 Conjunctival Redness as assessed by the Ora Calibra® Scale 
 TFBUT  
 Tear Osmolarity 
 Schirmer’s Test (unanesthetized) 
 Blink Rate 
 Ora Calibra® Ocular Discomfort Scale  
 Ora Calibra® Ocular Discomfort and 4-Symptom Questionnaire  
 Visual Analog Scale (VAS)   
 Burning/ Stinging 
 Itching 
 Foreign Body Sensation 


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 Blurred Vision 
 Eye Dryness 
 Photophobia 
 Pain 
 OSDI©  
6.1.4 
 
 
 
 
 
 
 
 
 
 
 Safety Measures 
The safety measures being evaluated are: 
 
  
 
 
 
AE query 
 
 
 
 
 
 
 
 
 
Maximum dose tolerability by comparing the 
 K-161 
 arm to the 
 and 
 K-161 
 arms 
 Other Measures 
The other measures being evaluated are: 
 
 
 
 
 
 
 
  
 
 
 
  
 
 
 
 


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 Clinical Laboratory Measurements 
The following assessments are being conducted: 
Hematology: 
 
 
   
Clinical chemistry: 
 
 
 
 
 
   
Urinalysis: 
 
 
7 STUDY MATERIALS 
 Study Treatments 
7.1.1 Masking 
All arms will be double-masked. To ensure masking, an unmasked technician 
delegated by the Investigator will perform all study drug instruction, dispensation, 
collection and accountability. This technician cannot perform any other study visit 
procedures. Study Treatments/Formulations 
 
 K-161; 
 
 
 K-161; 
 
 
 K-161; 
    
 Placebo Ophthalmic Solution (Vehicle); 
  
7.1.2 Description of and Justification for the Route of Administration, Dosage, 
Dosage Regimen, and Treatment Period. 
Topical ophthalmic dosing is the optimal route of administration for dry eye 
treatments. The dosage and dosage regimen were selected based on non-clinical 
studies. The proposed treatment period of 4 weeks is based on results from pre-
clinical studies and on the anti-inflammatory mechanism of action of the drug. 


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7.1.3 Instructions for Use and Administration 
Subjects who were randomized to 
 arm will be instructed to administer study drug 
 Subjects who were randomized to 
 arm will be 
instructed to administer study drug 
 If 
missed, the subject must not administer the eye drop if the next dosing is in less than 2 
hours. At Visits 2, 3, 4, and 5, all subjects must visit their study sites without 
administering any topical ophthalmic preparations, including study drug, and must not 
administer topical ophthalmic preparations until all examinations are finished. 
Subjects, Sponsor, CRO, and site personnel (with the exception of the following 
person) will be masked to treatment assignment. To ensure masking, a dedicated 
unmasked staff member/technician will be delegated to dispense and observe 
instillation of randomized study drug and collect randomized study drug from a 
subject for drug accountability. This person cannot perform any other study-related 
procedures. Additionally, the ICF will not indicate any relationship between dosing 
regimen and treatment. Subjects will be instructed not to discuss their assigned dosing 
regimen or any perceived treatment effects with other study participants. 
 Labeling, Packaging, Storage, Accountability, and Return or 
Disposal of Investigational Product 
7.2.1 Labeling/Packaging 
Investigational product (IP) will be packaged and labeled into clinical kits. 
Run-in Period 
For the run-in period, 
 
 to provide a 
sufficient medication supply.  
Treatment Period 
 Dosing: For the treatment period, 9
 
 to 
provide a sufficient supply of randomized study drug. 
 Dosing: For the treatment period, 
 
 to provide a 
sufficient supply of randomized study drug. 
 
7.2.2 Storage of Investigational Product 
The IPs must be stored in a secure area accessible only to the investigator and his/her 
designees. K-161 must be stored at controlled room temperature of 20-25°C (68-
77°F) with excursions permitted between 15°C and 30°C (59-86°F), as indicated on 
the product label.  
7.2.3 Accountability of Investigational Product 
The IP is to only be prescribed by the PI or his/her named Sub-Investigator(s), and is 
to only be used in accordance with this protocol. The IP must only be distributed to 
subjects properly qualified as described in this protocol to receive IP. 


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The investigator must keep an accurate accounting of the IP received from the 
supplier. This includes the amount of IP dispensed to subjects, amount of IP returned 
to the investigator by the subjects, and the amount returned or disposed upon the 
completion of the study. A detailed inventory must be completed for the IP. Study 
drug accountability will be performed by an Unmasked Technician as delegated by 
the PI. To ensure masking, a dedicated unmasked staff member/technician will be 
delegated to dispense and collect randomized study drug from a subject for drug 
accountability. This person cannot perform any other study-related procedures. 
7.2.4 Return or Disposal of Investigational Product 
All IP (used or unused) will be returned to the Sponsor or their designee. Requests for 
the return of IP must be specified in writing. 
 Other Study Supplies 
Other study supplies include 
 Schirmer’s test strips, tear 
meniscometry strips, sodium fluorescein, lissamine green, 
 
tear osmolarity cards, 
 
 
8 STUDY METHODS AND PROCEDURES 
 Subject Entry Procedures 
8.1.1 Overview 
Subjects as defined by the criteria in sections 5.2 and 5.3 will be considered for entry 
into this study. 
8.1.2 Informed Consent 
Prior to a subject’s participation in the study (i.e., changes in a subject’s medical 
treatment and/or study related procedures), the study will be discussed with each 
subject, and subjects wishing to participate must give written informed consent using 
an ICF. The ICF must be the most recent version that has received approval/favorable 
review by a properly constituted Institutional Review Board (IRB). 
8.1.3 Washout Intervals 
Prohibited medications, treatments, and activities are outlined in the exclusion criteria 
(Section 5.4). 
8.1.4 Procedures for Final Study Entry 
Subjects must meet all inclusion and none of the exclusion criteria (Section 5.3 and 
5.4). 
8.1.5 Methods for Assignment to Treatment Groups: 
Before the initiation of study run-in at Visit 1, each subject who provides written 
informed consent will be assigned a screening number. All screening numbers will be 
assingned in strict numerical sequence at a site and no numbers will skipped or 
omitted. Each subject who meets all the inclusion and none of the exclusion criteria at 
Visit 1 and Visit 2 will be assigned a randomization number at the end of Visit 2. The 
Interactive Web Response System (IWRS) will be used to assign all randomization 
numbers. 


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For the non-Japanese subjects, randomization will be further stratified by the 
following factors and cut-offs:  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Randomization and kit numbers will be assigned automatically to each subject as they 
are entered into the IWRS.  
The site staff will dispense kit(s) required until the next visit. Both the randomization 
number and the dispensed study drug kit number(s) will be recorded on the subject’s 
source document and electronic case report form (eCRF). Subjects, Sponsor, CRO, 
and site personnel will be masked to treatment assignment. To ensure masking, a 
dedicated unmasked staff member/technician will be delegated to dispense and 
observe instillation of randomized study drug and collect randomized study drug from 
a subject for drug accountability. This person cannot perform any other study-related 
procedures. 
 Concurrent Therapies 
The use of any concurrent medication, prescription or OTC, is to be recorded on the 
subject’s source document and corresponding eCRF along with the reason the 
medication was taken. 
Concurrent enrollment in another investigational drug or medical device study is not 
permitted. 
8.2.1 Prohibited Medications/Treatments 
Disallowed medications/treatments during the study are outlined in the Exclusion 
Criteria (Section 5.4).  
8.2.2 Escape Medications 
No escape medications are required for this study. 
8.2.3 Special Diet or Activities 
No special diets or activities are required for this study. 
 Examination Procedures 
8.3.1 Procedures to be Performed at Each Study Visit with Regard to Study 
Objectives 
Procedures listed below should be performed in the given order. See Appendix 1 for 
the Schedule of Visits and Measurements Appendix 2 for details on methodologies 
and grading systems. 


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8.3.2 Visit 1: Day –14 ± 2 – CAE Screening  
All subjects will undergo the following screening assessments: 
  
 Informed Consent/HIPAA  
 
 
 
 
 
 
 
 
 
  
 Ora Calibra® Ocular Discomfort Scale  
 Ora Calibra® Ocular Discomfort & 4-Symptom Questionnaire  
 OSDI© Questionnaire 
 Visual Analog Scale (VAS) 
 
 
 
  
 Conjunctival Redness 
 TFBUT 
 Fluorescein Staining  
 Lissamine Green Staining  
 At least 15-minute wait between lissamine green staining and Schirmer’s test 
 Schirmer’s test 
 
 
 
 
 
 
 
 
 
 Ora Calibra® Ocular Discomfort Scale  
 Ora Calibra® Ocular Discomfort & 4-Symptom Questionnaire  
 Visual Analog Scale (VAS) 
 
 
 Conjunctival Redness 
 TFBUT 
 Fluorescein Staining 
 Lissamine Green Staining 


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 Dispensation of run-in (Vehicle) for 
 dosing until Visit 2 
 
 
 
 
 
 
 
 
 
 
 
 Subject Instructions Dispensation 
 
 
 
 
 
 
 AE Query 
 Subjects will be scheduled for Visit 2. 
8.3.3 Visit 2: Day 1 – CAE Confirmation and Baseline 
  
 Run-in Collection 
 
 
 Medical/medication history update 
 AE query 
 
 
 Ora Calibra® Ocular Discomfort Scale  
 Ora Calibra® Ocular Discomfort & 4-Symptom Questionnaire  
 OSDI© Questionnaire 
 Visual Analog Scale (VAS) 
 
 
 
  
 Conjunctival Redness 
 Blink Rate 
 Tear Osmolarity 
 
 
 TFBUT 


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 Fluorescein Staining  
 Lissamine Green Staining  
 At least 15-minute wait between lissamine green staining and Schirmer’s test 
 Schirmer’s test 
 
 
 
 
 
 
 
 
 
 Ora Calibra® Ocular Discomfort Scale  
 Ora Calibra® Ocular Discomfort & 4-Symptom Questionnaire  
 Visual Analog Scale (VAS) 
 
 
 
 
 Conjunctival Redness 
 TFBUT 
 Fluorescein Staining 
 Lissamine Green Staining 
 
  
 Randomization  
 Study Drug Kit Dispensation: All subjects having a positive response and 
meeting all other screening eligibility criteria at the end of Visit 2 will be 
randomized to one of four treatment groups utilizing the IWRS system. 
Subjects will receive their assigned study drug kit with sufficient supply to last 
until Visit 3.  
 
 
  
 
 
 
 
 
 
 Subject Instructions Dispensation  
 
 
 
 
 
 


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 AE Query 
 Subjects will be scheduled for Visit 3. 
8.3.4 Visit 3: Day 8 ±1  
 Study Drug Collection by unmasked staff member 
 Medical/medication history update 
 AE Query 
 Ora Calibra® Ocular Discomfort Scale  
 Ora Calibra® Ocular Discomfort & 4-Symptom Questionnaire  
 OSDI© Questionnaire 
 Visual Analog Scale (VAS) 
 
 
 
  
 Conjunctival Redness 
 Blink Rate 
 Tear Osmolarity 
 TFBUT 
 Fluorescein Staining  
 Lissamine Green Staining  
 At least 15-minute wait between lissamine green staining and Schirmer’s test 
 Schirmer’s Test 
 Study Drug Kit Dispensation: Prior to discharge from the study site on Visit 3, 
subjects will be assigned a new study drug kit via the IWRS system for at-
home dosing up to Visit 4. 
 Subject Instructions Dispensation  
 
 
 
 
 
 


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8.3.5 Visit 4: Day 15 ± 2  
 
 Study Drug Collection by unmasked staff member 
 Medical/medication history update 
 AE query 
 Ora Calibra® Ocular Discomfort Scale  
 Ora Calibra® Ocular Discomfort & 4-Symptom Questionnaire  
 OSDI© Questionnaire 
 Visual Analog Scale (VAS) 
 
 
 
  
 Conjunctival Redness 
 Blink Rate 
 Tear Osmolarity 
 TFBUT 


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 Fluorescein Staining  
 Lissamine Green Staining  
 At least 15-minute wait between lissamine green staining and Schirmer’s test 
 Schirmer’s Test 
 
 
 
 
 
 
 
 
 
 Ora Calibra® Ocular Discomfort Scale  
 Ora Calibra® Ocular Discomfort & 4-Symptom Questionnaire  
 Visual Analog Scale (VAS) 
 
 
 Conjunctival Redness 
 TFBUT 
 Fluorescein Staining 
 Lissamine Green Staining 
 Study Drug Kit Dispensation: Prior to discharge from the study site on Visit 4, 
subjects will be assigned a new study drug kit via the IWRS system for at-
home dosing up to Visit 5. 
 Subject Instructions Dispensation  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 


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 AE Query 
 Subjects will be scheduled for Visit 5. 
8.3.6 Visit 5: Day 29 ± 2 
 
 Study Drug Collection by unmasked staff member 
 Medical/medication history update 
 AE query 
 
 
 
  
 Ora Calibra® Ocular Discomfort Scale  
 Ora Calibra® Ocular Discomfort & 4-Symptom Questionnaire  
 OSDI© Questionnaire 
 Visual Analog Scale (VAS) 
 
 
 
  
 Conjunctival Redness 
 Blink Rate 
 Tear Osmolarity 
 
 
 TFBUT 
 Fluorescein Staining  
 Lissamine Green Staining  
 At least 15-minute wait between lissamine green staining and Schirmer’s test 
 Schirmer’s Test 
 
 
 
 
 
 
 
 
 
 Ora Calibra® Ocular Discomfort Scale  
 Ora Calibra® Ocular Discomfort & 4-Symptom Questionnaire  
 Visual Analog Scale (VAS) 
 
 
 
 


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 Conjunctival Redness 
 TFBUT 
 Fluorescein Staining 
 Lissamine Green Staining 
 
 
 
 
 
 
 AE Query 
8.3.7 Follow-up phone call Day 36 ± 2 
 Follow-up phone call (about 7 days after the final day of randomized study 
drug treatment) 
 AE query 
 Study exit 
 
Early Termination/Discontinuation  
If a subject is discontinued from the study prior to Visit 5 (Day 29 ± 2), then all safety 
evaluations and 
 evaluations for Visit 5 (Day 29 ± 2) should be performed 
on the day of discontinuation (early termination) or at the discretion of the 
investigator.  
AEs (both elicited and observed) and SAEs will be monitored throughout the study. 
The investigator will promptly review all AEs (both elicited and observed) for 
accuracy and completeness. All AEs will be documented on the appropriate source 
document and case report form. 
 
 
 
 
 
 
 
 Schedule of Visits, Measurements and Dosing 
8.4.1 Scheduled Visits 
Refer to Appendix 1 for a schedule of visits and measurements. 
8.4.2 Unscheduled Visits 
These visits may be performed in order to ensure subject safety. All procedures 
performed at an unscheduled visit will be recorded in the source documents and on 
the Unscheduled Visit eCRF pages. Any procedure indicated in the eCRF that is not 
performed should be indicated as “Not done.” 
Evaluations that may be conducted at an Unscheduled Visit include: 
 
 


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 Assessment of AEs 
 
 
 
 
 Compliance with Protocol 
Subjects will be given written instructions; instructed on proper instillation; and 
instructed on proper storage of the IP at the end of Visits 1, 2, 3, and 4. The subject 
used/unused 
 will be collected at each visit from Visit 2 up to and 
including Visit 5 to assess dosing compliance. Dosing compliance will be based on 
 If the subject is less than 80% or more than 125% compliant 
with dosing based on 
, then the subject will be 
deemed non-compliant and a dosing deviation should be recorded in the source 
document. The investigator will use these guidelines to determine subject study 
compliance and deviation compliance.  
 Subject Disposition 
8.6.1 Completed Subjects 
A completed subject is one who has not been discontinued from the study. 
8.6.2 Discontinued Subjects 
Subjects may be discontinued prior to their completion of the study due to: 
 subject request/withdrawal 
 AEs 
 protocol violations 
 administrative reasons (e.g., inability to continue, lost to follow up) 
 sponsor termination of study 
 other 
Note: In addition, any subject may be discontinued for any sound medical reason. 
Notification of a subject discontinuation and the reason for discontinuation will be 
reported to 
 and/or the Sponsor and clearly documented on the electronic case 
report form (eCRF). 
 Study Termination 
The study may be stopped at any time by the investigator, Sponsor, and/or 
 with 
prior notification. 


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 Study Duration 
An individual subject’s participation will involve 5 visits over approximately a 6-
week (~42 days) period (14 days pre-screening, 28 days of treatment) and a follow-up 
phone call. 
 Monitoring and Quality Assurance 
During the course of the study, an 
 monitor, or designee, will make routine site 
visits to review protocol compliance, assess IP accountability, and ensure the study is 
being conducted according to the pertinent regulatory requirements. The review of the 
subjects’ medical records will be performed in a manner that adequately maintains 
subject confidentiality. Further details of the study monitoring will be outlined in a 
monitoring plan. 
Regulatory authorities of domestic and foreign agencies, quality assurance (QA) and 
or its designees may carry out on-site inspections and/or audits which may include 
source data checks. Therefore, direct access to the original source data will be 
required for inspections and/or audits. All inspections and audits will be carried out 
giving consideration to data protection as well as subject confidentiality to the extent 
that local, state, and federal laws apply. 
9 ADVERSE EVENTS 
 Adverse Event 
An AE is defined as any untoward medical occurrence associated with the use of an 
IP in humans, whether or not considered IP-related. An AE can be any unfavorable 
and unintended sign (e.g., an abnormal laboratory finding), symptom, or disease 
temporally associated with the use of an IP, without any judgment about causality. An 
AE can arise from any use of the IP (e.g., off-label use, use in combination with 
another drug or medical device) and from any route of administration, formulation, or 
dose, including an overdose. An AE can arise from any delivery, implantation, or use 
of a medical device, including medical device failure, subject characteristics that may 
impact medical device performance (e.g., anatomical limitations), and therapeutic 
parameters (e.g., energy applied, sizing, dose release, and anatomic fit) associated 
with medical device use. 
All AEs spontaneously reported by the subject and/or in response to an open question 
from study personnel or revealed by observation, physical examination or other 
diagnostic procedures will be recorded in the source document and on the appropriate 
pages of the CRF. Any clinically relevant deterioration in clinical finding is 
considered an AE and must be recorded. When possible, signs and symptoms 
indicating a common underlying pathology will be noted as one comprehensive event. 
Documentation regarding the AE will include the nature, date of onset, end date, 
severity, relationship to IP, action(s) taken, seriousness, and outcome of any sign or 
symptom observed by the investigator or reported by the subject upon indirect 
questioning. Exacerbation of conditions related to the signs and symptoms of DED 
will not be reported as an AE. 


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9.1.1 Severity 
Severity of an AE is defined as a qualitative assessment of the degree of intensity of 
an AE as determined by the investigator or reported by the subject. The assessment of 
severity is made irrespective of relationship to the IP or seriousness of the event and 
will be evaluated according to the following scale: 
 Mild: Event is noticeable to the subject, but is easily tolerated and does not 
interfere with the subject’s daily activities. 
 Moderate: Event is bothersome, possibly requiring additional therapy, and 
may interfere with the subject’s daily activities. 
 Severe: Event is intolerable, necessitates additional therapy or alteration of 
therapy, and interferes with the subject’s daily activities. 
9.1.2 Relationship to Investigational Product 
The relationship of each AE to the IP will be determined by the investigator using 
these explanations: 
 Related: A reasonable possibility exists that the IP caused the AE. A related 
AE can be further defined as follows: 
 Occurs within a reasonable temporal sequence to administration of study 
drug  
 Cannot be explained by concurrent disease or other drugs or chemicals  
 Improves or disappears on stopping or reducing study drug (de-challenge)  
 Reappears on repeated exposure to study drug (re-challenge)  
 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 
 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 IP caused the AE. 
A not related AE can be further defined as follows: 
 Occurs with a temporal relationship to administration of study drug which 
makes a causal relationship improbable 
 Other drugs, chemicals or underlying disease provide plausible 
explanations of causality 
 Is known to be associated with the participant’s clinical condition, or with 
other medication taken by the participant 
Suspected adverse reaction means any AE for which there is a reasonable possibility 
that the IP caused the AE. “Reasonable possibility” means there is evidence to suggest 
a causal relationship between the IP and the AE. Types of evidence that would 
suggest a causal relationship between the IP and the AE event include: a single 
occurrence of an event that is uncommon and known to be strongly associated with IP 
exposure (e.g., angioedema, hepatic injury, Stevens-Johnson Syndrome); one or more 
occurrences of an event that is not commonly associated with IP exposure, but is 
otherwise uncommon in the population exposed to the IP (e.g., tendon rupture); an 


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aggregate analysis of specific events observed in a clinical trial (such as known 
consequences of the underlying disease or condition under investigation or other 
events that commonly occur in the study population independent of drug therapy) that 
indicates those events occur more frequently in the IP-treatment group than in a 
concurrent or historical control group. 
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. 
9.1.3 Expectedness 
The expectedness of an AE should be determined based upon existing safety 
information about the IP using these explanations: 
 Unexpected: An AE that is not listed in the Investigator’s Brochure (IB) or is 
not listed at the specificity or severity that has been observed. 
 Expected: An AE that is listed in the IB at the specificity and severity that has 
been observed. 
 Not applicable: An AE unrelated to the IP. 
AEs that are mentioned in the IB as occurring with a class of products or as 
anticipated from the pharmacological/mechanical (or other) properties of the product, 
but are not specifically mentioned as occurring with the particular product under 
investigation are to be considered unexpected. 
The investigator will initially classify the expectedness of an AE, but the final 
classification is subject to the Medical Monitor’s determination. 
 Serious Adverse Events 
An AE is considered serious if, in the view of either the investigator or Sponsor, it 
results in any of the following outcomes: 
 Death; 
 Is life-threatening; 
Note: An AE is considered “life-threatening” if, in the view of either the 
investigator or sponsor, its occurrence places the subject at immediate risk of 
death. It does not include an AE that, had it occurred in a more severe form, 
might have caused death. 
 Inpatient hospitalization or prolongation of existing hospitalization; 
Note: The term “inpatient hospitalization” refers to any inpatient admission 
(even if less than 24 hours), unless the inpatient admission was pre-planned 
prior to the signing of the informed consent. For chronic or long-term 
inpatients, inpatient admission includes transfer within the hospital to an 
acute/intensive care inpatient unit. Inpatient hospitalization does not include: 
emergency room visits; outpatient/same-day/ambulatory procedures; 
observation/short stay units; rehabilitation facilities; hospice facilities; nursing 
homes; or clinical research/phase 1 units. 
Note: The term “prolongation of existing hospitalization” refers to any 
extension of an inpatient hospitalization beyond the stay anticipated or 


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required for the reason for the initial admission as determined by the 
investigator or treating physician. 
 A persistent or significant incapacity or substantial disruption of the ability to 
conduct normal life functions; 
Note: A serious adverse event (SAE) specifically related to visual threat would 
be interpreted as any potential impairment or damage to the subject’s eyes 
(e.g., hemorrhage, retinal detachment, central corneal ulcer or damage to the 
optic nerve). 
 A congenital anomaly/birth defect. 
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 subject and may require 
medical or surgical intervention to prevent one of the outcomes listed in this 
definition. 
 Procedures for Reporting Serious Adverse Events 
All SAEs and their outcomes, regardless of causality or expectedness, must be 
reported to 
 and the Sponsor as required by the IRB/Independent Ethics 
Committee(IEC), federal, state, or local regulations and governing health authorities 
and recorded on the appropriate CRF. Adverse events will be collected from the time 
of the signing of the ICF until the follow-up phone call (about 7 days after the final 
day of randomized study drug treatment). 
9.3.1 Reporting a Serious Unexpected Suspected Adverse Reaction 
All SAEs that are both ‘suspected’ and ‘unexpected’ are also to be reported to the 
IRB/IEC and the regulatory authorities as required by the IRB/IEC, federal, state, or 
local regulations and governing health authorities. 
9.3.2 Reporting a Serious Adverse Event 
To ensure subject safety, all SAEs, regardless of relationship to the IP, must be 
immediately reported. All information relevant to the SAE must be recorded on the 
appropriate CRFs. The investigator is obligated to pursue and obtain information 
requested by 
 and/or the Sponsor in addition to that information reported on the 
CRF. All subjects experiencing a SAE must be followed up and the outcome reported. 
In the event of a SAE, the investigator will notify 
 and the Sponsor immediately 
using the contact information below; obtain and maintain all pertinent medical 
records, information, and medical judgments from colleagues who assisted in the 
treatment and follow-up of the subject; provide 
 and the Sponsor a complete case 
history, which includes a statement as to whether the event was or was not suspected 
to be related to the use of the IP; and inform the IRB/IEC of the SAE within their 
guidelines for reporting SAEs. 
 
 


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Contact information for reporting SAEs: 
 Procedures for Unmasking (if applicable) 
All subjects, investigators, and study personnel involved with the conduct of the study 
will be masked with regard to treatment assignments. When medically necessary, the 
investigator may need to determine what treatment group has been assigned to a 
subject. When possible (i.e., in non-emergent situations), 
 and/or the Sponsor will 
be notified before unmasking the investigator. 
 and/or the Sponsor must be 
informed immediately about any unmasking event. 
If the investigator identifies a medical need that requires unmasking the treatment 
assignment of a subject, 
 and/or the medical monitor will be contacted prior to 
unmasking the identity of the IP, if possible. 
 will ask the staff to complete and 
send them the Unmasking Request Form. 
 will notify the Sponsor and jointly 
determine if the unmasking request should be granted. In addition, they may consult 
the medical monitor as needed. The result of the request will be documented on the 
Unmasking Request Form. If approval is granted to unmask a subject, written 
permission will be provided on the Unmasking Request Form. The investigator will 
unmask the subject using the interactive web response system (IWRS), complete the 
Unmasking Memo form, include it in the subject’s study file and make a copy for the 
trial master file (TMF). For each unmasked request, the reason, date, signature, and 
name of the person unmasking the subject must be noted in the subject’s study file.  
Unmasked subjects will be discontinued from the study and followed for safety 
monitoring, until resolution of the AE or study completion, whichever occurs last. 
 Type and Duration of the Follow-up of Subjects after Adverse 
Events 
The investigator will follow unresolved AEs to resolution until the subject is lost to 
follow-up, or until the AE is otherwise classified. Resolution means the subject has 
returned to baseline state of health or the investigator does not expect any further 


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improvement or worsening of the AE. If the subject is lost to follow-up, the 
investigator will make 3 reasonable attempts to contact the subject via telephone, 
USPS, or certified mail. All follow-up will be documented in the subject’s source 
document. Non-serious AEs identified during the last scheduled contact must be 
recorded on the AE eCRF with the status noted.  
If the investigator becomes aware of any new information regarding an existing SAE 
(i.e., resolution, change in condition, or new treatment), a new SAE/Unanticipated 
Report Form must be completed and faxed to 
 within 24 hours of the site’s 
awareness of the new information. The original SAE form is not to be altered. The 
report will include a description of the event, treatment, and whether it was resolved 
or continues. 
10 STATISTICAL HYPOTHESES AND METHODS OF 
ANALYSES 
 Analysis Populations 
The following analysis populations will be considered: 
 Intent-to-Treat Population – The intent-to-treat (ITT) population includes all 
randomized subjects. Subjects in the ITT population will be analyzed as 
randomized. 
 Per-Protocol Population – The per-protocol (PP) population includes subjects 
in the ITT population who do not have significant protocol deviations and who 
complete the study. Protocol deviations will be assessed prior to database lock 
and unmasking. Subjects in the PP population will be analyzed as treated. 
 Safety Population – The safety population includes all randomized subjects 
who have received at least one dose of the investigational product. Subjects in 
the Safety population will be analyzed as treated.  
The statistical analysis of safety data will be performed for the safety population. 
The analysis of efficacy data will be performed for the ITT population and on the 
PP population as sensitivity analyses. 
 Statistical Hypotheses 
The following primary hypotheses will be tested against their respective two-sided 
alternative hypotheses in the order: 
H01:  There is no difference in the change from baseline in the post-CAE inferior 
corneal staining score after 28 days of treatment of 
 K-161 
 compared to 
vehicle.   
H02:  There is no difference in the change from baseline in the post-CAE ocular 
discomfort score after 28 days of treatment of 
 K-161 
 compared to vehicle.   
Upon rejecting both H01 and H02, the secondary hypotheses will be tested as detailed 
in Section 10.4.4 in the following order  
H03:  There is no difference in the change from baseline in the pre-CAE Schirmer’s 
test value after 28 days of treatment of 
 K-161 
 compared to vehicle. 
H04:  There is no difference in the change from baseline in the post-CAE TFBUT 
after 28 days of treatment of 
 K-161 
 compared to vehicle. 


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These four hypotheses will be tested hierarchically, each at the alpha = 0.05 level to 
maintain a study-wise Type I error rate at 0.05. 
 Sample Size  
This study is expected to enroll 240 subjects in a 1:1:1:1 ratio across four treatment 
arms, or 60 subjects per treatment arm. In addition, randomization will be stratified 
such that 
 will be randomized in each treatment arm.  
The standard deviation (SD) for change from baseline in post-CAE inferior corneal 
fluorescein staining ranges between 0.68 and 0.81 units. Assuming a common SD of 
0.77, a sample size of 60 subjects per group will have approximately 90% power to 
detect a difference of 0.46 units between the active treatment group and the vehicle 
group using a two-sample t-test at a two-sided significance level of 0.05. Again, it is 
assumed that adjusting for baseline and site will further reduce variability and provide 
>90% power. 
Likewise, the SD for change from baseline scores in the post-CAE ODS at Day 29 is 
assumed a common SD of 0.82, a sample size of 60 subjects per group will have 
approximately 90% power to detect a difference of 0.49 units between the active 
treatment group and the vehicle group using a two-sample t-test at a two-sided 
significance level of 0.05. It is assumed that adjusting for baseline and site will further 
reduce variability and provide >90% power. 
 Statistical Analysis 
10.4.1 General Considerations 
Quantitative variables will be summarized descriptively using number of subjects (n), 
mean, SD, median, minimum, and maximum. Qualitative variables will be 
summarized using counts and percentages. 
All summaries will be presented by treatment group. Summaries will be provided for 
demographics, baseline medical history, concurrent therapies, and subject disposition. 
For the purpose of summarization, medical history, concurrent therapies, and AEs will 
be coded using the MedDRA and WHO drug dictionaries, as appropriate.  
Change from pre-CAE to post-CAE will be calculated as post-CAE value minus pre-
CAE value. Baseline measures are defined as the last non-missing measure prior to 
the initiation of randomized study treatment. Change from baseline will be calculated 
as follow-up visit value minus baseline value. Treatment comparisons between active 
and vehicle will be calculated as active minus vehicle. 
All analyses will be 2-sided at a significance level of 0.05 unless otherwise specified. 
For all efficacy analyses, 95% confidence intervals on the difference between each 
dose of K-161 and vehicle will be provided. 
10.4.2 Unit of Analysis 
Safety endpoints will be analyzed for both eyes. For efficacy endpoints, the unit of 
analysis will be the study eye, or the “worst eye,” as defined by the following:  
Worst Eye: Eyes are eligible for analysis if they meet all of the inclusion criteria. At 
least one eye (the right eye or the left eye) must meet all of the criterial. In the case 
that both eyes are eligible for analysis, the worst eye will be selected as the eye with 
the worst post-CAE inferior corneal staining at Visit 2. If the post-CAE inferior 


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corneal staining at Visit 2 is the same in both eyes then the eye with the worst post-
CAE ODS at Visit 2 will be worst eye. If the post-CAE inferior corneal staining and 
ocular discomfort are the same in both eyes then the right eye will be selected as the 
worst eye. 
10.4.3 Missing Data 
Missing data will be imputed using multiple imputation with a control-based pattern 
mixture model on the ITT population for the primary analyses, the important secondary, 
other secondary, and exploratory comparisons.   
Sensitivity analyses of the primary analyses and important secondary comparisons will 
include the following in order to provide a robust understanding of the impact of 
missing and spurious data:  
 Using complete case data (i.e. observed data only) on the ITT population 
 Using last observation carried forward (LOCF) on the ITT population 
 Multiple imputation under missing at random assumption with Markov Chain 
Monte Carlo (MCMC) techniques on the ITT population 
 Using complete case data on the PP population.  
No imputation will be used for safety endpoints. 
10.4.4 Multiplicity Consideration 
Common factors for multiplicity are multiple arms and multiple endpoints. 
1) Multiple arms 
The primary treatment comparison will be between the 
 K-161 
 treatment arm 
and the vehicle
 treatment arm. 
 
  
2) Multiple endpoints 
The primary and important secondary endpoints will be tested hierarchically to 
maintain the study-wise Type I error rate of 0.05. First, change from baseline in inferior 
corneal fluorescein staining will be tested at an alpha level of 0.05. The test for change 
from baseline scores in the ODS will be conducted at an alpha level of 0.05 only if the 
previous test demonstrates significance. The test for change from baseline in Schirmer’s 
test will be conducted at an alpha level of 0.05 only if the previous test demonstrates 
significance. The test for change from baseline in TFBUT will be conducted at an alpha 
level of 0.05 only if the previous test demonstrates significance. 
 
 
The hierarchical testing order will be as follows: 
Primary comparisons: 
1. Comparison of the change from baseline in post-CAE inferior corneal staining 
at Day 29 (
 K-161 
 vs vehicle) 
2. Comparison of the change from baseline in post-CAE ocular discomfort at Day 
29 (
 K-161 
 vs vehicle) 
Important Secondary comparisons: 
3. Comparison of the change from baseline in pre-CAE Schirmer’s test value at 
Day 29 (
 K-161 
 vs vehicle) 


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4. Comparison of the change from baseline in post-CAE TFBUT at Day 29 (
 
K-161 
 vs vehicle) 
Thus, the study-wise Type I error rate will be maintained at 0.05 by considering only 
one dose of K-161 as the primary treatment comparison and using a hierarchical testing 
procedure. 
10.4.5 Efficacy Analyses 
Primary Efficacy Analyses 
The primary comparisons of change from baseline in post-CAE inferior corneal 
staining and ocular discomfort between the 
 K-161 
 group and the vehicle 
group at Day 29, will be performed using analysis of covariance (ANCOVA) models. 
The respective baseline post-CAE score will be included as a covariate in each model 
and site will be included as a fixed effect. Treatment by baseline and treatment by site 
interactions will be explored in separate models and, if significant, analyses will be 
performed by baseline stratification and/or site, respectively, to further examine 
significant interactions. The primary analyses will use the ITT population. 
For the primary endpoints, multiple imputation with MCMC techniques will be used. 
Imputation will be performed by treatment arm with imputation terms for baseline and 
Day 29 scores. 
Secondary Efficacy Analyses 
Secondary and exploratory endpoints will be analyzed similarly to the primary 
analyses on the ITT population. Continuous and ordinal variables collected at each 
visit will be summarized descriptively (n, mean, standard deviation, median, 
minimum and maximum), and analyzed with ANCOVA models comparing each K-
161 group to the vehicle group. All visit-based data will be analyzed by visit and for 
each timepoint, if applicable, as well as the change from baseline.  
Data collected pre- and post-CAE will also be analyzed for the change from pre- to 
post-CAE within each visit. Data collected during the CAE will also be analyzed 
using repeated measures models including all of the time points from a CAE 
exposure.  
For the two important secondary endpoints, other secondary, and exploratory 
endpoints, multiple imputation with MCMC techniques will be used. Imputation will 
be performed by treatment arm with imputation terms for baseline and Day 29 scores. 
 
 
 
 
10.4.6 Safety Variables 
Adverse events will be coded using the MedDRA dictionary. Frequencies and 
percentages of subjects with treatment-emergent adverse events (TEAEs), serious 
TEAEs, and TEAEs causing premature 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 will be given of subjects 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 


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treatment-related TEAEs; and by system organ class, preferred term, and study day of 
onset. Separate summaries will be performed for ocular and non-ocular AEs.  
 
 
 
 
 
 
10.4.7 
 
 
 
 
10.4.8 
 
 
 
 
 
 
Other analyses may be conducted and the details will be included in a separate 
statistical analysis plan. 
10.4.9 
 
 
 
 
10.4.10 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
10.4.11 Interim Analyses 
There will be no interim analyses in this study. 


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11 COMPLIANCE WITH GOOD CLINICAL PRACTICES, 
ETHICAL CONSIDERATIONS, AND ADMINISTRATIVE 
ISSUES 
This study will be conducted in compliance with the protocol, current versions of the 
FDA Good Clinical Practice (GCP) regulations, the International Council for the 
Harmonisation of Technical Requirements for Human Use (ICH) GCP guidance, and 
in general, consistent with the Declaration of Helsinki. In addition, all applicable 
local, state, and federal requirements relevant to the use of IP will be met. 
 Protection of Human Subjects 
11.1.1 Subject Informed Consent 
Informed consent/assent must take place before any study specific procedures are 
initiated. Signed and dated written informed consent must be obtained from each 
subject and/or from the subject’s parent or legal guardian prior to enrollment into the 
study. The subject must also be given a copy of the signed ICF. 
All informed consent forms must be approved for use by the Sponsor and receive 
approval/favorable opinion from an IRB/IEC 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 
 prior to submission to the governing IRB/IEC and that it is read, signed and dated 
by all subjects currently and subsequently enrolled in the study. 
If informed consent is taken under special circumstances (oral informed consent), then 
the procedures to be followed must be determined by 
 and/or the Sponsor and 
provided in writing by 
 and/or the Sponsor prior to the consent process. 
11.1.2 Institutional Review Board (IRB) Approval 
This study is to be conducted in accordance with IRB/IEC regulations (e.g., US FDA 
21 Code of Federal Regulations Part 56.103). The PI must obtain appropriate 
IRB/IEC approval before initiating the study and re-approval at least annually. 
Only an IRB/IEC approved version of the ICF will be used. 
 Ethical Conduct of the Study 
This study will be conducted in accordance with the ethical principles that originated 
with the Declaration of Helsinki. 
 Subject Confidentiality 
All personal study subject data collected and processed for the purposes of this study 
will be maintained by the PI and site staff with adequate precautions as to ensure that 
the confidentiality of the data is in accordance with local, state, and federal laws and 
regulations. 
Monitors, auditors and other authorized representatives of 
 the Sponsor, the 
IRB/IEC approving this study, the FDA, the Department of Health and Human 
Services, other domestic government agencies, and other foreign regulatory agencies 
will be granted direct access to the subject’s original medical and study records for 
verification of the data and/or clinical study procedures. Access to this information 
will be permitted to the aforementioned individuals to the extent permitted by law. 


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A report of the results of this study may be published or sent to the appropriate health 
authorities in any country in which the IP may ultimately be marketed, but the 
subject’s identity will not be disclosed in these documents. 
 Documentation 
Source documents may include a subject’s medical records, hospital charts, clinic 
charts, the study subject files, as well as the results of diagnostic tests such as X-rays, 
laboratory tests, and electrocardiograms. The site’s copy of the CRFs serves as the 
PI’s record of a subject’s study-related data. 
11.4.1 Retention of Documentation 
All study related correspondence, subject records, consent forms, record of the 
distribution and use of all IP, and copies of CRFs must be maintained on file for at 
least two years after the last approval of a marketing application in an ICH region and 
until there are no pending or contemplated marketing applications in an ICH region; 
or until at least two years have elapsed since the formal discontinuation of clinical 
development of the IP. These documents will be retained for a longer period if 
required by the applicable regulatory requirements or by an agreement with the 
Sponsor. It is the responsibility of the Sponsor to inform the PI when these documents 
no longer need to be retained. 
If the PI retires, relocates, or for other reasons withdraws from the responsibility of 
keeping study records, the custody of site study data must be transferred to a person 
who will accept the responsibility. The Sponsor must be notified in writing of the 
name and address of the new custodian. 
 Recording of Data on Source Documents and Case Reports 
Forms (CRFs) 
The PI is responsible for ensuring that study data is completely and accurately 
recorded on each subject’s CRF, source document, and all study-related material. All 
study data should also be attributable, legible, contemporaneous, accurate, complete, 
and original. Recorded data must only be corrected in a manner that does not 
obliterate, destroy, or render illegible the previous entry (e.g., by drawing a single line 
through the incorrect entry and writing the revision next to the corrected data. The  
individual correcting the entry must initial and date it.   
Data entries for all randomized subjects will use software that conforms to 21 CFR 
Part 11 requirements, and will be performed only by staff who have access and have 
been trained on the system. Screen failure data will also be entered in the eCRF. An 
audit trail will be maintained within the electronic system to capture all changes made 
within the eCRF database. After the end of the study and database lock, compact discs 
(CDs) containing copies of all applicable subjects’ eCRFs will be provided to each 
investigator site to be maintained on file by the PI. 
 Publications 
All data derived from the study will be the property of the Sponsor and must be kept 
strictly confidential. The investigator must not submit any of the data from this study 
for publication without prior consent of the Sponsor. The Sponsor will have the final 
decision regarding any manuscript and publication. 
 


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12 REFERENCES 
Bron, A. J., C. S. de Paiva, S. K. Chauhan, S. Bonini, E. E. Gabison, S. Jain, E. Knop, 
M. Markoulli, Y. Ogawa, V. Perez, Y. Uchino, N. Yokoi, D. Zoukhri and D. A. 
Sullivan (2017). "TFOS DEWS II pathophysiology report." Ocul Surf 15(3): 438-510. 
CEQUA (2018). "CEQUA (cyclosporine ophthalmic solution) 0.9% [drug label]. Sun 
Pharmaceuticals." 
Kudlacz, E., M. Conklyn, C. Andresen, C. Whitney-Pickett and P. Changelian (2008). 
"The JAK-3 inhibitor CP-690550 is a potent anti-inflammatory agent in a murine 
model of pulmonary eosinophilia." Eur J Pharmacol 582(1-3): 154-161. 
Mah, F., M. Milner, S. Yiu, E. Donnenfeld, T. M. Conway and D. A. Hollander 
(2012). "PERSIST: Physician's Evaluation of Restasis((R)) Satisfaction in Second 
Trial of topical cyclosporine ophthalmic emulsion 0.05% for dry eye: a retrospective 
review." Clin Ophthalmol 6: 1971-1976. 
 
 
 
 
 
 
 
Schaumberg, D. A., R. Dana, J. E. Buring and D. A. Sullivan (2009). "Prevalence of 
dry eye disease among US men: estimates from the Physicians' Health Studies." Arch 
Ophthalmol 127(6): 763-768. 
Schaumberg, D. A., D. A. Sullivan, J. E. Buring and M. R. Dana (2003). "Prevalence 
of dry eye syndrome among US women." Am J Ophthalmol 136(2): 318-326. 
Schaumberg, D. A., D. A. Sullivan and M. R. Dana (2002). "Epidemiology of dry eye 
syndrome." Adv Exp Med Biol 506(Pt B): 989-998. 
Stevenson, W., Z. Sadrai, J. Hua, S. Kodati, J. F. Huang, S. K. Chauhan and R. Dana 
(2014). "Effects of topical Janus kinase inhibition on ocular surface inflammation and 
immunity." Cornea 33(2): 177-183. 
Tauber, J., P. Karpecki, R. Latkany, J. Luchs, J. Martel, K. Sall, A. Raychaudhuri, V. 
Smith, C. P. Semba and O.-. Investigators (2015). "Lifitegrast Ophthalmic Solution 
5.0% versus Placebo for Treatment of Dry Eye Disease: Results of the Randomized 
Phase III OPUS-2 Study." Ophthalmology 122(12): 2423-2431. 
 
 


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13 
APPENDICES 
APPENDIX 1: SCHEDULE OF VISITS AND MEASUREMENTS 
Procedure 
Visit 1 
Day -14 ± 2 
Visit 2 
Day 1 
Visit 3 
Day 8 
± 1 
Visit 4 
Day 15 ± 2 
Visit 5 
Day 29 ± 2 
Follow-up 
Phone Call 
(Day 36 ± 2) 
 
Pre  
CAE 
Post  
CAE 
Pre 
CAE 
Post 
CAE 
Non 
CAE 
Pre 
CAE 
Post 
CAE 
Pre 
CAE 
Post  
CAE 
 
Informed Consent / 
HIPAA 
X 
 
 
 
 
 
 
 
 
 
Medical / Medication 
History and 
Demographics 
X 
 
 
 
 
 
 
 
 
 
Medical / Medication 
Update 
 
 
X 
 
X 
X 
 
X 
 
 
Adverse Event Query 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Ora Calibra® Ocular 
Discomfort Scale 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
Ora Calibra® Ocular 
Discomfort & 4-Symptom 
Questionnaire 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
OSDI© Questionnaire 
X 
 
X 
 
X 
X 
 
X 
 
 
Visual Analog Scale 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
Conjunctival Redness 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
Tear Osmolarity 
 
 
X 
 
X 
X 
 
X 
 
 
TFBUT 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
Fluorescein Staining 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
Lissamine Green Staining 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
Schirmer’s Test 
X 
 
X 
 
X 
X 
 
X 
 
 
Blink Rate 
 
 
X 
 
X 
X 
 
X 
 
 


K-161 
Sponsor: Kowa Research Institute (KRI) 
Clinical Trial Protocol No.: K-161-2.01US 
Amendment 2 26Jul2019 
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Procedure 
Visit 1 
Day -14 ± 2 
Visit 2 
Day 1 
Visit 3 
Day 8 
± 1 
Visit 4 
Day 15 ± 2 
Visit 5 
Day 29 ± 2 
Follow-up 
Phone Call 
(Day 36 ± 2) 
 
Pre  
CAE 
Post  
CAE 
Pre 
CAE 
Post 
CAE 
Non 
CAE 
Pre 
CAE 
Post 
CAE 
Pre 
CAE 
Post  
CAE 
 
Vehicle Run-In 
Dispensation 
 
X 
 
 
 
 
 
 
 
 
Vehicle Run-In 
Instillation 
 
X 
 
 
 
 
 
 
 
 
Vehicle Run-in Collection 
 
 
X 
 
 
 
 
 
 
 
Randomization 
 
 
 
X 
 
 
 
 
 
 
Study Drug Dispensation 
 
 
 
X 
X 
 
X 
 
 
 
Study Drug Collection 
 
 
 
 
X 
X 
 
X 
 
 
Exit Subject from Study 
 
 
 
 
 
 
 
 
 
X 
   
 
 
 
 
 


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Sponsor: Kowa Research Institute (KRI) 
Clinical Trial Protocol No.: K-161-2.01US 
Amendment 2 26Jul2019 
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Sponsor: Kowa Research Institute (KRI) 
Clinical Trial Protocol No.: K-161-2.01US 
Amendment 2 26Jul2019 
Confidential 
 
 
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K-161 
Sponsor: Kowa Research Institute (KRI) 
Clinical Trial Protocol No.: K-161-2.01US 
Amendment 2 26Jul2019 
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Sponsor: Kowa Research Institute (KRI) 
Clinical Trial Protocol No.: K-161-2.01US 
Amendment 2 26Jul2019 
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Sponsor: Kowa Research Institute (KRI) 
Clinical Trial Protocol No.: K-161-2.01US 
Amendment 2 26Jul2019 
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Sponsor: Kowa Research Institute (KRI) 
Clinical Trial Protocol No.: K-161-2.01US 
Amendment 2 26Jul2019 
Confidential 
 
 
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Clinical Trial Protocol No.: K-161-2.01US 
Amendment 2 26Jul2019 
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K-161 
Sponsor: Kowa Research Institute (KRI) 
Clinical Trial Protocol No.: K-161-2.01US 
Amendment 2 26Jul2019 
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Sponsor: Kowa Research Institute (KRI) 
Clinical Trial Protocol No.: K-161-2.01US 
Amendment 2 26Jul2019 
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Sponsor: Kowa Research Institute (KRI) 
Clinical Trial Protocol No.: K-161-2.01US 
Amendment 2 26Jul2019 
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Clinical Trial Protocol No.: K-161-2.01US 
Amendment 2 26Jul2019 
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Clinical Trial Protocol No.: K-161-2.01US 
Amendment 2 26Jul2019 
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K-161 
Sponsor: Kowa Research Institute (KRI) 
Clinical Trial Protocol No.: K-161-2.01US 
Amendment 2 26Jul2019 
Confidential 
 
 
Page 71 
 
APPENDIX 3: PROTOCOL AMENDMENT SUMMARY 
Not Applicable. 




K-161 
Sponsor: Kowa Research Institute (KRI) 
Clinical Trial Protocol No.: K-161-2.01US 
Amendment 2 26Jul2019 
Confidential 
 
 
Page 72 
 
APPENDIX 4: SPONSOR AND 
 APPROVALS 
Protocol Title: 
A Phase 2, Prospective, Double-Masked, 
Randomized, Multi-Center, Vehicle-Controlled, 
Parallel-group, 4-week Administration Study 
Assessing the Safety, Efficacy, and Optimum 
Dosage of K-161 in non-Japanese/Japanese Adult 
Subjects with Moderate to Severe Dry Eye 
Disease Both in Environmental and Controlled 
Adverse Environmental (CAE) Settings 
Protocol Number: K-161-2.01US / 
 
Amendment 2 Final Date:  
26Jul2019 
This clinical study protocol was subject to critical review and has been approved by 
the Sponsor.  The following personnel contributed to writing and/or approving this 
protocol. 




K-161 
Sponsor: Kowa Research Institute (KRI) 
Clinical Trial Protocol No.: K-161-2.01US 
Amendment 2 26Jul2019 
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Page 73 
 
APPENDIX 5: INVESTIGATOR’S SIGNATURE 
 
Protocol Title: 
A Phase 2, Prospective, Double-Masked, 
Randomized, Multi-Center, Vehicle-Controlled, 
Parallel-group, 4-week Administration Study 
Assessing the Safety, Efficacy, and Optimum 
Dosage of K-161 in non-Japanese/Japanese Adult 
Subjects with Moderate to Severe Dry Eye 
Disease Both in Environmental and Controlled 
Adverse Environmental (CAE) Settings 
Protocol Number: K-161-2.01US / 
 
Amendment 2 Final Date:  
26Jul2019 
I agree to implement and conduct the study diligently and in strict compliance with 
the protocol, Declaration of Helsinki, Health Insurance Portability and Accountability 
Act, Good Clinical Practice, and all applicable laws and regulations. I agree to 
maintain all information supplied by 
and the Sponsor in confidence and, when 
this information is submitted to an Institutional Review Board / Independent Ethics  
Committee or another group, it will be submitted with a designation that it is 
confidential. 
I have read this protocol in its entirety, including the above statement, and I agree to 
all aspects. 
 
 
 
Signed: 
 
 
Date:_______________ 
 
 
 
   dd mm yyyy 
 
 
 

SAP_003.pdf: 
K-161-2.01US 
 
 
A Phase 2, Prospective, Double-Masked, Randomized, Multi-Center, Vehicle-Controlled, 
Parallel-group, 4-week Administration Study Assessing the Safety, Efficacy, and 
Optimum Dosage of K-161 in non-Japanese and Japanese Adult Subjects with Moderate 
to Severe Dry Eye Disease Both in Environmental and Controlled Adverse Environmental 
(CAE®) Settings 
 
NCT #: 04084483 
Statistical Analysis Plan 
Ver. 1.0 
 03 Jan 2020 
 


 
STATISTICAL ANALYSIS PLAN  
A Phase 2, Prospective, Double-Masked, Randomized, Multi-Center, 
Vehicle-Controlled, Parallel-group, 4-week Administration Study 
Assessing the Safety, Efficacy, and Optimum Dosage of K-161 in non-
Japanese and Japanese Adult Subjects with Moderate to Severe Dry 
Eye Disease Both in Environmental and Controlled Adverse 
Environmental (CAE®) Settings 
 
 
 
Sponsor:   
 
Kowa Research Institute, Inc. (KRI) 
 
 
 
 
 
 
Protocol Number: 
K-161-2.01US / 
 
 
 
Date:    
 
03JAN2020 
Version:  
 
1.0 
 
 
 
 
 
 
 
 
 
 


SIGN


 
 
 
Page 2 of 57 
 
A Phase 2, Prospective, Double-Masked, Randomized, Multi-Center, Vehicle-Controlled, Parallel-
group, 4-week Administration Study Assessing the Safety, Efficacy, and Optimum Dosage of K-161 
in non-Japanese and Japanese Adult Subjects with Moderate to Severe Dry Eye Disease Both in 
Environmental and Controlled Adverse Environmental (CAE®) Settings 
Protocol Number: 
K-161-2.01US / 
 
 
SAP Version:   
1.0 
SAP Date:   
 
03JAN2020 
 
Statistical Analysis Plan Approval 


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Table of Contents 
1. 
Introduction............................................................................................................................... 8 
2. 
Study Objectives ...................................................................................................................... 8 
2.1 Primary Efficacy Endpoints ...................................................................................................... 8 
2.2 Important Secondary Efficacy Endpoints ................................................................................. 8 
2.3 Secondary Efficacy Endpoints ................................................................................................. 8 
2.4 Exploratory Efficacy Endpoints ................................................................................................ 9 
2.5 Safety Variables ....................................................................................................................... 9 
2.6 Other Measures...................................................................................................................... 10 
2.7 Statistical Hypotheses ............................................................................................................ 10 
3. 
Study Design and Procedures ............................................................................................... 10 
3.1 General Study Design ............................................................................................................ 10 
3.2 Schedule of Visits and Assessments ..................................................................................... 11 
4. 
Study Treatments ................................................................................................................... 13 
4.1 Method of Assigning Subjects to Treatment Groups ............................................................. 13 
4.2 Masking and Unmasking ........................................................................................................ 14 
5. 
Sample Size and Power Considerations ................................................................................ 15 
6. 
Data Preparation .................................................................................................................... 15 
6.1 Input Data ............................................................................................................................... 15 
6.2 Output Data ............................................................................................................................ 16 
7. 
Analysis Populations .............................................................................................................. 16 
7.1 Intent-to-Treat......................................................................................................................... 16 
7.2 Per Protocol............................................................................................................................ 16 
7.3 Safety ..................................................................................................................................... 16 
 
8. 
General Statistical Considerations ......................................................................................... 17 
8.1 Unit of Analysis....................................................................................................................... 17 
8.2 Missing or Inconclusive Data Handling .................................................................................. 17 
8.3 Definition of Baseline ............................................................................................................. 17 
8.4 Data Analysis Conventions .................................................................................................... 18 
8.5 Adjustments for Multiplicity ..................................................................................................... 18 
9. 
Disposition of Subjects ........................................................................................................... 19 
10. 
Demographic and Pretreatment Variables ............................................................................. 20 
10.1 Demographic Variables .......................................................................................................... 20 
10.2 Pretreatment Variables .......................................................................................................... 20 
11. 
Medical History and Concomitant Medications ...................................................................... 21 
11.1 Medical History ....................................................................................................................... 21 


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11.2 Concomitant Medications ....................................................................................................... 21 
12. 
Dosing Compliance and Treatment Exposure ....................................................................... 21 
12.1 Dosing Compliance ................................................................................................................ 21 
12.2 Treatment Exposure ............................................................................................................... 22 
13. 
Efficacy Analyses ................................................................................................................... 22 
13.1 Primary Analysis .................................................................................................................... 22 
13.1.1 
Inferior Corneal Fluorescein Staining Score At Visit 5 (Day 29) Post-CAE, 
 K-161 
 
vs Vehicle 
 ............................................................................................................................. 23 
13.1.2 
Ocular Discomfort Scale at Visit 5 (Day 29) Post-CAE, 
 K-161 
 vs Vehicle 
 
27 
13.2 Important Secondary Analyses .............................................................................................. 29 
13.2.1 
Unanesthetized Schirmer’s Test at Visit 5 (Day 29), 
 K-161 
 vs Vehicle 
29 
13.2.2 
Tear Film Break Up Time ........................................................................................... 30 
13.3 Secondary Analyses .............................................................................................................. 31 
13.3.1 
Fluorescein Staining (Ora Calibra® Scale) ................................................................. 32 
13.3.2 
Lissamine Green Staining (Ora Calibra® Scale) ........................................................ 33 
13.3.3 
Conjunctival Redness ................................................................................................ 33 
13.3.4 
Tear Film Break-Up Time ........................................................................................... 34 
13.3.5 
Tear Osmolarity .......................................................................................................... 34 
13.3.6 
Unanesthetized Schirmer’s Test ................................................................................ 35 
13.3.7 
Blink Rate ................................................................................................................... 36 
13.3.8 
Ocular Discomfort Scale (Ora Calibra®) ..................................................................... 36 
13.3.8.1 
Ocular Discomfort Scale (Ora Calibra®) During CAE® ....................................... 37 
13.3.8.2 
Ocular Discomfort Scale (Ora Calibra®) During CAE® Mixed Model Repeated Measures
 37 
13.3.9 
Ocular Discomfort & 4-Symptom Questionnaire (Ora Calibra® Scale) ...................... 39 
13.3.10 
Visual Analog Scale ................................................................................................... 39 
13.3.11 
Ocular Surface Disease Index ................................................................................... 40 
14. 
 
 
 
 
 
 
 
 
 
 
 
 
15. 
Safety Analyses ..................................................................................................................... 43 
15.1 Adverse Events ...................................................................................................................... 44 
 
 


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15.8 Maximum dose tolerability by comparing the 
 K-161 
 arm to the 
 and 
 K-161 
 arms ........................................................................................................................................ 47 
 
 
 
 
 
 
 
18. 
Changes from Protocol-Stated Analyses ............................................................................... 49 
19. 
Revision History ..................................................................................................................... 49 
20. 
Tables ..................................................................................................................................... 49 
21. 
Listings ................................................................................................................................... 54 
22. 
Figures ................................................................................................................................... 55 
 
 
 


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List of Abbreviations 
ADaM 
Analysis Data Model 
AE 
Adverse Event 
ANCOVA 
Analysis of Covariance 
ATC 
Anatomical Therapeutic Chemical 
CI 
Confidence Interval 
CRO 
Clinical Research Organization 
CS 
Clinically Significant 
DMP 
Data Management Plan 
eCRF 
Electronic Case Report Form 
IB 
Investigator’s Brochure 
ICF 
Informed Consent Form 
ICH 
International Conference on Harmonisation 
ITT 
Intent-to-Treat 
IWRS 
Interactive Web Response System 
LOCF 
Last Observation Carried Forward 
LS 
Least Squares 
MCMC 
Markov Chain Monte Carlo 
MedDRA 
Medical Dictionary for Regulatory Activities 
NCS 
Not Clinically Significant 
ODS 
Ocular Discomfort Score 
OSDI© 
Ocular Surface Disease Index 
OU 
Oculus uterque (Both Eyes) 
PDF 
Portable Document Format 
PP 
Per Protocol 
PT 
Preferred Term 
RTF 
Rich Text Format 
SAE 
Serious Adverse Event 
SAP 
Statistical Analysis Plan 
SDC 
Statistics & Data Corporation 
SDTM 
Study Data Tabulation Model 
SE 
Standard Error 
SOC 
System Organ Class 
TEAE 
Treatment-Emergent Adverse Event 
TFBUT 
Tear Film Break-Up Time 
TMF 
Trial Master File 


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WHODrug 
World Health Organization Drug Dictionary 
 
 


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1. Introduction 
The purpose of this statistical analysis plan (SAP) is to describe the planned analyses and reporting for 
protocol K-161-2.01US / 
 Amendment 2 dated 26JUL2019 
This SAP is being written with due consideration of the recommendations outlined in the most recent 
International Conference on Harmonisation (ICH) E9 Guideline entitled Guidance for Industry: Statistical 
Principles for Clinical Trials and the most recent ICH E3 Guideline, entitled Guidance for Industry: Structure 
and Content of Clinical Study Reports. 
This SAP describes the data that will be analyzed and the subject characteristics, efficacy, and safety 
assessments that will be evaluated. This SAP provides details of the specific statistical methods that will 
be used. The statistical analysis methods presented in this document will supersede the statistical analysis 
methods described in the clinical protocol. If additional analyses are required to supplement the planned 
analyses described in this SAP, they may be completed and will be identified in the clinical study report. 
2. Study Objectives 
The objectives of the study are to assess the safety, efficacy, optimum dosage, and dosing regimen of K-
161 compared to its vehicle from Visit 2 (Day 1) to Visit 5 (Day 29) in non-Japanese and Japanese adult 
subjects with moderate to severe dry eye disease both in environmental and Controlled Adverse 
Environment (CAE®) settings. 
2.1 
Primary Efficacy Endpoints 
The primary efficacy endpoints are the following: 
• 
Change in inferior corneal staining score from Visit 2 (Day 1) to Visit 5 (Day 29) by comparing 
 
K-161 
 to its vehicle 
 in CAE® setting 
• 
Change in Ora Calibra® Ocular Discomfort Scale from Visit 2 (Day 1) to Visit 5 (Day 29) by 
comparing 
 K-161 
 to its vehicle 
 in CAE® setting 
2.2 
Important Secondary Efficacy Endpoints 
The important secondary efficacy endpoints include the following: 
• 
Change in Schirmer’s Test value (unanesthetized) from Visit 2 (Day 1) to Visit 5 (Day 29) by 
comparing 
 K-161 
 to its vehicle 
 in environmental setting 
• 
Change in tear film break up time (TFBUT) from Visit 2 (Day 1) to Visit 5 (Day 29) by comparing 
 K-161 
 to its vehicle 
 in CAE® setting 
2.3 
Secondary Efficacy Endpoints 
The secondary efficacy endpoints for comparisons of the vehicle 
 and K-161 
 (i.e., 
 K-161 
 
and 
 K-161 
 treatment groups include the following: 


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• 
Fluorescein staining by region: central, superior, inferior, temporal, nasal, and corneal sum as 
assessed by the Ora Calibra® Corneal and Conjunctival Staining Scale 
• 
Lissamine green staining by region: central, superior, inferior, temporal, nasal, and conjunctival 
sum as assessed by the Ora Calibra® Corneal and Conjunctival Staining Scale 
• 
Conjunctival Redness as assessed by the Ora Calibra® Scale 
• 
TFBUT  
• 
Tear Osmolarity 
• 
Schirmer’s Test (unanesthetized) 
• 
Blink Rate 
• 
Ora Calibra® Ocular Discomfort Scale 
• 
Ora Calibra® Ocular Discomfort and 4-Symptom Questionnaire 
• 
Visual Analog Scale (VAS): Burning/Stinging, Itching, Foreign Body Sensation, Blurred Vision, Eye 
Dryness, Photophobia, and Pain 
• 
Ocular Surface Disease Index (OSDI©) 
2.4 
 
 
 
 
 
 
 
 
 
 
 
 
2.5 
Safety Variables 
The safety variables include the following: 
 
 
 
 
• 
Adverse Event (AE) query 
 
 
 
 
 
 
 
 
• 
Maximum dose tolerability by comparing the 
 K-161 
 arm to the 
 and 
 K-161 
 arms 


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2.6 
Other Measures 
The other measures being evaluated are: 
 
 
 
 
 
 
  
 
 
2.7 
Statistical Hypotheses 
The following primary hypotheses will be tested against their respective two-sided alternative hypotheses 
in the order: 
H01:  There is no difference in the change from baseline in the post-CAE® inferior corneal 
staining score after 28 days of treatment of 
 K-161 
 compared to vehicle.  
H02:  There is no difference in the change from baseline in the post-CAE® ocular discomfort 
score after 28 days of treatment of 
 K-161 
 compared to vehicle.   
Upon rejecting both H01 and H02, the secondary hypotheses will be tested in the following order:  
H03:  There is no difference in the change from baseline in the pre-CAE® Schirmer’s test 
value after 28 days of treatment of 
 K-161 
 compared to vehicle. 
H04:  There is no difference in the change from baseline in the post-CAE® TFBUT after 28 
days of treatment of 
 K-161 
 compared to vehicle. 
These four hypotheses will be tested hierarchically, each at the alpha = 0.05 level to maintain a study-wise 
Type I error rate at 0.05. 
3. Study Design and Procedures 
3.1 
General Study Design 
This is a Phase 2, multicenter, randomized, double-masked, vehicle controlled, parallel-group design with 
block enrollment. Subjects will be randomized to one of the following treatment groups at Visit 2 (Day 1):  
• 
 K-161; 
 (N=~60) 
• 
 K-161; 
 (N=~60) 
• 
 K-161; 
 (N=~60)  
• 
Vehicle Ophthalmic Solution (Vehicle); 
 (N=~60) 
Approximately 240 subjects will be randomly assigned to one of the four treatment groups (1:1:1:1). 
 
 
 Subjects, Sponsor, Contract research organization (CRO), and site personnel will be 
masked to treatment assignment. To ensure masking, a dedicated unmasked staff member/technician will 


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be delegated to dispense and observe instillation of randomized study drug and collect randomized study 
drug from a subject for drug accountability. This person cannot perform any other study-related procedures. 
Additionally, the informed consent form (ICF) will not indicate any relationship between dosing regimen and 
treatment. Subjects will be instructed not to discuss their assigned dosing regimen or perceived treatment 
effects with other study participants. 
During the screening period, two 90-minute exposures to the CAE® will be conducted to ascertain eligibility 
to enter the study. Subjects who qualify after the initial screening visit will enter the run-in phase, where 
they will self-administer vehicle 
 for approximately 14 days. Those who qualify at Visit 2 (Day 1) will be 
randomized to receive study drug in a double-masked fashion for 28 days. 
 
 
 Subjects will self-administer drops either 
 or 
 
At Visit 4 (Day 15) and Visit 5 (Day 29), CAE® exposure will occur, with pre-CAE®, during CAE® (symptoms 
only) and post-CAE® assessments of ocular signs and symptoms. At Visit 3, no CAE® exposure will occur 
but signs and symptoms will be assessed. Study drug will be discontinued at Visit 5. Subjects will exit from 
the study at this visit. The follow-up phone call will occur about 7 days after the final day of randomized 
study drug treatment. 
Study visits will be referred to in all tables and listings as the expected study day corresponding to the visit 
to enable reviewers to understand the assessment timing without referring to the protocol visit schedule. 
Table 1 shows the scheduled study visits, their planned study day (note that there is no Day 0 and that Day 
1 corresponds to the day of randomization), and the acceptable visit window for each study visit: 
Table 1. Study Visit Windows 
Scheduled Visit 
Planned Study Day 
Visit Window 
Visit 1 
Day -14 
± 2 Days 
Visit 2 
Day 1 
N/A 
Visit 3 
Day 8 
± 1 Days 
Visit 4 
Day 15 
± 2 Days 
Visit 5 
Day 29 
± 2 Days 
Follow-up Phone Call 
Day 36 
± 2 Days 
3.2 
Schedule of Visits and Assessments 
The schedule of visits and assessments is provided on Table 2. 
 
 
 


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Table 2. Schedule of Visits and Assessments 
Procedure 
Visit 1 
Day -14 ± 2 
Visit 2 
Day 1 
Visit 3 
Day 8 ± 
1 
Visit 4 
Day 15 ± 2 
Visit 5 
Day 29 ± 2 
Follow-up 
Phone Call 
(Day 36 ± 2) 
 
Pre  
CAE 
Post  
CAE 
Pre 
CAE 
Post 
CAE 
Non 
CAE 
Pre 
CAE 
Post 
CAE 
Pre 
CAE 
Post  
CAE 
 
Informed Consent / HIPAA 
X 
 
 
 
 
 
 
 
 
 
Medical / Medication History 
and Demographics 
X 
 
 
 
 
 
 
 
 
 
Medical / Medication Update 
 
 
X 
 
X 
X 
 
X 
 
 
Adverse Event Query 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Ora Calibra® Ocular 
Discomfort Scale 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
Ora Calibra® Ocular 
Discomfort & 4-Symptom 
Questionnaire 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
OSDI© Questionnaire 
X 
 
X 
 
X 
X 
 
X 
 
 
Visual Analog Scale 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
Conjunctival Redness 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
Tear Osmolarity 
 
 
X 
 
X 
X 
 
X 
 
 
TFBUT 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
Fluorescein Staining 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
Lissamine Green Staining 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
Schirmer’s Test 
X 
 
X 
 
X 
X 
 
X 
 
 
Blink Rate 
 
 
X 
 
X 
X 
 
X 
 
 


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Procedure 
Visit 1 
Day -14 ± 2 
Visit 2 
Day 1 
Visit 3 
Day 8 ± 
1 
Visit 4 
Day 15 ± 2 
Visit 5 
Day 29 ± 2 
Follow-up 
Phone Call 
(Day 36 ± 2) 
 
Pre  
CAE 
Post  
CAE 
Pre 
CAE 
Post 
CAE 
Non 
CAE 
Pre 
CAE 
Post 
CAE 
Pre 
CAE 
Post  
CAE 
 
Vehicle Run-In Dispensation 
 
X 
 
 
 
 
 
 
 
 
Vehicle Run-In Instillation 
 
X 
 
 
 
 
 
 
 
 
Vehicle Run-in Collection 
 
 
X 
 
 
 
 
 
 
 
Randomization 
 
 
 
X 
 
 
 
 
 
 
Study Drug Dispensation 
 
 
 
X 
X 
 
X 
 
 
 
Study Drug Collection 
 
 
 
 
X 
X 
 
X 
 
 
Exit Subject from Study 
 
 
 
 
 
 
 
 
 
X 
 
   
 
 
 
 
4. Study Treatments 
4.1 
Method of Assigning Subjects to Treatment Groups 
Before the initiation of study run-in at Visit 1 (Day -14), each subject who provides written informed consent 
will be assigned a screening number. All screening numbers will be assigned in strict numerical sequence 
at a site and no numbers will skipped or omitted. Each subject who meets all the inclusion and none of the 
exclusion criteria at Visit 1 (Day -14) and Visit 2 (Day 1) will be assigned a randomization number at the 
end of Visit 2 (Day 1). The Interactive Web Response System (IWRS) will be used to assign all 
randomization numbers. 


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For the non-Japanese subjects, randomization will be further stratified by the following factors and cut-offs:  
 
 
 
 
 
 
 
 
 
 
Randomization and kit numbers will be assigned automatically to each subject as they are entered into the 
IWRS.  
The site staff will dispense kit(s) required until the next visit. Both the randomization number and the 
dispensed study drug kit number(s) will be recorded on the subject’s source document and electronic case 
report form (eCRF).  
4.2 
Masking and Unmasking 
Subjects, Sponsor, CRO, and site personnel (with the exception of the following person) will be masked to 
treatment assignment. To ensure masking, a dedicated unmasked staff member/technician will be 
delegated to dispense and observe instillation of randomized study drug and collect randomized study drug 
from a subject for drug accountability. This person cannot perform any other study-related procedures. Prior 
to database lock, select eCRF pages will only be viewable by unmasked study members as detailed in the 
Data Management Plan (DMP) to ensure masking.  
When medically necessary, the Investigator may need to determine what treatment group has been 
assigned to a subject. When possible (i.e., in non-emergent situations), 
 and/or the Sponsor will be 
notified before unmasking the Investigator. 
 and/or the Sponsor must be informed immediately about 
any unmasking event. 
If the Investigator identifies a medical need that requires unmasking the treatment assignment of a subject, 
 and/or the Medical Monitor will be contacted prior to unmasking the identity of the IP, if possible. 
 
will ask the staff to complete and send them the Unmasking Request Form. 
will notify the Sponsor and 
jointly determine if the unmasking request should be granted. In addition, they may consult the Medical 
Monitor as needed. The result of the request will be documented on the Unmasking Request Form. If 
approval is granted to unmask a subject, written permission will be provided on the Unmasking Request 
Form. The Investigator will unmask the subject using the IWRS, complete the Unmasking Memo form, 
include it in the subject’s study file and make a copy for the trial master file (TMF). For each unmasked 
request, the reason, date, signature, and name of the person unmasking the subject must be noted in the 
subject’s study file.  


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Unmasked subjects will be discontinued from the study and followed for safety monitoring, until resolution 
of the AE or study completion, whichever occurs last. 
5. Sample Size and Power Considerations 
This study is expected to enroll 240 subjects in a 1:1:1:1 ratio across four treatment groups, or 60 subjects 
per treatment group. In addition, 
 
  
The standard deviation (SD) for change from baseline in post-CAE® inferior corneal fluorescein staining 
ranges between 0.68 and 0.81 units. Assuming a common SD of 0.77, a sample size of 60 subjects per 
group will have approximately 90% power to detect a difference of 0.46 units between the active treatment 
group and the vehicle group using a two-sample t-test at a two-sided significance level of 0.05. Again, it is 
assumed that adjusting for baseline and site will further reduce variability and provide >90% power. 
Likewise, the SD for change from baseline scores in the post-CAE® ODS at Day 29 is assumed a common 
SD of 0.82, a sample size of 60 subjects per group will have approximately 90% power to detect a difference 
of 0.49 units between the active treatment group and the vehicle group using a two-sample t-test at a two-
sided significance level of 0.05. It is assumed that adjusting for baseline and site will further reduce 
variability and provide >90% power. 
6. Data Preparation 
6.1 
Input Data 
Electronic Case Report Forms will be developed by Statistics & Data Corporation (SDC). SDC will utilize 
the Electronic Data Capture (EDC) system, iMedNet™ (iMedNet v1.192.1) for this study. Data from source 
documents will be entered into the eCRF by site personnel. 
In addition, the following study data which is not captured directly within the RDC system but is obtained 
from external vendors will also be included for analysis. These data sources are described in detail in data 
transfer agreements developed between data management and the respective external laboratory or 
reading center: 
 
 
 
 
 
 
When all prerequisites for database lock have been met, including availability of all masked external data, 
the database will be locked. Following database lock, approval will be obtained from the Sponsor to unmask 
the study. Once the study has been unmasked, unmasked laboratory data will be sent to SDC. Any changes 
to the database after data have been locked can only be made with the approval of the Sponsor in 
consultation with SDC.  


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Final analysis will be carried out after the following have occurred: 
• 
Database lock has occurred, including receipt of all final versions of external vendor data, with 
written authorization provided by appropriate SDC and Sponsor personnel. 
• 
Protocol deviations have been identified and status defined (major/minor deviations). 
• 
Analysis populations have been determined. 
• 
Randomized treatment codes have been unblinded. 
6.2 
Output Data 
Data from EDC and external data will be transferred to Biostatistics and incorporated into standard formats 
following the Study Data Tabulation Model (SDTM). Data will then be mapped to analysis datasets using 
the Analysis Data Model (ADaM).  Both SDTM- and ADaM-formatted data will be used to create the subject 
listings, while all tables and figures will be based on the ADaM-formatted data. 
SDTM will follow the SDTM version 1.4 model and will be implemented using the SDTM Implementation 
Guide version 3.2 and the SDTM Controlled Terminology version 2019-06-28. ADaM data will follow the 
ADaM version 2.1 model and will be implemented using the ADaM Implementation Guide version 1.1. Both 
SDTM and ADaM will be validated using Pinnacle 21 version 3.0.1. Any discrepancies in the validation will 
be noted in reviewer’s guides accompanying the final data transfers. 
Define.xml will be created for SDTM and ADaM using the Define-XML version 2.0 model. 
7. Analysis Populations 
7.1 
Intent-to-Treat 
The intent-to-treat (ITT) population includes all randomized subjects. Subjects in the ITT population will be 
analyzed as randomized. 
7.2 
Per Protocol 
The per-protocol (PP) population includes subjects in the ITT population who do not have significant 
protocol deviations and who complete the study. Protocol deviations will be assessed prior to database lock 
and unmasking. Subjects in the PP population will be analyzed as treated. 
7.3 
Safety 
The safety population includes all randomized subjects who have received at least one dose of the 
investigational product. Subjects in the safety population will be analyzed as treated. 
7.4 
 
 
 
 


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8. General Statistical Considerations 
8.1 
Unit of Analysis 
Safety endpoints will be analyzed for both eyes. For subject-level efficacy endpoints, the unit of analysis 
will be the subject. For efficacy endpoints, the unit of analysis will be the study eye, or the “worst eye,” as 
defined by the following:  
Study (worst) Eye: Eyes are eligible for analysis if they meet all of the inclusion criteria. At least one eye 
(the right eye or the left eye) must meet all of the criteria. In the case that both eyes are eligible for analysis, 
the worst eye will be selected as the eye with the worst post-CAE® inferior corneal staining at Visit 2 (Day 
1). If the post-CAE® inferior corneal staining at Visit 2 (Day 1) is the same in both eyes then the eye with 
the worst post-CAE® Ocular Discomfort Score (ODS) at Visit 2 (Day 1) will be worst eye. If the post-CAE® 
inferior corneal staining and ocular discomfort are the same in both eyes then the right eye will be selected 
as the worst eye. 
8.2 
Missing or Inconclusive Data Handling 
Missing data will be imputed using multiple imputation with a control-based pattern mixture model on the 
ITT population for the primary analyses, the important secondary, other secondary, and exploratory 
comparisons.   
Sensitivity analyses of the primary analyses and important secondary comparisons will include the following 
in order to provide a robust understanding of the impact of missing and spurious data:  
• 
Using complete case data (i.e., observed data only) on the ITT population 
• 
Using last observation carried forward (LOCF) on the ITT population 
• 
Multiple imputation under missing at random assumption with Markov Chain Monte Carlo (MCMC) 
techniques on the ITT population 
• 
Using complete case data on the PP population.  
No imputation will be used for safety endpoints. 
8.3 
Definition of Baseline 
Baseline is defined as the last measurement prior to the first dose of study medication. If a measure is 
taken both pre-CAE® and post-CAE®, the baseline will be the time point matched value. For changes from 
pre-CAE® to post-CAE® after the first treatment, the change from pre-CAE® to post-CAE® will be considered 
the baseline value. 
For 
 baseline will be measurements taken at Visit 1 
(Day -14). 
Change from baseline will be calculated as follow-up visit minus baseline visit. 


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8.4 
Data Analysis Conventions 
All data analysis will be performed by SDC after the study is completed and the database has been locked 
and released for unmasking. Statistical programming and analyses will be performed using SAS® version 
9.4 or higher. Output will be provided in rich text format (RTF) for tables and portable document format 
(PDF) for tables, listings, and figures using landscape orientation. All study data will be listed by subject, 
treatment, and visit (as applicable) based on all randomized subjects unless otherwise specified. 
Summaries for continuous and ordinal variables will include the number of observations (n), arithmetic 
mean, SD, median, minimum, and maximum. Minima and maxima will be reported with the same precision 
as the raw values; means and medians will be presented to one additional decimal place than reported in 
the raw values. Standard deviations will be presented to one additional decimal place than reported in the 
raw values. Summaries for discrete variables will include counts and percentages. All percentages will be 
rounded to one decimal place (i.e., XX.X%). Differences between active treatment groups and Vehicle will 
be calculated as active minus Vehicle and change from baseline will be calculated as follow-up visit minus 
baseline.  
All statistical tests will be two-sided with a significance level of 0.05 (α = 0.05) unless otherwise specified. 
Confidence intervals (CI) for differences between treatment groups will be two-sided at 95% confidence. 
All p-values will be rounded to 4 decimal places; p-values less than 0.0001 will be presented as “<0.0001”; 
p-values greater than 0.9999 will be presented as “>0.9999.” 
Unless otherwise specified, summaries will be presented by treatment group and, where appropriate, visit. 
Listings will be sorted by treatment group, subject number, visit/time point, and parameter as applicable. 
For statistical analyses that use site as a fixed effect, any site that enrolls fewer than 10 subjects will be 
pooled with the site with the next smallest enrollment until each pooled site contains at least 10 subjects.  
8.5 
Adjustments for Multiplicity 
Common factors for multiplicity are multiple groups and multiple endpoints. 
1. Multiple groups 
The primary treatment comparison will be between the 
 K-161 
 treatment group and the vehicle 
 treatment group. The other treatment comparisons will be considered secondary/exploratory.  
2. Multiple endpoints 
The primary and important secondary endpoints will be tested hierarchically to maintain the study-wise 
Type I error rate of 0.05. First, change from baseline in inferior corneal fluorescein staining will be tested at 
an alpha level of 0.05. The test for change from baseline scores in the ODS will be conducted at an alpha 
level of 0.05 only if the previous test demonstrates significance. The test for change from baseline in 
Schirmer’s test will be conducted at an alpha level of 0.05 only if the previous test demonstrates 
significance. The test for change from baseline in TFBUT will be conducted at an alpha level of 0.05 only if 


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the previous test demonstrates significance. All other secondary endpoints and treatment comparisons will 
be considered exploratory. 
The hierarchical testing order will be as follows: 
Primary comparisons: 
1. Comparison of the change from baseline in post-CAE® inferior corneal staining at Visit 5 (Day 29)  
(
 K-161 
 vs vehicle) 
2. Comparison of the change from baseline in post-CAE® ocular discomfort at Visit 5 (Day 29) (
 
K-161 
 vs vehicle) 
Important Secondary comparisons: 
3. Comparison of the change from baseline in pre-CAE® Schirmer’s test value at Visit 5 (Day 29) 
(
 K-161 
 vs vehicle) 
4. Comparison of the change from baseline in post-CAE® TFBUT at Visit 5 (Day 29) (
 K-161 
 
vs vehicle) 
Thus, the study-wise Type I error rate will be maintained at 0.05 by considering only one dose of K-161 as 
the primary treatment comparison and using a hierarchical testing procedure. 
9. Disposition of Subjects 
Subject disposition will be presented in terms of the numbers and percentages of subjects who were 
randomized to blinded study medication with subcategories of dosed with the blinded study medication, did 
not dose with blinded study medication; who were included in the following analysis populations: ITT, PP, 
safety, 
 and who completed the study and discontinued from the study. Subjects who are not 
discontinued from the study will be considered study completers. Disposition will be summarized by 
treatment group and for all subjects. Percentages will be calculated using randomized subjects as the 
denominator unless otherwise specified.  
The total number of enrolled subjects and screen failed subjects will be presented.  
The reasons for premature study discontinuation will be summarized by treatment group for all discontinued 
subjects. Percentages will be calculated using discontinued subjects as the denominator. The reasons for 
study discontinuation that will be summarized include: AE, Subject Request/Withdrawal, Protocol 
Violation(s), Administrative Reasons, Sponsor Termination of Study, and Other. A subject listing will be 
provided that includes the date of and reason for premature study discontinuation. 
The number and percentage of subjects with any deviation, major deviation, and minor deviation will be 
summarized by treatment group for all randomized subjects. The protocol deviations that will be 
summarized include the following categories: Informed Consent, Inclusion/Exclusion and Randomization, 
Test Article/Study Drug Instillation and Assignment at Site, Improper Protocol Procedures at Site, Site’s 


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Failure to Report Serious Adverse Event (SAE)/AE, Visit Out of Window, Subject’s Non-compliance with 
Test Article/Study Drug, Subject’s Use of Prohibited Concomitant Medication, Subject’s Failure to Follow 
Instructions, and Other. A subject listing will be provided that includes the date of the deviation, the deviation 
code, the deviation description, and the classification of whether the deviation was judged to be major or 
minor in a masked review. 
In addition, subject listings will be provided that include informed consent date, inclusion and exclusion 
criteria violations, exclusions from the PP population, and screen failures. Details of the study 
randomization, including randomization date and time, and randomized treatment, will also be included 
within a subject listing. 
10. Demographic and Pretreatment Variables 
10.1 
Demographic Variables 
The demographic variables collected in this study include age, sex, ethnicity, race, whether the subject is 
Japanese, if the subject’s parents or grandparents are of Japanese descent, height, and weight. Subjects 
who record more than one race will be grouped into a single category denoted as Multiple. Demographic 
variables will be summarized for the ITT and safety populations, separately. 
Age (years) will be summarized, overall and by treatment, using continuous descriptive statistics.  Age will 
also be categorized as follows:  < 65 years and ≥ 65 years.  Age will be reported in years and calculated 
using the following formula: 
Age = (Informed Consent Date – Date of Birth) / 365.25, truncated as an integer 
The number and percentage of subjects will be presented, overall and by treatment, for age category, sex, 
race, ethnicity, age, sex, ethnicity, race, ethnic Japanese, Japanese descent, and stratification category.  
A subject listing that includes all demographic variables will be provided. 
10.2 
Pretreatment Variables 
Baseline disease characteristics will be summarized, overall and by treatment, for the ITT and safety 
populations using continuous descriptive statistics for inferior corneal staining score; ocular discomfort 
score; uanesthetized Schirmer’s test value; TFBUT; fluorescein staining score (Ora Calibra® scale) in the 
regions: central, superior, inferior, temporal, corneal sum, conjunctival sum and total eye score; lissamine 
green staining by region: central, superior, inferior, temporal, nasal, and conjunctival sum as assessed by 
the Ora Calibra® Corneal and Conjunctival Staining Scale; 
 The scale for each assessment is 
provided in the variables’ respective subsection in Section 13 and Section 15 of this SAP. 


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11. Medical History and Concomitant Medications 
11.1 
Medical History 
Medical history will be coded using the Medical Dictionary for Regulatory Activities (MedDRA) 22.0. 
Ocular and non-ocular medical history will be summarized using discrete summary statistics and presented 
by treatment and overall at the subject level by System Organ Class (SOC) and Preferred Term (PT) using 
the safety population. If a subject reports the same PT multiple times within the same SOC, that PT will 
only be reported once within that SOC. As with the PT, if a subject reports multiple conditions within the 
same SOC, that SOC will only be reported once. SOCs are listed in alphabetical order; PTs within a SOC 
are listed in order of descending frequency across all subjects. 
Listings of medical history will be generated separately for ocular and non-ocular data. 
11.2 
Concomitant Medications 
Ocular and non-ocular concomitant medications will be coded using the World Health Organization Drug 
Dictionary (WHODrug) Global (B3, March 2019) and summarized to the therapeutic drug class (Anatomical 
Therapeutic Chemical [ATC] 4 classification) and preferred name. If the ATC 4 classification is not provided, 
then the next lowest classification that is provided in the coding dictionary will be used. The preferred name 
will be defined as the active ingredient; if the active ingredient is not provided or includes more than two 
ingredients (e.g., multivitamins), then the drug name will be summarized as the preferred name. Any 
uncoded terms will be summarized under the ATC classification and preferred name of “Uncoded.” 
Concomitant medications are defined as those medications listed as having been taken (1) prior to initiation 
of study drug administration and continuing for any period of time following the first administration of study 
drug or (2) at any time following the first administration of study drug. Prior medications are reported 
medications that have been taken prior to initiation of study drug administration but not during the study. 
Concomitant medications will be summarized using the ITT population. Medications will be tabulated for 
each treatment group using frequencies and percentages. Subjects may have more than one medication 
per ATC text. At each level of subject summarization, a subject will be counted once if he/she reports one 
or more medications. Percentages will be based on the number of subjects in each treatment group. Listings 
of prior and concomitant medications will be generated separately for ocular and non-ocular data. 
12. Dosing Compliance and Treatment Exposure 
12.1 
Dosing Compliance 
Dosing compliance (% compliance) will be assessed by calculating the number of actual doses received 
and comparing that to the number of expected doses as follows: 
Compliance (%) = 
Number of Actual Doses Received 
x 100% 
Number of Expected Doses 


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The number of actual doses received will be recorded in the eCRF and determined through the in-office 
instillations. The number of expected doses that will be used for calculating compliance will be calculated 
as follows:  
• 
For subjects in 
 dosing group: 4 x {[Date of Study Completion/Discontinuation – Date 
of Visit 2 (Day 1)]} – 1 x [number of visits attended in (Visit 2, Visit 3, Visit 4)] 
• 
For subjects in 
 dosing groups: 2 x {[Date of Study Completion/Discontinuation – Date 
of Visit 2 (Day 1)]} 
If a randomized subject discontinues from the study on Day 1, the number of expected doses will be 1. 
A categorical dosing compliance variable will also be derived as non-compliant (<80%), compliant (≥80% 
and ≤125%), and over compliant (>125%). 
Dosing compliance (%) will be summarized with continuous descriptive statistics for each treatment group 
using the safety population. The compliance category defined above will be summarized with discrete 
summary statistics.  
A subject listing of dosing compliance will also be produced.  
A subject listing of run-in, run-in instillation, and run-in replacement will be produced. 
A subject listing of study drug assignment, study drug instillation, and study drug replacement will be 
produced. 
12.2 
Treatment Exposure 
Extent of treatment exposure for completed or discontinued subjects will be calculated in days using the 
following: 
Extent of Exposure (days) = (Date of Study Completion/Discontinuation – Date of Visit 2 (Day 1))  
If a randomized subject discontinues from the study on Day 1, the extent of exposure will be 1 day. 
Extent of treatment exposure for subjects who were lost to follow-up will be calculated in days using the 
following: 
Extent of Exposure (days) = (Date of Last Recorded Visit – Date of Visit 2 (Day 1)) + 1 
Extent of treatment exposure for each subject exposed to study drug will be summarized with continuous 
descriptive statistics for each treatment group using the safety population. A subject listing of treatment 
exposure will also be produced. 
13. Efficacy Analyses 
13.1 
Primary Analysis 
The primary efficacy endpoints of the study are: 


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• 
Mean change from baseline in post-CAE® inferior corneal fluorescein staining score on the Ora 
Calibra® scale at Visit 5 (Day 29), comparing 
 K-161 
 to vehicle 
 
• 
Mean change from baseline in post-CAE® ocular discomfort scale on the Ora Calibra® scale at Visit 
5 (Day 29), comparing 
 K-161 
 to vehicle 
 
Change from baseline for both endpoints will be calculated as Visit – Baseline, where a positive difference 
indicates a worsening of dry eye signs or symptoms and a negative difference indicates an improvement 
of dry eye signs or symptoms. Treatment comparisons between 
 K-161 
 and vehicle 
 will be 
calculated as 
 K-161 
 - vehicle 
 All primary endpoints will be described in subject listings. 
13.1.1 INFERIOR CORNEAL FLUORESCEIN STAINING SCORE AT VISIT 5 (DAY 29) POST-CAE, 
 K-161 
 
VS VEHICLE 
 
Fluorescein staining will be conducted at all visits at pre-CAE® and post-CAE®. Grading will be conducted 
using the Ora Calibra® Scale from 0 to 4 with the use of half grade (0.5) increments, where grade 0 = None 
and 4 = Severe. The regions to be assessed will be the central, superior, inferior, temporal, nasal, corneal 
sum, conjunctival sum, and total eye score for study eye only. 
Inferior corneal fluorescein staining will be summarized at Visit 5 (Day 29) Post-CAE® by treatment groups 
using continuous descriptive statistics. Primary analysis will use an analysis of covariance (ANCOVA) 
model adjusted for baseline value, site, and with treatment group as the explanatory variable. Changes 
from baseline for each treatment group in inferior corneal fluorescein staining will be compared between 
 K-161 
 and vehicle 
 In addition, treatment by baseline and treatment by study site interactions 
will be explored in separate models to evaluate how the treatment effect may differ for baseline value and 
study sites. Analyses will be performed by baseline stratification (≤ 3.0 and >3.0) and/or site to understand 
how the treatment effect differs for baseline value and study sites. Least squares (LS) means for each 
treatment group and the LS mean difference between treatment groups will be presented from the models 
together with standard errors (SE), two-sided p-values, and two-sided 95% CIs.  
For the primary analysis, the primary efficacy endpoint of inferior corneal fluorescein staining will have 
missing data imputed using a control-based pattern mixture model under the assumption of a missing not 
at random mechanism. The imputation will first impute non-monotone missing data using MCMC to obtain 
a dataset with a monotone missing pattern, then a control-based pattern mixture model will be run. The 
SAS® code for obtaining multiple pattern mixture model imputation data is: 
PROC MI DATA = INDATA SEED = 6849548 OUT = MDATA NIMPUTE = 100 
 
 
 
MINIMUM = 0 MAXIMUM = 4 ROUND = 0.5; 
 
 
  BY TREATMENT; 
 
 
  MCMC IMPUTE=MONOTONE; 
 
 
  VAR BASELINE IFS4 IFS5; 
 
 
RUN; 
 
PROC MI DATA = MDATA SEED = 3541655 OUT = OUTDATA NIMPUTE = 1 


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MINIMUM = . 0 0 0 MAXIMUM = . 4 4 4 ROUND = . 0.5 0.5 0.5; 
BY _Imputation_; 
CLASS TREATMENT; 
 
MONOTONE REG(IFS4 = BASELINE/ DETAILS); 
MONOTONE REG(IFS5 = BASELINE IFS4/ DETAILS);   
MNAR MODEL(IFS4 IFS5 / MODELOBS=(TREATMENT=’Vehicle’)); 
VAR BASELINE IFS4 IFS5; 
RUN; 
where 
- INDATA is the name of the input dataset 
- MDATA is the name an intermediary dataset with a monotone missing pattern 
- OUTDATA is the name of the output dataset 
- TREATMENT is the name of the treatment group variable 
- BASELINE is the baseline inferior corneal fluorescein staining 
- IFS4-IFS5 are the inferior corneal fluorescein staining at Visits 4 (Day 15) through Visit 5 (Day 29) 
If multiple pattern mixture model imputation fails to generate imputations, baseline total sum fluorescein 
staining score will be added to the VAR statement and multiple imputation will be reattempted. If multiple 
imputation still fails to generate the required imputation, then MINIMUM, MAXIMUM, and ROUND 
statements will be removed. 
After the imputed data sets are obtained, the following code will be used to execute the ANCOVA model 
on each imputed data set and the results combined from the analyses: 
PROC MIXED DATA = OUTDATA; 
  BY _IMPUTATION_; 
  CLASS TREATMENT SITE; 
  MODEL CHG = BASELINE TREATMENT SITE/ SOLUTION COVB; 
  LSMEANS TREATMENT / CL PDIFF; 
  ODS OUTPUT LSMEANS = OUTLS DIFFS = OUTDIFFS; 
RUN; 
 
 
PROC SORT DATA=OUTLS; BY TREATMENT _IMPUTATION_; RUN; 
PROC MIANALYZE DATA=OUTLS; 
  BY TREATMENT; 
  MODELEFFECTS ESTIMATE; 
  STDERR STDERR; 
RUN; 
 
DATA OUTDIFFS; 
  SET OUTDIFFS; 
  COMPARISON = TREATMENT||’ – ‘||LEFT(_TREATMENT); 


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RUN; 
PROC SORT DATA=OUTDIFFS; BY COMPARISON _IMPUTATION_; RUN; 
PROC MIANALYZE DATA=OUTDIFFS; 
  BY COMPARISON; 
  MODELEFFECTS ESTIMATE; 
  STDERR STDERR; 
RUN; 
 
where 
- TREATMENT is the name of the treatment group variable  
- BASELINE is the baseline inferior corneal fluorescein staining  
- CHG is the change from baseline of the inferior corneal fluorescein staining at Visit 5 (Day 29) – 
BASELINE 
- SITE is the site ID 
- OUTLS is the name of the output dataset that contains the statistical results for the treatment 
mean from the ANCOVA model that is run on each of the 100 imputation datasets 
- OUTDIFFS is the name of the output dataset that contains the statistical results for the 
difference in treatment mean from the ANCOVA model that is run on each of the 100 imputation 
datasets 
Two sample t-tests will use similar SAS code to execute pattern mixture model multiple imputation 
analysis. 
Sensitivity analyses will also include using ITT population with observed data only and ITT population with  
last observation carried forward (LOCF). 
Markov chain Monte Carlo (MCMC) imputation with the ITT population will be used for sensitivity analysis 
under the assumption of a missing at random mechanism. The SAS® procedure PROC MI will be used for 
the MCMC imputation of 100 complete data sets. Then, imputation will proceed with The SAS code for 
obtaining the imputed data is: 
PROC MI DATA = INDATA SEED = 2568716 OUT = OUTDATA NIMPUTE = 100 
MINIMUM = 0 MAXIMUM = 4 ROUND = 0.5; 
  BY TREATMENT; 
  MCMC INITIAL = EM; 
  VAR BASELINE IFS4 IFS5; 
RUN; 
where 
- INDATA is the name of the input dataset 
- OUTDATA is the name of the output dataset 
- TREATMENT is the name of the treatment group variable  


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- BASELINE is the baseline inferior corneal fluorescein staining 
- IFS4-IFS5 are the inferior corneal fluorescein staining at Visits 4 (Day 15) through 5 (Day 29) 
If MCMC multiple imputation fails to generate imputations, baseline total eye fluorescein staining score 
will be added to the VAR statement and multiple imputation will be reattempted. If MCMC multiple 
imputation still fail to generate the required imputation, then MINIMUM, MAXIMUM, and ROUND statements 
will be removed.  
Tipping point analyses will be included for further sensitivity analyses. The SAS® procedure PROC MI will 
be used to impute non-monotone missing data using MCMC to obtain 100 complete datasets with a 
monotone missing pattern as described for the control-based pattern mixture model imputation. Then, the 
monotone datasets will be imputed using a set of shift values for the active treatment group. The set of shift 
values for the imputation will be from 0 to 4 by 0.1 increments. The SAS® code for obtaining the imputed 
data is: 
PROC MI DATA = INDATA SEED = 935769  OUT = MDATA NIMPUTE = 100 
 
 
 
MINIMUM = 0 MAXIMUM = 4 ROUND = 0.5; 
 
 
 
BY TREATMENT; 
 
 
  MCMC IMPUTE=MONOTONE; 
 
 
  VAR BASELINE IFS4 IFS5; 
RUN; 
PROC MI DATA = MDATA SEED = 427586 OUT = OUTDATA NIMPUTE = 1 
MINMAXITER = 1000000 MINIMUM = . 0 0 0 MAXIMUM = . 4 4 4  
ROUND = . 0.5 0.5 0.5; 
 BY _Imputation_; 
 CLASS TREATMENT; 
 MONOTONE REG (IFS5 = BASELINE IFS4/DETAILS); 
 MONOTONE REG (IFS4 = BASELINE /DETAILS); 
 MNAR ADJUST (IFS5/ SHIFT = X ADJUSTOBS = (TREATMENT = ‘ACTIVE   
TREATMENT')); 
 VAR BASELINE IFS4 IFS5; 
RUN; 
where 
- INDATA is the name of the input dataset 
- MDATA is the name an intermediary dataset with a monotone missing pattern 
- OUTDATA is the name of the output dataset 


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- TREATMENT is the name of the treatment group variable 
- BASELINE is the baseline inferior corneal fluorescein staining 
- IFS4-IFS5 are the inferior corneal fluorescein staining at Visits 4 (Day 15) through Visit 5 (Day 29) 
- X is the shift parameter within the set of shift parameters [0 to 4 by 0.1] 
Least squares mean differences, SEs, two-sided CIs and p-values will be reported for each shift value. 
Further, primary efficacy analyses will be performed with the PP population with observed data only for 
sensitivity analysis. The following SAS® code is an example of the ANCOVA model for observed data, 
LOCF, and PP analyses: 
PROC MIXED; 
CLASS TREATMENT SITE; 
MODEL CHG = BASELINE TREATMENT SITE / SOLUTION COVB; 
LSMEANS TREATMENT / CL PDIFF; 
RUN; 
Two sample t-tests will be conducted as sensitivity analyses using pattern mixture model imputation with 
the ITT population, observed data only with the ITT population, LOCF imputation with the ITT population, 
MCMC imputation with the ITT population, and observed data only with the PP population. Wilcoxon rank 
sum tests will be conducted as sensitivity analyses using observed data only with the ITT population, 
LOCF imputation with the ITT population, and observed data only with the PP population. 
LS Means for inferior corneal fluorescein staining changes from baseline pre-CAE® and post-CAE® at 
Visit 5 (Day 29) will be displayed graphically in a bar chart with 95% CI bars by treatment group based on 
the ANCOVA analysis of the pattern mixture model imputation with the ITT population.  
13.1.2 OCULAR DISCOMFORT SCALE AT VISIT 5 (DAY 29) POST-CAE, 
 K-161 
 VS VEHICLE 
 
Ocular discomfort scores will be subjectively graded by the subjects using the Ora Calibra® Ocular 
Discomfort Scale at all visits at pre-CAE® and post-CAE® for each eye separately. The Ocular Discomfort 
Scale ranges from 0 to 4 where 0 = No Discomfort, 1 = Intermittent Awareness, 2 = Constant Awareness, 
3 = Intermittent Discomfort, and 4 = Constant Discomfort. Analyses will only be produced for the study eye. 
Ocular discomfort will be summarized at Visit 5 (Day 29) Post-CAE® by treatment groups using continuous 
descriptive statistics. Primary analysis will use an ANCOVA model adjusted for baseline ocular discomfort, 
site, and with treatment group as the explanatory variable. Changes from baseline for each treatment group 
in ocular discomfort will be compared between 
 K-161 
 and vehicle 
 In addition, treatment by 
baseline and treatment by study site interactions will be explored in separate models to evaluate how the 
treatment effect may differ for baseline value and study sites. In the case of a significant interaction at the 
0.05 level, analyses will be performed by baseline stratification (≤3.0 and >3.0) and/or site to understand 
how the treatment effect differs for baseline value and study sites. Least squares means for each treatment 


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group and the LS mean difference between treatment groups will be presented from the models together 
with SE, two-sided p-values, and two-sided 95% CIs. 
The primary analysis will use control-based pattern mixture model imputation on the ITT population at Visit 
5 (Day 29). SAS® code for the multiple imputation analysis will resemble the code in Section 13.1.1 for 
inferior corneal fluorescein staining. The random number seeds for the monotone imputation and pattern 
mixture model imputation described in Section 13.1.1 will be SEED = 354846 and SEED = 956546, 
respectively. In addition, the rounding parameter will be ROUND = 1. 
Should control-based pattern mixture model imputation fail to produce the required imputations, baseline 
measurements of overall ocular discomfort, burning, dryness, grittiness, and stinging from the Ora Calibra® 
Ocular Discomfort & 4-Symptom Questionnaire will added to the VAR statement in an iterative fashion until 
imputation is successful. If multiple imputation still fail to generate the required imputations, then MINIMUM, 
MAXIMUM, and ROUND statements will be removed.  
Sensitivity analyses will be performed using on the ITT population using observed data only and ITT 
population using LOCF. 
Sensitivity analyses under the assumption of a missing at random mechanism will be performed using 
MCMC imputation on the ITT population as described in section 13.1.1 except the random number seed 
for PROC MI will be SEED = 146645 and the rounding parameter will be ROUND = 1.  
Should MCMC imputation fail to produce the required imputations, baseline measurements of overall ocular 
discomfort, burning, dryness, grittiness, and stinging from the Ora Calibra® Ocular Discomfort & 4-Symptom 
Questionnaire will added to the VAR statement in an iterative fashion until imputation is successful. If MCMC 
multiple imputation still fail to generate the required imputation, then MINIMUM, MAXIMUM, and ROUND 
statements will be removed. 
Tipping point analysis will be included for further sensitivity analyses in the manner described in section 
13.1.1. Then, the monotone datasets will be imputed using a set of shift values for the active treatment 
group. The random number seeds for the monotone imputation and pattern mixture model imputation 
described in Section 13.1.1 will be SEED = 5324652 and SEED = 236135, respectively. The set of shift 
values for the imputation will be from 0 to 4.0 by 0.1 increments. The MINIMUM, MAXIMUM, and ROUND 
statements will be removed. 
Further, primary efficacy analyses will be performed with the PP population with observed data only for 
sensitivity analysis. 
Two sample t-tests will be conducted as sensitivity analyses using pattern mixture model imputation with 
the ITT population, observed data only with the ITT population, LOCF imputation with the ITT population, 
MCMC imputation with the ITT population, and observed data only with the PP population. Wilcoxon rank 


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sum tests will be conducted as sensitivity analyses using observed data only with the ITT population, LOCF 
imputation with the ITT population, and observed data only with the PP population. 
Least squares means for Ocular Discomfort Score changes from baseline pre-CAE® and post-CAE® at Visit 
5 (Day 29) will be displayed graphically in a bar chart with 95% CI bars by treatment group based on the 
ANCOVA analysis of the multiple pattern mixture model imputation of the ITT population. 
13.2 
Important Secondary Analyses 
13.2.1 UNANESTHETIZED SCHIRMER’S TEST AT VISIT 5 (DAY 29), 
 K-161 
 VS VEHICLE 
 
Unanesthetized Schirmer’s test will be conducted at all visits at pre-CAE®. The Schirmer’s test strip will be 
placed in the lower temporal lid margin of each eye. After 5 minutes, the test strip will be removed and the 
length of the moistened area will be recorded in mm for each eye. Lower values indicate less tears produced 
in the eye. Analyses will only be produced for study eye. 
Unanesthetized Schirmer’s test will be summarized at Visit 5 (Day 29) Pre-CAE® by treatment groups using 
continuous descriptive statistics. Primary analysis will use an ANCOVA model adjusted for baseline 
unanesthetized Schirmer’s test, site and with treatment group as the explanatory variable. Changes from 
baseline for each treatment group in ocular discomfort will be compared between 
 K-161 
 and 
vehicle 
 In addition, treatment by baseline and treatment by study site interactions will be explored in 
separate models to evaluate how the treatment effect may differ for baseline value and study sites. In the 
case of a significant interaction at the 0.05 level, analyses will be performed by baseline median 
stratification and/or site to understand how the treatment effect differs for baseline value and study sites. 
Least squares means for each treatment group and the LS mean difference between treatment groups will 
be presented from the models together with SE, two-sided p-values, and two-sided 95% CIs. 
The primary analysis will use control-based pattern mixture model imputation with the ITT population. The 
random number seeds for the monotone imputation and pattern mixture model imputation described in 
Section 13.1.1 will be SEED = 465485 and SEED = 849159, respectively. The MINIMUM, MAXIMUM, and 
ROUND statements will be removed. 
Sensitivity analyses will be performed using on the ITT population using observed data only and ITT 
population using LOCF. 
Sensitivity analyses under the assumption of a missing at random mechanism will be performed using 
MCMC imputation on the ITT population as described in section 13.1.1 except the random number seed 
for PROC MI will be SEED = 884564 and the MINIMUM, MAXIMUM, and ROUND statements will be removed. 
Tipping point analysis will be included for further sensitivity analyses in the manner described in section 
13.1.1 on the ITT population. The random number seeds for the monotone imputation and pattern mixture 
model imputation described in Section 13.1.1 will be SEED = 231219 and SEED = 981982, respectively. 


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The set of shift values for the imputation will be from 0 to -5 by an increment of -0.25. The MAXIMUM, 
MINIMUM and ROUND statements will be removed.  
Further, primary efficacy analyses will be performed with the PP population with observed data only for 
sensitivity analysis. 
Two sample t-tests will be conducted as sensitivity analyses using pattern mixture model imputation with 
the ITT population, observed data only with the ITT population, LOCF imputation with the ITT population, 
MCMC imputation with the ITT population, and observed data only with the PP population. Wilcoxon rank 
sum tests will be conducted as sensitivity analyses using observed data only with the ITT population, LOCF 
imputation with the ITT population, and observed data only with the PP population. 
Sensitivity analyses will be performed on the ITT and PP populations using observed data only, and on the 
ITT population using LOCF methodology.  
Least squares means for unanesthetized Schirmer’s test changes from baseline at Visit 5 (Day 29) will be 
displayed graphically in a bar chart with 95% CI bars by treatment group based on the ANCOVA analysis 
of the multiple pattern mixture model imputation of the ITT population. 
13.2.2 TEAR FILM BREAK UP TIME 
The TFBUT will be recorded at all visits at pre-CAE® and post-CAE®. For each eye, 2 measurements will 
be taken and averaged unless the 2 measurements are >2 seconds apart and are each <10 seconds, in 
which case, a third measurement would be taken and the 2 closest of the 3 would be averaged. This 
average will then be used for analyses. Analyses will be provided for study eye only. 
Tear Film Break Up Time will be summarized at Visit 5 (Day 29) Post-CAE® by treatment groups using 
continuous descriptive statistics. Primary analysis will use an ANCOVA model adjusted for baseline TFBUT, 
site and with treatment group as the explanatory variable. Changes from baseline for each treatment group 
in TFBUT will be compared between 
 K-161 
 and vehicle 
 In addition, treatment by baseline 
and treatment by study site interactions will be explored in separate models to evaluate how the treatment 
effect may differ for baseline value and study sites. In the case of a significant interaction at the 0.05 level, 
analyses will be performed by baseline median stratification and/or site to understand how the treatment 
effect differs for baseline value and study sites. Least squares means for each treatment group and the LS 
mean difference between treatment groups will be presented from the models together with standard errors 
SE, two-sided p-values, and two-sided 95% CIs. 
The primary analysis will use control-based pattern mixture model imputation with the ITT population. The 
random number seeds for the monotone imputation and pattern mixture model imputation described in 
Section 13.1.1 will be SEED = 5466765 and SEED = 903573, respectively. The MINIMUM, MAXIMUM, 
and ROUND statements will be removed. 


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Sensitivity analyses will be performed using on the ITT population using observed data only and ITT 
population using LOCF. 
Tipping point analysis will be included for further sensitivity analyses in the manner described in section 
13.1.1. Then, the monotone datasets will be imputed using a set of shift values for the active treatment 
group. The set of shift values for the imputation will be from 0 to -2 by an increment of -0.1. The random 
number seeds for the monotone imputation and pattern mixture model imputation described in Section 
13.1.1 will be SEED = 392187 and SEED = 748451, respectively. The MAXIMUM, MINIMUM and ROUND 
statements will be removed.  
Sensitivity analyses under the assumption of a missing at random mechanism will be performed using 
MCMC imputation on the ITT population as described in section 13.1.1 except the random number seed 
for PROC MI will be SEED = 234993 and the MINIMUM, MAXIMUM, and ROUND statements will be removed. 
Two sample t-tests will be conducted as sensitivity analyses using pattern mixture model imputation with 
the ITT population, observed data only with the ITT population, LOCF imputation with the ITT population, 
MCMC imputation with the ITT population, and observed data only with the PP population. Wilcoxon rank 
sum tests will be conducted as sensitivity analyses using observed data only with the ITT population, LOCF 
imputation with the ITT population, and observed data only with the PP population. 
Least squares means for TFBUT changes from baseline pre-CAE® and post-CAE® at Visit 5 (Day 29) will 
be displayed graphically in a bar chart with 95% CI bars by treatment group based on the ANCOVA analysis 
of the multiple pattern mixture model imputation of the ITT population. 
13.3 
Secondary Analyses 
Secondary efficacy variables will be summarized using continuous descriptive statistics (n, mean, SD, 
median, minimum, and maximum) by visit and treatment group. Two-sample t-tests will be used to analyze 
the efficacy variables for visit-based data between treatment groups. 
Change from baseline in secondary efficacy variables will be summarized by visit and treatment group 
using continuous descriptive statistics. Change from baseline will be analyzed using an ANCOVA model 
adjusting for baseline value and site, and with treatment group as the explanatory variable. Two-sample t-
tests will be used for sensitivity analysis. Paired t-tests will be used to assess change from baseline within 
each treatment group.  
All secondary efficacy analyses will be performed on the ITT population with control-based multiple pattern 
mixture model imputation. All secondary endpoints will be described under subject listings. 
The following secondary efficacy variables will be tested: 
• 
Fluorescein staining by region: central, superior, inferior, temporal, nasal, and corneal sum as 
assessed by the Ora Calibra® Corneal and Conjunctival Staining Scale; 


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• 
Lissamine green staining by region: central, superior, inferior, temporal, nasal, and conjunctival 
sum as assessed by the Ora Calibra® Corneal and Conjunctival Staining Scale 
• 
Conjunctival Redness as assessed by the Ora Calibra® Scale 
• 
TFBUT 
• 
Tear Osmolarity 
• 
Unanesthetized Schirmer’s Test 
• 
Blink Rate 
• 
Ora Calibra® Ocular Discomfort Scale  
• 
Ora Calibra® Ocular Discomfort & 4-Symptom Questionnaire  
• 
Visual Analog Scale: Burning/Stinging, Itching, Foreign Body Sensation, Blurred Vision, Eye 
Dryness, Photophobia, and Pain 
• 
Ocular Surface Disease Index 
13.3.1 FLUORESCEIN STAINING (ORA CALIBRA® SCALE) 
Fluorescein staining will be conducted at all visits at pre-CAE® and post-CAE®. Grading will be conducted 
using the Ora Calibra® Scale from 0 to 4 with the use of half grade (0.5) increments, where grade 0 = None 
and 4 = Severe. The regions to be assessed will be the central, superior, inferior, temporal, corneal sum 
(central, superior, and inferior regions), conjunctival sum (temporal and nasal regions), and total eye score 
for study eye only. 
Visit-based data will be summarized using continuous descriptive statistics for each region, sum score, and 
time point (pre-CAE®, post-CAE®, and change from pre- to post-CAE®). Change from baseline will also be 
summarized using continuous descriptive statistics. 
Two-sample t-tests will be used to analyze differences between treatment groups at each visit between 
active treatment and vehicle. The differences in means, two-sided 95% CIs for the difference in means, and 
two-sided p-values will be reported.  
Change from baseline will be analyzed using ANCOVA with adjustment for baseline fluorescein staining 
score and site, and treatment group as the explanatory variable. The LS means, LS mean differences, SEs, 
two-sided 95% CIs for LS means, two-sided 95% CIs for the difference in means, and two-sided p-values 
will be reported from the ANCOVA model. Two-sample t-tests will be used as sensitivity analysis. Paired t-
tests will be used to analyze change from baseline within each treatment group.  
Analyses will use ITT population with control-based pattern mixture model imputation as described in 
section 13.1.1. The random number seeds for the monotone imputation and pattern mixture model 
imputation will be SEED = 879921 and SEED = 562265, respectively.  
A subject level listing of fluorescein staining will also be produced. 


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13.3.2 LISSAMINE GREEN STAINING (ORA CALIBRA® SCALE) 
Subjects will undergo lissamine green staining at all visits at pre-CAE® and post-CAE®. The grading in the 
inferior, superior, central, temporal, nasal, corneal sum (central, superior, and inferior regions), conjunctival 
sum (temporal and nasal regions), and total eye sum regions will be measured by the Ora Calibra® Corneal 
and Conjunctival Staining Scale for lissamine green staining. A standardized grading system of 0 to 4 is 
used for each of the 5 regions with 0 = No Staining and 4 = Confluent Staining. Half (0.5) grade increments 
may be used. Analyses will be provided for study eye only.   
Visit-based data will be summarized using continuous descriptive statistics by treatment group for each 
region, sum score, and timepoint (pre-CAE®, post-CAE®, and change from pre- to post-CAE®). Change 
from baseline will also be summarized with continuous descriptive statistics. 
Two-sample t-tests will be used to analyze differences between treatment groups at each visit between 
active treatment and vehicle. The differences in means, two-sided 95% CIs for the difference in means, and 
two-sided p-values will be reported.  
Change from baseline will be analyzed using ANCOVA adjusted for baseline lissamine green staining score 
and site, and treatment group as the explanatory variable. The LS means, LS mean differences, SEs, two-
sided 95% CIs for LS means, two-sided 95% CIs for the difference in means, and two-sided p-values will 
be reported from the ANCOVA model. Two-sample t-tests will be used as sensitivity analysis. Paired t-tests 
will be used to analyze change from baseline within each treatment group.  
Analyses will use ITT population with control-based pattern mixture model imputation as described in 
section 13.1.1. The random number seeds for the monotone imputation and pattern mixture model 
imputation will be SEED = 965464 and SEED = 331546, respectively.  
A subject level listing of lissamine green staining will also be produced. 
13.3.3 CONJUNCTIVAL REDNESS 
The Ora Calibra® Conjunctival Redness Scale for Dry Eye will be performed at all visits at pre-CAE® and 
post-CAE®. The conjunctival redness scale ranges from 0 to 4 (half increments may be used) where 0 = 
Normal, without Vasodilation; 1 = Trace Ciliary or Conjunctival Vasodilation; 2 = Broad Ciliary Vasodilation, 
3 = Broad Ciliary and Slight, Horizontal Conjunctival Vasodilation; and 4 = Broad Ciliary and Prominent, 
Horizontal Conjunctival Vasodilation. Analyses will be provided for study eye only.  
Visit-based data will be summarized using continuous descriptive statistics by treatment group for each 
time point (pre-CAE®, post-CAE®, and change from pre-CAE® to post-CAE®). Change from baseline will 
also be summarized with continuous descriptive statistics. 
Two-sample t-tests will be used to analyze differences between treatment groups at each visit between 
active treatment and vehicle. The differences in means, two-sided 95% CIs for the difference in means, and 
two-sided p-values will be reported.  


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Change from baseline will be analyzed using ANCOVA adjusted for baseline redness score and site,  and 
treatment group as the explanatory variable. The LS means, LS mean differences, SEs, two-sided 95% CIs 
for LS means, two-sided 95% CIs for the difference in means, and two-sided p-values will be reported from 
the  ANCOVA model. Two-sample t-tests will be used as sensitivity analysis. Paired t-tests will be used to 
analyze change from baseline within each treatment group.  
Analyses will use ITT population with control-based pattern mixture model imputation as described in 
section 13.1.1. The random number seeds for the monotone imputation and pattern mixture model 
imputation will be SEED = 465526 and SEED = 579516, respectively.  
A subject level listing of conjunctival redness will also be produced. 
13.3.4 TEAR FILM BREAK-UP TIME 
The TFBUT will be recorded at all visits at pre-CAE® and post-CAE®. For each eye, 2 measurements will 
be taken and averaged unless the 2 measurements are >2 seconds apart and are each <10 seconds, in 
which case, a third measurement would be taken and the 2 closest of the 3 would be averaged. This 
average will then be used for analyses. Analyses will be provided for study eye only.  
Visit-based data will be summarized using continuous descriptive statistics by treatment group at each time 
point (pre-CAE®, post-CAE®, change from pre- to post-CAE®). Change from baseline will also be 
summarized with continuous descriptive statistics at each post-baseline visit. 
Two-sample t-tests will be used to analyze differences between treatment groups at each visit between 
active treatment and vehicle. The differences in means, two-sided 95% CIs for the difference in means, and 
two-sided p-values will be reported.  
Change from baseline will be analyzed using ANCOVA adjusted for baseline TFBUT and site, and treatment 
group as the explanatory variable. The LS means, LS mean differences, SEs, two-sided 95% CIs for LS 
means, two-sided 95% CIs for the difference in means, and two-sided p-values will be reported from the 
ANCOVA model. Two-sample t-tests will be used as sensitivity analysis. Paired t-tests will be used to 
analyze change from baseline within each treatment group.  
Analyses will use ITT population with control-based pattern mixture model imputation as described in 
section 13.1.1. The random number seeds for the monotone imputation and pattern mixture model 
imputation will be SEED = 897985 and SEED = 381325, respectively.  
A subject level listing of TFBUT will also be produced. 
13.3.5 TEAR OSMOLARITY 
Tear osmolarity will be measured at Visit 2 (Day 1), Visit 3 (Day 8), Visit 4 (Day 15), and Visit 5 (Day 29) at 
pre-CAE®. Tear osmolarity will be taken once from the temporal canthus of each eye and the measurement 
will be recorded. A second reading may be taken if the first reading is out of range. A maximum of 2 attempts 


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will be made per eye. Tear osmolarity will be measured in milliosmoles per liter (mOsm/L). Analyses will be 
provided for study eye only.  
Visit-based data will be summarized using continuous descriptive statistics by treatment group. Change 
from baseline will also be summarized with continuous descriptive statistics at each post-baseline visit. 
Two-sample t-tests will be used to analyze differences between treatment groups at each visit between 
active treatment and vehicle. The differences in means, two-sided 95% CIs for the difference in means, and 
two-sided p-values will be reported.  
Change from baseline will be analyzed using ANCOVA adjusted for baseline tear osmolarity and site,  and 
treatment group as the explanatory variable. The LS means, LS mean differences, SEs, two-sided 95% CIs 
for LS means, two-sided 95% CIs for the difference in means, and two-sided p-values will be reported from 
the  ANCOVA model. Two-sample t-tests will be used as sensitivity analysis. Paired t-tests will be used to 
analyze change from baseline within each treatment group.  
Analyses will use ITT population with control-based pattern mixture model imputation as described in 
section 13.1.1. The random number seeds for the monotone imputation and pattern mixture model 
imputation will be SEED = 542354 and SEED = 8976544, respectively.  
A subject level listing of tear osmolarity will also be produced. 
13.3.6 UNANESTHETIZED SCHIRMER’S TEST 
Unanesthetized Schirmer’s test will be conducted at all visits at pre-CAE®. The Schirmer’s test strip will be 
placed in the lower temporal lid margin of each eye. After 5 minutes, the test strip will be removed and the 
length of the moistened area will be recorded in mm for each eye. Lower values indicate less tears produced 
in the eye. Analyses will only be produced for study eye. 
Visit-based data will be summarized using continuous descriptive statistics by treatment group. Change 
from baseline will also be summarized with continuous descriptive statistics. 
Two-sample t-tests will be used to analyze differences between treatment groups at each visit between 
active treatment and vehicle. The differences in means, two-sided 95% CIs for the difference in means, and 
two-sided p-values will be reported.  
Change from baseline will be analyzed using an ANCOVA model with adjustment for baseline 
unanesthetized Schirmer’s test reading and site,  and treatment group as the explanatory variable. The LS 
means, LS mean differences, SEs, two-sided 95% CIs for LS means, two-sided 95% CIs for the difference 
in means, and two-sided p-values will be reported from the ANCOVA model. Two-sample t-tests will be 
used as sensitivity analysis. The mean differences, SEs, two-sided 95% CIs for the difference in means, 
and two-sided p-values will be reported from the sensitivity analyses where applicable. Paired t-tests will 
be used to analyze change from baseline within each treatment group. 


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Analyses will use ITT population with control-based pattern mixture model imputation as described in 
section 13.1.1. The random number seeds for the monotone imputation and pattern mixture model 
imputation will be SEED = 6342576 and SEED = 765121, respectively.  
A subject level listing of unanesthetized Schirmer’s test will also be produced. 
13.3.7 BLINK RATE 
Blink rate will be recorded at Visit 2 (Day 1), Visit 3 (Day 8), Visit 4 (Day 15), and Visit 5 (Day 29) at pre-
CAE®. Analyses will only be produced for study eye. 
Visit-based data will be summarized using continuous descriptive statistics by treatment group. Change 
from baseline will also be summarized with continuous descriptive statistics. 
Two-sample t-tests will be used to analyze differences between treatment groups at each visit between 
active treatment and vehicle. The differences in means, two-sided 95% CIs for the difference in means, and 
two-sided p-values will be reported.  
Change from baseline will be analyzed using an ANCOVA model with adjustment for baseline blink rate 
and site, and treatment group as the explanatory variable. The LS means, LS mean differences, SEs, two-
sided 95% CIs for LS means, two-sided 95% CIs for the difference in means, and two-sided p-values will 
be reported from the ANCOVA model. Two-sample t-tests will be used as sensitivity analysis. The mean 
differences, SEs, two-sided 95% CIs for the difference in means, and two-sided p-values will be reported 
from the sensitivity analyses where applicable. Paired t-tests will be used to analyze change from baseline 
within each treatment group. 
Analyses will use ITT population with control-based pattern mixture model imputation as described in 
section 13.1.1. The random number seeds for the monotone imputation and pattern mixture model 
imputation will be SEED = 6754416 and SEED = 234123, respectively.  
A subject level listing of blink rate will also be produced. 
13.3.8 OCULAR DISCOMFORT SCALE (ORA CALIBRA®) 
Ocular discomfort scores will be subjectively graded by the subjects using the Ora Calibra® Ocular 
Discomfort Scale at all visits at pre-CAE® and post-CAE®. The Ocular Discomfort Scale ranges from 0 to 4 
where 0 = No Discomfort, 1 = Intermittent Awareness, 2 = Constant Awareness, 3 = Intermittent Discomfort, 
and 4 = Constant Discomfort. Analyses will only be produced for study eye. 
Visit-based data will be summarized using continuous descriptive statistics for each symptom by treatment 
group at each time point (pre-CAE® and post-CAE®). Change from baseline will also be summarized with 
continuous descriptive statistics. 
Two-sample t-tests will be used to analyze differences between treatment groups at each visit between 
active treatment and vehicle. The differences in means, two-sided 95% CIs for the difference in means, and 
two-sided p-values will be reported.  


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Change from baseline will be analyzed using ANCOVA adjusted for baseline discomfort score and site,  
and treatment group as the explanatory variable. The LS means, LS mean differences, SEs, two-sided 95% 
CIs for LS means, two-sided 95% CIs for the difference in means, and two-sided p-values will be reported 
from the ANCOVA model. Two-sample t-tests will be used as sensitivity analysis. Paired t-tests will be used 
to analyze change from baseline within each treatment group.  
Analyses will use ITT population with control-based pattern mixture model imputation as described in 
section 13.1.1. The random number seeds for the monotone imputation and pattern mixture model 
imputation will be SEED = 8675478 and SEED = 523426, respectively. 
A subject-level listing of ocular discomfort scores will also be produced. 
13.3.8.1 
OCULAR DISCOMFORT SCALE (ORA CALIBRA®) DURING CAE® 
Ocular discomfort scores will be assessed every 5 minutes during the CAE® exposure at Visit 1 (Day -14), 
Visit 2 (Day 1), Visit 4 (Day 15), and Visit 5 (Day 29). Assessments at 0 minutes, 90 minutes, change from 
0 to 90 minutes, change from 0 to last timepoint and changes from baseline will be summarized by treatment 
group, visit, and timepoint using continuous descriptive statistics, including two-sided 95% CIs. Last 
timepoint is described as last recorded discomfort score within a CAE® exposure.   
For the ocular discomfort score at 0 minutes, at 90 minutes, change from 0 to 90 minutes, and change from 
0 to last time point, two-sample t-tests will be employed to compare treatment and Vehicle means at each 
post-baseline visit and time point. The differences in means, two-sided 95% CIs for the difference in means, 
and p-values will be reported.  
Changes from baseline will be compared between treatment groups using ANCOVA models that adjust for 
baseline and site. The LS means, LS mean differences, SEs, two-sided 95% CIs for the difference in means, 
and two-sided p-values will be reported. Two sample t-tests will also be conducted. Within each treatment 
group, paired t-tests will be conducted to compare change from baseline.  
LS means from the ANCOVA will be displayed graphically in a line graph with standard error bars by 
treatment group. 
Analyses will use ITT population with control-based pattern mixture model imputation as described in 
section 13.1.1. The random number seeds for the monotone imputation and pattern mixture model 
imputation will be SEED = 728436 and SEED = 543685, respectively.  
A subject listing of ocular discomfort scores during CAE® will be provided. 
13.3.8.2 
OCULAR DISCOMFORT SCALE (ORA CALIBRA®) DURING CAE® MIXED MODEL REPEATED 
MEASURES 
Ocular discomfort scores will be assessed every 5 minutes during the CAE® exposure at Visit 1 (Day -14), 
Visit 2 (Day 1), Visit 4 (Day 15), and Visit 5 (Day 29). Assessments at 0 minutes, 90 minutes, change from 


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0 to 90 minutes and changes from baseline will be summarized by treatment group, visit, and timepoint 
using continuous descriptive statistics, including two-sided 95% CIs.  
Change from baseline will be assessed using a mixed-effect model for repeated measures (MMRM) to 
compare active treatment and vehicle at Visit 4 (Day 15), and Visit 5 (Day 29) while accounting for the 
correlations among the repeated measurements during the CAE®. The model will include treatment group; 
time (nominal time will be used); treatment by time interaction, and timepoint matched baseline ocular 
discomfort score as fixed effects; and subject as the random effect. The following SAS® code will be used: 
PROC MIXED DATA = INDATA METHOD=REML; 
CLASS SUBJID TREATMENT TIME SITE; 
MODEL CHG_ODS = ODS_BASE SITE TREATMENT | TIME 
/ SOLUTION COVB DDFM=KR; 
 
 
REPEATED TIME / TYPE = UN SUBJECT = SUBJID; 
LSMEANS TREATMENT TREATMENT*TIME/ CL PDIFF; 
ODS OUTPUT LSMEANS = OUTLS DIFFS = OUTDIFFS; 
RUN; 
 
where 
- SUBJID is the subject ID 
- SITE is the Site ID 
- TREATMENT is the name of the treatment group variable  
- TIME is the nominal time of the measurement 
- CHG_ODS is the change from baseline ocular discomfort score 
- ODS_BASE is the timepoint matched baseline ocular discomfort score in the study eye 
- OUTLS is the name of the output dataset that contains the statistical results for the treatment 
means from the MMRM 
- OUTDIFFS is the name of the output dataset that contains the statistical results for the 
differences in treatment means from the MMRM 
If the MMRM does not converge with an unstructured (TYPE  = UN)  covariance matrix, Toeplitz (TYPE  = 
TOEP) and compound symmetry (TYPE = CS) structures will be utilized in order until convergence is 
achieved. If the MMRM with compound symmetry does not converge, MMRM statistical inferences will 
represented as not calculable. 
The LS means, LS mean differences, SEs, two-sided 95% CIs for the difference in means, and two-sided 
p-values will be reported from the MMRM.  
Analyses will use ITT population with observed data only. 


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13.3.9 OCULAR DISCOMFORT & 4-SYMPTOM QUESTIONNAIRE (ORA CALIBRA® SCALE) 
Subjects will rate the severity of each of the following symptoms (for both eyes [OU]) with regard to how 
both their eyes feel in general: overall ocular discomfort, burning, dryness, grittiness, and stinging according 
to the following 6-point (0 to 5) scale where 0 = None and 5 = Worst. Questionnaires will be recorded at all 
visits at pre-CAE® and post-CAE®.  
Visit-based data will be summarized using continuous descriptive statistics for each symptom by treatment 
group at each time point pre-CAE® and post-CAE®. Change from baseline will also be summarized with 
continuous descriptive statistics. 
Two-sample t-tests will be used to analyze differences between treatment groups at each visit between 
active treatment and vehicle. The differences in means, two-sided 95% CIs for the difference in means, and 
two-sided p-values will be reported.  
Change from baseline will be analyzed using ANCOVA adjusted for baseline symptom score and site,  and 
treatment group as the explanatory variable. The LS means, LS mean differences, SEs, two-sided 95% CIs 
for LS means, two-sided 95% CIs for the difference in means, and two-sided p-values will be reported from 
the ANCOVA model. Two-sample t-tests will be used as sensitivity analysis. Paired t-tests will be used to 
analyze change from baseline within each treatment group.  
Analyses will use ITT population with control-based pattern mixture model imputation as described in 
section 13.1.1. The random number seeds for the monotone imputation and pattern mixture model 
imputation will be SEED = 3658465 and SEED = 9631723, respectively.  
A subject-level listing of symptom scores will also be produced. 
13.3.10 VISUAL ANALOG SCALE 
Ocular symptoms of the VAS will recorded at all visits at pre-CAE® and post-CAE®. Subject will be asked 
to subjectively rate ocular symptoms (OU) by placing a vertical mark on the horizontal line to indicate the 
level of discomfort. The length of the assessment line is 100 mm; a measure of 0 mm corresponds to “No 
Discomfort” and 100 mm corresponds to “Maximal Discomfort.” The ocular symptoms used for analysis are 
Burning/Stinging, Itching, Foreign Body Sensation, Blurred Vision, Eye Dryness, Photophobia, and Pain.  
Visit-based data will be summarized using continuous descriptive statistics for each symptom by treatment 
group for each time point (pre-CAE® and post-CAE®). Change from baseline will also be summarized with 
continuous descriptive statistics. 
Two-sample t-tests will be used to analyze differences between treatment groups at each visit between 
active treatment and vehicle. The differences in means, two-sided 95% CIs for the difference in means, and 
two-sided p-values will be reported.  
Change from baseline will be analyzed using ANCOVA adjusted for baseline ocular symptom score and 
site, and treatment group as the explanatory variable. The LS means, LS mean differences, SEs, two-sided 


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95% CIs for LS means, two-sided 95% CIs for the difference in means, and two-sided p-values will be 
reported from the ANCOVA. Two-sample t-tests will be used as sensitivity analysis. Paired t-tests will be 
used to analyze change from baseline within each treatment group.  
Analyses will use ITT population with control-based pattern mixture model imputation as described in 
section 13.1.1. The random number seeds for the monotone imputation and pattern mixture model 
imputation will be SEED = 432467 and SEED = 9434382, respectively.  
A subject-level listing of VAS will also be produced. 
13.3.11 OCULAR SURFACE DISEASE INDEX 
The OSDI© is assessed on a scale of 0 to 4, where 0 = None of the Time, 1 = Some of the Time, 2 = Half 
of the Time, 3 = Most of the Time, and 4 = All of the Time. The OSDI© asks the following 12 questions at 
the subject level: 
Have you experienced any of the following during the last week? 
1. Eyes that are sensitive to light? 
2. Eyes that feel gritty? 
3. Painful or sore eyes? 
4. Blurred vision? 
5. Poor vision? 
Have problems with your eyes limited you in performing any of the following during the last week? 
6. Reading? 
7. Driving at night? 
8. Working with a computer or bank machine (ATM)? 
9. Watching TV? 
Have your eyes felt uncomfortable in any of the following situations during the last week? 
10. Windy conditions? 
11. Places or areas with low humidity (very dry)? 
12. Areas that are air conditioned? 
The total OSDI© score is calculated by the following: 
OSDI© = 
(Sum of Scores) x 25 
# of Questions Answered 
Note that the number of questions answered in the denominator should exclude those questions with a 
response of “N/A.”  
Ocular Surface Disease Index© will be assessed at all visits at pre-CAE®. 


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Visit-based data will be summarized using continuous descriptive statistics for each OSDI© subtotal score 
and total OSDI© score by treatment group. Change from baseline will also be summarized with continuous 
descriptive statistics. 
Two-sample t-tests will be used to analyze differences between treatment groups at each visit between 
active treatment and vehicle. The differences in means, two-sided 95% CIs for the difference in means, and 
two-sided p-values will be reported.  
Change from baseline will be analyzed using ANCOVA adjusted for baseline OSDI score and site,  and 
treatment group as the explanatory variable. The LS means, LS mean differences, SEs, two-sided 95% CIs 
for LS means, two-sided 95% CIs for the difference in means, and two-sided p-values will be reported from 
the ANCOVA. Two-sample t-tests will be used as sensitivity analysis. Paired t-tests will be used to analyze 
change from baseline within each treatment group.  
Analyses will use ITT population with control-based pattern mixture model imputation as described in 
section 13.1.1. The random number seeds for the monotone imputation and pattern mixture model 
imputation will be SEED = 354715 and SEED = 863267, respectively.  
A subject-level listing of OSDI will also be produced. 
14. 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
  
 
 
 
 
 


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14.1.1 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
  
 
 
 
 
  
 
  
 
14.1.2 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 


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14.1.3 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
  
 
 
 
 
 
 
   
 
14.1.4 EFFICACY ENDPOINTS THAT ARE COMPARED AGAINST 
 K-161 FOUR TIMES DAILY (
 (I.E., 
 
K-161 TWICE DAILY [
 
 K-161 
 AND VEHICLE 
 
These analyses will conducted as described in section 13 with secondary endpoints. 
15. Safety Analyses 
All safety analyses will be conducted using the safety population. 


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15.1 
Adverse Events 
An AE is defined as any untoward medical occurrence associated with the use of an IP in humans, whether 
or not considered IP-related. An AE can be any unfavorable and unintended sign (e.g., an abnormal 
laboratory finding), symptom, or disease temporally associated with the use of an IP, without any judgment 
about causality. An AE can arise from any use of the IP (e.g., off-label use, use in combination with another 
drug or medical device) and from any route of administration, formulation, or dose, including an overdose. 
An AE can arise from any delivery, implantation, or use of a medical device, including medical device failure, 
subject characteristics that may impact medical device performance (e.g., anatomical limitations), and 
therapeutic parameters (e.g., energy applied, sizing, dose release, and anatomic fit) associated with 
medical device use. 
All AEs spontaneously reported by the subject and/or in response to an open question from study personnel 
or revealed by observation, physical examination, or other diagnostic procedures will be recorded in the 
source document and on the appropriate pages of the CRF. Any clinically relevant deterioration in clinical 
finding is considered an AE and must be recorded. When possible, signs and symptoms indicating a 
common underlying pathology will be noted as one comprehensive event. 
Documentation regarding the AE will include the nature, date of onset, end date, severity, relationship to 
IP, action(s) taken, seriousness, and outcome of any sign or symptom observed by the investigator or 
reported by the subject upon indirect questioning. Exacerbation of conditions related to the signs and 
symptoms of dry eye disease will not be reported as an AE. All AEs will be coded using MedDRA 22.0.  
Treatment-emergent adverse events (TEAE) are defined as any event that occurs or worsens on or after 
the first dose of study treatment. Adverse events recorded in the eCRF which began prior to treatment will 
not be included in the summary tables but will be included in the AE data listings. 
Severity of an AE is defined as a qualitative assessment of the degree of intensity of an AE as determined 
by the Investigator or reported to him/her by the subject. The assessment of severity is made irrespective 
of relationship to study drug or seriousness of the event and should be evaluated according to the following 
scale: 
• Mild: Event is noticeable to the subject, but is easily tolerated and does not interfere with the subject’s 
daily activities. 
• Moderate: Event is bothersome, possibly requiring additional therapy, and may interfere with the 
subject’s daily activities. 
• Severe: Event is intolerable, necessitates additional therapy or alteration of therapy, and interferes 
with the subject’s daily activities. 
The relationship of each AE to the study drug should be determined by the Investigator using these 
explanations: 


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• 
Related: A reasonable possibility exists that the IP caused the AE. A related AE can be further 
defined as follows: 
 
Occurs within a reasonable temporal sequence to administration of study drug 
 
Cannot be explained by concurrent disease or other drugs or chemicals 
 
Improves or disappears on stopping or reducing study drug (de-challenge) 
 
Reappears on repeated exposure to study drug (re-challenge) 
 
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 
 
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 IP caused the AE. A not related AE 
can be further defined as follows: 
 
Occurs with a temporal relationship to administration of study drug which makes a causal 
relationship improbable 
 
Other drugs, chemicals, or underlying disease provide plausible explanations of causality 
 
Is known to be associated with the participant’s clinical condition, or with other medication taken 
by the participant 
The expectedness of an AE should be determined based upon existing safety information about the IP 
using these explanations: 
• 
Unexpected: An AE that is not listed in the Investigator’s Brochure (IB) or is not listed at the 
specificity or severity that has been observed. 
• 
Expected: An AE that is listed in the IB at the specificity and severity that has been observed. 
• 
Not applicable: An AE unrelated to the IP. 
An overall summary will be presented that includes the number of events and the number and percentage 
of subjects who experienced at least one AE, ocular AE, and non-ocular AE by treatment group and over 
all subjects. This summary will also include breakdowns of TEAEs further categorized as ocular or non-
ocular, TEAEs by severity, TEAEs by relationship to study drug, TEAEs causing premature treatment 
discontinuation, and TEAEs leading to death.  TE-SAEs will also be categorized as ocular or non-ocular, 
TE-SAEs by severity, TE-SAEs by relationship to study drug, TE-SAEs causing premature treatment 
discontinuation, and TE-SAEs leading to death.   
Summaries will be provided for the following categories of AEs:  
• 
Ocular and non-ocular TEAEs by SOC and PT 
• 
Ocular and non-ocular TEAEs by SOC, PT, and maximal severity 
• 
Ocular and non-ocular treatment-related TEAEs by SOC and PT 
• 
Ocular and non-ocular TEAEs by SOC, PT and visit. 


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If a subject reports the same PT multiple times within the same SOC, that PT will only be reported once 
within that SOC. As with the PT, if a subject reports multiple conditions within the same SOC, that SOC will 
only be reported once. In the summary, SOCs will be listed in ascending alphabetical order; PTs will be 
listed in order of descending frequency for all subjects within each SOC.   
All AEs will be presented in a subject listing. In addition, all SAEs will be presented in a separate listing. 
15.2 
 
 
 
 
 
15.3 
 
 
 
 
 
 
 
 
 
15.4 
 
 
 
  
 
 
 
 
 
15.5 
 
 
 


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15.6 
 
 
 
 
 
 
15.7 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
15.8 
Maximum dose tolerability by comparing the 
 K-161 
 arm to the 
 and 
 K-
161 
 arms  
Safety analyses as described in Section 15 will include summarizations by treatment group. No additional 
analyses will be conducted to otherwise examine maximum dose tolerability. 


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16. Other Measures 
16.1 
 
 
 
 
  
 
  
 
 
16.2 
 
 
 
 
 
 
 
 
 
 
  
 
 
16.3 
 
 
 
16.4 
 
  
 


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17. 
 
 
 
 
 
 
 
 
 
  
 
18. Changes from Protocol-Stated Analyses 
In the protocol, it was stated that analyses of exploratory endpoints will use ITT population with pattern 
mixture model imputation. Analyses for OCT and strip meniscometry  will use ITT population with observed 
data only. 
19. Revision History 
Documentation of revision to the SAP will commence after approval of the final version 1.0. 
20. Tables 
Tables that will be included in the topline delivery are shown in boldface font. 
Table Number 
Title 
Population 
Table  14.1.1 
 Subject Disposition 
 All Screened 
Subjects 
Table  14.1.2.1 
 Demographic Characteristics 
 ITT Population 
Table  14.1.2.2 
 Demographic Characteristics 
 Safety Population 
Table  14.1.3.1 
 Baseline Disease Characteristics 
 ITT Population 
Table  14.1.3.2 
 Baseline Disease Characteristics 
 Safety Population 
Table  14.1.4.1 
 Ocular Medical History 
 Safety Population 
Table  14.1.4.2 
 Non-Ocular Medical History 
 Safety Population 
Table  14.1.5.1 
 Ocular Concomitant Medications 
 ITT Population 
Table  14.1.5.2 
 Non-Ocular Concomitant Medications 
 ITT Population 
Table  
14.2.1.1.1 
 Inferior Corneal Fluorescein Staining (Ora Calibra 
Scale) 
 K-161 
 vs Vehicle 
 ITT Population with 
PMM 
Table  
14.2.1.1.2 
 Inferior Corneal Fluorescein Staining (Ora Calibra Scale) 
by Baseline Stratification and Site 
 K-161 
 vs 
Vehicle  
 ITT Population PMM 


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Table  
14.2.1.1.3 
 Inferior Corneal Fluorescein Staining (Ora Calibra Scale) 
by Baseline Stratification 
 K-161 
 vs Vehicle  
 ITT Population with 
PMM 
Table  
14.2.1.1.4 
 Inferior Corneal Fluorescein Staining (Ora Calibra Scale) 
by Site 
 K-161 
 vs Vehicle  
 ITT Population with 
PMM 
Table  
14.2.1.1.5 
 Inferior Corneal Fluorescein Staining (Ora Calibra Scale) 
 K-161 
 vs Vehicle 
 ITT Population with 
Observed Data Only 
Table  
14.2.1.1.6 
 Inferior Corneal Fluorescein Staining (Ora Calibra Scale) 
 K-161 
 vs Vehicle 
 ITT Population with 
LOCF 
Table  
14.2.1.1.7 
 Inferior Corneal Fluorescein Staining (Ora Calibra Scale) 
 K-161 
 vs Vehicle 
 ITT Population with 
MCMC 
Table  
14.2.1.1.8 
 Tipping Point Analysis: Inferior Corneal Fluorescein 
Staining (Ora Calibra Scale) 
 K-161 
 vs Vehicle 
 ITT Population with 
PMM 
Table  
14.2.1.1.9 
 Inferior Corneal Fluorescein Staining (Ora Calibra Scale) 
 K-161 
 vs Vehicle 
 PP Population with 
Observed Data Only 
Table  
14.2.1.2.1 
 Ocular Discomfort Scale (Ora Calibra Scale) 
 K-
161 
 vs Vehicle 
 ITT Population with 
PMM 
Table  
14.2.1.2.2 
 Ocular Discomfort Scale (Ora Calibra Scale) by Baseline 
Median and Site 
 K-161 
 vs Vehicle 
 ITT Population with 
PMM 
Table  
14.2.1.2.3 
 Ocular Discomfort Scale (Ora Calibra Scale) by Baseline 
Median 
 K-161 
 vs Vehicle 
 ITT Population with 
PMM 
Table  
14.2.1.2.4 
 Ocular Discomfort Scale (Ora Calibra Scale) by Site 
 
K-161 
 vs Vehicle 
 ITT Population with 
PMM 
Table  
14.2.1.2.5 
 Ocular Discomfort Scale (Ora Calibra Scale) 
 K-161 
 vs Vehicle 
 ITT Population with 
Observed Data Only 
Table  
14.2.1.2.6 
 Ocular Discomfort Scale (Ora Calibra Scale) 
 K-161 
 vs Vehicle 
 ITT Population with 
LOCF 
Table  
14.2.1.2.7 
 Ocular Discomfort Scale (Ora Calibra Scale) 
 K-161 
 vs Vehicle 
 ITT Population with 
MCMC 
Table  
14.2.1.2.8 
 Tipping Point Analysis: Ocular Discomfort Scale (Ora 
Calibra Scale) 
 K-161 
 vs Vehicle 
 ITT Population with 
PMM 
Table  
14.2.1.2.9 
 Ocular Discomfort Scale (Ora Calibra Scale) 
 K-161 
 vs Vehicle 
 PP Population with 
Observed Data Only 
Table  
14.2.2.1.1 
 Unanesthetized Schirmer’s Test (mm) 
 K-161 
 
vs Vehicle 
 ITT Population with 
PMM 
Table  
14.2.2.1.2 
 Unanesthetized Schirmer’s Test (mm) by Baseline Median 
and Site 
 K-161 
 vs Vehicle 
 ITT Population with 
PMM 
Table  
14.2.2.1.3 
 Unanesthetized Schirmer’s Test (mm) by Baseline Median 
 K-161 
 vs Vehicle 
 ITT Population with 
PMM 
Table  
14.2.2.1.4 
 Unanesthetized Schirmer’s Test (mm) by Site 
 K-161 
 vs Vehicle 
 ITT Population with 
PMM 
Table  
14.2.2.1.5 
 Unanesthetized Schirmer’s Test (mm) 
 K-161 
 vs 
Vehicle 
 ITT Population with 
Observed Data Only 
Table  
14.2.2.1.6 
 Unanesthetized Schirmer’s Test (mm) 
 K-161 
 vs 
Vehicle 
 ITT Population with 
LOCF 
Table  
14.2.2.1.7 
 Unanesthetized Schirmer’s Test (mm) 
 K-161 
 vs 
Vehicle 
 ITT Population with 
MCMC 
Table  
14.2.2.1.8 
 Tipping Point Analysis: Unanesthetized Schirmer’s Test 
(mm) 
 K-161 
 vs Vehicle 
 ITT Population with 
PMM 


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Table  
14.2.2.1.9 
 Unanesthetized Schirmer’s Test (mm) 
 K-161 
 vs 
Vehicle 
 PP Population with 
Observed Data Only 
Table  
14.2.2.2.1 
 Tear Film Break-Up Time (seconds) 
 K-161 
 vs 
Vehicle 
 ITT Population with 
PMM 
Table  
14.2.2.2.2 
 Tear Film Break-Up Time (seconds) by Baseline Median 
and Site 
 K-161 
 vs Vehicle 
 ITT Population with 
PMM 
Table  
14.2.2.2.3 
 Tear Film Break-Up Time (seconds) by Baseline Median 
 K-161 
 vs Vehicle 
 ITT Population with 
PMM 
Table  
14.2.2.2.4 
 Tear Film Break-Up Time(seconds) by Site 
 K-161 
 vs Vehicle 
 ITT Population with 
PMM 
Table  
14.2.2.2.5 
 Tear Film Break-Up Time (seconds) 
 K-161 
 vs 
Vehicle 
 ITT Population with 
Observed Data Only 
Table  
14.2.2.2.6 
 Tear Film Break-Up Time (seconds) 
 K-161 
 vs 
Vehicle 
 ITT Population with 
LOCF 
Table  
14.2.2.2.7 
 Tear Film Break-Up Time (seconds) 
 K-161 
 vs 
Vehicle 
 ITT Population with 
MCMC 
Table  
14.2.2.2.8 
 Tipping Point Analysis: Tear Film Break-Up Time 
(seconds) 
 K-161 
 vs Vehicle 
ITT Population with 
PMM 
Table  
14.2.2.2.9 
 Tear Film Break-Up Time (seconds) 
 K-161 
 vs 
Vehicle 
 PP 
Population 
with 
Observed Data Only 
Table  14.2.3.1 
 Fluorescein Staining (Ora Calibra Scale) 
 ITT Population with 
PMM 
Table  14.2.3.2 
 Lissamine Green Staining (Ora Calibra Scale) 
 ITT Population with 
PMM 
Table  14.2.3.3 
 Conjunctival Redness (Ora Calibra Scale) 
 ITT Population with 
PMM 
Table  14.2.3.4 
 Tear Film Break-Up Time (seconds) 
 ITT Population with 
PMM 
Table  14.2.3.5 
 Tear Osmolarity (mOsm/L) 
 ITT Population with 
PMM 
Table  14.2.3.6 
 Unanesthetized Schirmer’s Test (mm) 
 ITT Population with 
PMM 
Table  14.2.3.7 
 Blink Rate (Blinks per 60 seconds) 
 ITT Population with 
PMM 
Table  14.2.3.8 
 Ocular Discomfort Scale (Ora Calibra) 
 ITT Population with 
PMM 
Table  
14.2.3.9.1 
 Ocular Discomfort Scale during CAE (Ora Calibra) 
 ITT Population with 
PMM 


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Table  
14.2.3.9.2 
 Ocular Discomfort Scale during CAE (Ora Calibra) MMRM 
Analysis 
 ITT Population with 
Observed Data Only 
Table  14.2.3.10 
 Ocular Discomfort & 4-Symptom Questionnaire (Ora 
Calibra Scale) 
 ITT Population with 
PMM 
Table  14.2.3.11  Visual Analogue Scale 
 ITT Population with 
PMM 
Table  14.2.3.12  Ocular Surface Disease Index 
 ITT Population with 
PMM 
Table  14.2.4 
 Summary of Efficacy Analyses 
 
Table  14.3.1 
Overall Summary of Adverse Events (AE) by Treatment 
Group 
 Safety Population 


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Table  14.3.2.1 
Ocular Treatment-Emergent Adverse Events (TEAE) by 
System Organ Class and Preferred Term 
 Safety Population 
Table  14.3.2.2 
Non-Ocular Treatment-Emergent Adverse Events (TEAE) 
by System Organ Class and Preferred Term 
 Safety Population 
Table  14.3.3.1 
Ocular Treatment-Emergent Adverse Events (TEAE) by 
System Organ Class, Preferred Term, and Maximal 
Severity 
 Safety Population 
Table  14.3.3.2 
Non-Ocular Treatment-Emergent Adverse Events (TEAE) 
by System Organ Class, Preferred Term, and Maximal 
Severity 
 Safety Population 
Table  14.3.4.1 
Ocular Treatment-Related Treatment-Emergent Adverse 
Events (TEAE) by System Organ Class and Preferred 
Term 
 Safety Population 
Table  14.3.4.2 
Non-Ocular Treatment-Related Treatment-Emergent 
Adverse Events (TEAE) by System Organ Class and 
Preferred Term 
 Safety Population 
Table  14.3.5.1 
All Ocular Treatment-Emergent Adverse Events (TEAE) by 
System Organ Class, Preferred Term, and Study Day of 
Onset 
 Safety Population 
Table  14.3.5.2 
 All Non-Ocular Treatment-Emergent Adverse Events 
(TEAE) by System Organ Class, Preferred Term, and 
Study Day of Onset   
 Safety Population 


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Table  14.3.15 
 Exposure to Study Drug 
 Safety Population 
21. Listings 
Listing Number 
Title 
Listing  16.1.7 
 Randomization Schedule 
Listing  16.2.1.1 
 Subject Disposition 
Listing  16.2.1.2 
 Inclusion/Exclusion Criteria and Screen Failure 
Listing  16.2.2 
 Protocol Deviations 
Listing  16.2.3 
 Study Population Inclusion 
Listing  16.2.4.1 
 Demographics 
Listing  16.2.4.2 
 Ocular Medical History 
Listing  16.2.4.3 
 Non-Ocular Medical History 
Listing  16.2.4.4 
 Ocular Prior and Concomitant Medications 
Listing  16.2.4.5 
 Non-Ocular Prior and Concomitant Medications 
Listing  16.2.5.1 
 Run-In, Run-In Instillation, and Run-In Replacement 
Listing  16.2.5.2 
 Study Drug Assignment, Instillation, and Replacement 
Listing  16.2.5.3 
 Study Drug Exposure and Dosing Compliance 
Listing  16.2.5.4 
 Study Drug Accountability 
Listing  16.2.6.1 
 Fluorescein Corneal and Conjunctival Staining (Ora Calibra) 
Listing  16.2.6.2 
 Ocular Discomfort Scale 
Listing  16.2.6.3 
 Unanesthetized Schirmer’s Test 
Listing  16.2.6.4 
 Tear Film Break-Up Time (TFBUT) 
Listing  16.2.6.5 
 Lissamine Green Corneal and Conjunctival Staining (Ora Calibra) 
Listing  16.2.6.6 
 Conjunctival Redness 
Listing  16.2.6.7 
 Tear Osmolarity 
Listing  16.2.6.8 
 Blink Rate (Blinks per 60 seconds) 
Listing  16.2.6.9 
 Ocular Discomfort Scale (Ora Calibra®) during CAE 
Listing  16.2.6.10 
 Ocular Discomfort & 4-Symptom Questionnaire (Ora Calibra) 
Listing  16.2.6.11 
 Visual Analog Scale (VAS) 
Listing  16.2.6.12 
 Ocular Surface Disease Index (OSDI) 


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Listing  16.2.7.1 
 All Adverse Events 
Listing  16.2.7.2 
 Ocular Adverse Events 
Listing  16.2.7.3 
 Non-Ocular Adverse Events 
Listing  16.2.7.4 
 Serious Adverse Events 
22. Figures 
 
Figure Number 
Title 
Population 
Figure  14.2.1.1.1 
 Inferior Corneal Fluorescein Staining (Ora Calibra 
Scale) 
 K-161 
 vs Vehicle 
 ITT Population with 
PMM 
Figure  14.2.1.2.1 
 Ocular Discomfort Scale (Ora Calibra Scale) 
 K-
161 
 vs Vehicle 
 ITT Population with 
PMM 
Figure  14.2.2.1.1 
 Unanesthetized Schirmer’s Test (mm) 
 K-161 
 vs Vehicle 
 ITT Population with 
PMM 
Figure  14.2.2.2.1 
 Tear Film Break-Up Time (seconds) 
 K-161 
 
vs Vehicle 
 ITT Population with 
PMM 
Figure 14.2.3.1 
Ocular Discomfort Scale during CAE (Ora Calibra)  
ITT Population 
with 
PMM 


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Protocol K-161-2.01US / 
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Prot_001.pdf: 
K-161-2.01US 
 
 
A Phase 2, Prospective, Double-Masked, Randomized, Multi-Center, Vehicle-Controlled, 
Parallel-group, 4-week Administration Study Assessing the Safety, Efficacy, and 
Optimum Dosage of K-161 in non-Japanese and Japanese Adult Subjects with Moderate 
to Severe Dry Eye Disease Both in Environmental and Controlled Adverse Environmental 
(CAE®) Settings 
 
NCT #: 04084483 
Clinical Trial Protocol 
Amendment 1 
 13 June 2019 
 


K-161 
Sponsor: Kowa Research Institute (KRI) 
Clinical Trial Protocol No.: K-161-2.01US 
Amendment 1 13June2019 
Clinical Trial Protocol: K-161-2.01US 
Protocol Title: 
A Phase 2, Prospective, Double-Masked, 
Randomized, Multi-Center, Vehicle-Controlled, 
Parallel-group, 4-week Administration Study 
Assessing the Safety, Efficacy, and Optimum 
Dosage of K-161 in non-Japanese and Japanese 
Adult Subjects with Moderate to Severe Dry Eye 
Disease Both in Environmental and Controlled 
Adverse Environmental (CAE®) Settings 
Protocol Number: 
K-161-2.01US / 
 
Study Phase: 
2 
Investigational Product 
Name: 
K-161 
IND/IDE/PMA Number: 
138738 
Indication: 
Dry eye disease 
Investigators: 
Multi-Center 
Sponsor: 
Kowa Research Institute, Inc. (KRI) 
 
 
 
Date 
Original Protocol: 14 September 2018 
Amendment 1: 
13 June 2019 
 
 
Confidentiality Statement 
 
This protocol contains confidential, proprietary information of 
 and/or Kowa 
Research Institute, Inc. Further dissemination, distribution or copying of this protocol 
or its contents is strictly prohibited. 
 


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SPONSOR PERSONNEL 
 
 
MEDICAL MONITOR 
 
 


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SYNOPSIS 
Protocol Title: 
A Phase 2, Prospective, Double-Masked, 
Randomized, Multi-Center, Vehicle-Controlled, 
Parallel-group, 4-week Administration Study 
Assessing the Safety, Efficacy, and Optimum 
Dosage of K-161 in non-Japanese and Japanese 
Adult Subjects with Moderate to Severe Dry Eye 
Disease Both in Environmental and Controlled 
Adverse Environmental (CAE) Settings 
Protocol Number: 
K-161-2.01US / 
 
Investigational Product: 
1. K-161 Ophthalmic Solution 
2. Placebo Ophthalmic Solution (Vehicle) 
Study Phase: 
2 
Objective(s): 
The objective of the study is to assess the safety, 
efficacy, optimum dosage, and dosing regimen 
of K-161 compared to its vehicle from Day 1 
(baseline) to Day 29 in non-Japanese and 
Japanese adult subjects with moderate to severe 
dry eye disease both in environmental and CAE 
settings. 
Overall Study Design: 
Structure: 
Prospective, double-masked, randomized, multi-
center, vehicle-controlled, parallel-group study 
Duration: 
An individual subject’s participation is estimated 
to be approximately 6 weeks (42 days) with a 
follow-up phone call. 
Controls: 
Placebo Ophthalmic Solution (Vehicle) 
Dosage/Dose Regimen/ 
Instillation/Application/Use: 
Subjects eligible to be randomized will receive 
one of the following treatments to be 
administered bilaterally for 28 days (from Visit 2 
to Visit 5). 
1) 
 K-161 Ophthalmic Solution; 
 
 
2) 
 K-161 Ophthalmic Solution; 
 
 
3) 
 K-161 Ophthalmic Solution; 
 
  
4) Placebo Ophthalmic Solution (Vehicle);  
 
 
During a 14-day study run-in period (for the 
purpose of subject selection) prior to 
randomization, all subjects will receive Placebo 


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Ophthalmic Solution (Vehicle) 
 
 
Summary of Visit Schedule: 
5 visits over the course of approximately 6 
weeks with a follow-up phone call. 
 Visit 1 = Day -14 ± 2, CAE Screening  
 Visit 2 = Day 1, CAE Confirmation/ Baseline 
 Visit 3 = Day 8 ± 1 
 Visit 4 = Day 15 ± 2 
 Visit 5 = Day 29 ± 2 
 Follow-up Phone Call = Day 36 ± 2  
Measures Taken to Reduce 
Bias: 
This is a double-masked, randomized treatment 
assignment study. 
Study Population Characteristics: 
Number of Subjects: 
Approximately 600 subjects will be screened to 
enroll approximately 240 (60 per treatment 
arm*) subjects 
 
Condition/Disease: 
Dry Eye Disease (DED) 
Inclusion Criteria: 
Subjects who meet all of the following criteria will be eligible to participate in the 
study. 
Subjects must: 


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1. Be at least 18 years of age at the time of informed consent visit 
2. Have a reported history of dry eye disease in both eyes 
 
and a history of eye drop use for dry eye 
symptoms 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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Exclusion Criteria: 
Subjects who meet any of the following criteria will not be eligible to participate in 
the study. 
Subjects must not: 
1. Have any clinically significant ocular condition 
 
 
 
 
 
 
2. Have a history of 
 
corneal refractive surgery, and/or any other ocular surgical 
procedure 
 within 12 months 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  


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Evaluation Criteria: 
 
Efficacy Measures and 
Endpoints: 
Primary Efficacy Endpoints: 
The primary efficacy endpoint (sign) is: 
 Change in inferior corneal staining score 
from Day 1 (baseline) to Day 29 by 
comparing 
 K-161 
 to its 
vehicle 
 in CAE setting 
The primary efficacy endpoint (symptom) is: 
 Change in Ora Calibra® ODS from Day 1 
(baseline) to Day 29 by comparing 
 
K-161 
 to its vehicle 
 
 in CAE setting 
Important Secondary Efficacy Endpoints: 
The important secondary efficacy endpoints are: 
 Change in Schirmer’s Test value 
(unanesthetized) from Day 1 (baseline) to 
Day 29 by comparing 
 K-161 
 
 to its vehicle 
 in 
environmental setting 
 Change in TFBUT from Day 1 (baseline) 
to Day 29 by comparing 
 K-161 
 to its vehicle 
 in 
CAE setting 
Secondary Efficacy Endpoints: 
The secondary efficacy endpoints are 
comparisons of the following associated with 
taking the vehicle 
 and K-161 
 (i.e., 
 K-161 
 and 
 K-161 
 for: 
 Fluorescein staining by region: central, 
superior, inferior, temporal, nasal and 
corneal sum as assessed by the Ora 
Calibra® Corneal and Conjunctival 
Staining Scale 
 Lissamine green staining by region: 
central, superior, inferior, temporal, 
nasal, and conjunctival sum as assessed 
by the Ora Calibra® Corneal and 
Conjunctival Staining Scale 
 Conjunctival Redness as assessed by the 
Ora Calibra® Scale 
 TFBUT  


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 Tear Osmolarity 
 Schirmer’s Test (unanesthetized) 
 Blink Rate 
 Ora Calibra® Ocular Discomfort Scale  
 Ora Calibra® Ocular Discomfort and 4-
Symptom Questionnaire  
 Visual Analog Scale (VAS)   
 Burning/ Stinging 
 Itching 
 Foreign Body Sensation 
 Blurred Vision 
 Eye Dryness 
 Photophobia 
 Pain 
 OSDI©  
 Daily diary  
Safety Measures: 
 
 
  
 
  
 Adverse event query  
 
  
 
 
 
 


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 Maximum dose tolerability by comparing 
the 
 K-161 
 arm to the 
 
and 
 K-161 
 arms 
Other: 
Analysis Populations 
 Intent-to-Treat Population – The intent-to-treat (ITT) population includes 
all randomized subjects. The primary analysis will be performed on the 
ITT population. Subjects in the ITT population will be analyzed as 
randomized. 
 Per Protocol Population – The per protocol (PP) population includes 
subjects in the ITT population who do not have significant protocol 
deviations and who complete the study. Protocol deviations will be 
assessed prior to database lock and unmasking. Subjects in the PP 
population will be analyzed as treated. 
 Safety Population – The safety population includes all subjects who have 
received at least one dose of the investigational product. The safety 
population will be analyzed for all safety assessments. Subjects in the 
Safety population will be analyzed as treated.  
Sample Size 
This study is expected to enroll 240 subjects in a 1:1:1:1 ratio across four 
treatment arms, or 60 subjects per treatment arm. In addition, randomization will 
be stratified such that 
 will be randomized in each treatment 
arm.  
The standard deviation for change from baseline in post-CAE inferior corneal 
fluorescein staining ranges between 0.68 and 0.81 units. Assuming a common 
standard deviation of 0.77, a sample size of 60 subjects per group will have 
approximately 90% power to detect a difference of 0.46 units between the active 
treatment group and the vehicle group using a two-sample t-test at a two-sided 
significance level of 0.05. Again, it is assumed that adjusting for baseline and site 
will further reduce variability and provide >90% power. 
Likewise, the standard deviation for change from baseline scores in the post-CAE 
ODS at Day 29 is assumed a common standard deviation of 0.82, a sample size of 
60 subjects per group will have approximately 90% power to detect a difference of 
0.49 units between the active treatment group and the vehicle group using a two-
sample t-test at a two-sided significance level of 0.05. It is assumed that adjusting 
for baseline and site will further reduce variability and provide >90% power. 


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Multiplicity Consideration: 
Common factors for multiplicity are multiple arms and multiple endpoints. 
1) Multiple arms 
The primary treatment comparison will be between the 
 K-161 
 treatment 
arm and the vehicle 
 treatment arm. Other treatment comparisons will be 
considered secondary or exploratory.  
2) Multiple endpoints 
The primary and important secondary endpoints will be tested hierarchically to 
maintain the study-wise Type I error rate of 0.05. First, change from baseline in 
inferior corneal fluorescein staining will be tested at an alpha level of 0.05. The 
test for change from baseline scores in the ODS will be conducted at an alpha 
level of 0.05 only if the previous test demonstrates significance. The test for 
change from baseline in Schirmer’s test will be conducted at an alpha level of 0.05 
only if the previous test demonstrates significance. The test for change from 
baseline in TFBUT will be conducted at an alpha level of 0.05 only if the previous 
test demonstrates significance. All other secondary and exploratory endpoints and 
treatment comparisons will be considered exploratory. 
The hierarchical testing order will be as follows: 
Primary comparisons: 
1. Comparison of the change from baseline in post-CAE inferior corneal 
staining at Day 29 (
 K-161 
 vs vehicle) 
2. Comparison of the change from baseline in post-CAE ocular discomfort at 
Day 29 (
 K-161 
 vs vehicle) 
Important Secondary comparisons: 
3. Comparison of the change from baseline in pre-CAE Schirmer’s test value 
at Day 29 (
 K-161 
 vs vehicle) 
4. Comparison of the change from baseline in post-CAE TFBUT at Day 29 
(
 K-161 
 vs vehicle) 
Thus, the study-wise Type I error rate will be maintained at 0.05 by considering 
only one dose of K-161 as the primary treatment comparison and using a 
hierarchical testing procedure. 
Primary Efficacy Analyses:  
The primary comparisons of change from baseline in post-CAE inferior corneal 
staining and ocular discomfort between the 
 K-161 
 group and the 
vehicle group at Day 29, will be performed using analysis of covariance 
(ANCOVA) models. The respective baseline post-CAE score will be included as a 
covariate in each model and site will be included as a fixed effect. Treatment by 
baseline and treatment by site interactions will be explored in separate models 
and, if significant, analyses will be performed by baseline stratification and/or site, 
respectively, to further examine significant interactions. The primary analyses will 
use the ITT population. 


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For the primary endpoints multiple imputation with a control-based pattern 
mixture model will be used.  
Secondary Efficacy Analyses 
Secondary and exploratory efficacy endpoints will be analyzed similarly to the 
primary analyses on the ITT population. Continuous and ordinal variables 
collected at each visit will be summarized descriptively (n, mean, standard 
deviation, median, minimum and maximum), and analyzed with ANCOVA 
models each K-161 
 group to the vehicle group. All visit-based data will be 
analyzed by visit and for each timepoint, if applicable, as well as the change from 
baseline.  
Data collected pre- and post-CAE will also be analyzed for the change from pre- 
to post-CAE within each visit. Data collected during the CAE will also be 
analyzed using repeated measures models including all of the time points from a 
CAE exposure. Daily subject diary symptom data will be analyzed using each 
weekly average score from the diaries, as well as using repeated measures models 
across the diary collection period. 
For the two important secondary endpoints, other secondary, and exploratory 
endpoints, multiple imputation with a control-based pattern mixture model will be 
used.   
 
 
 
 
Safety Variables 
Adverse events (AEs) will be coded using the MedDRA dictionary. Frequencies 
and percentages of subjects with treatment-emergent adverse events (TEAEs), 
serious TEAEs, and TEAEs causing premature 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 will be given of subjects 
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 performed for 
ocular and non-ocular AEs.  
 
 
 
 
 
 
 
 
 
  


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Other analyses may be conducted and the details will be included in a separate 
statistical analysis plan. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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TABLE OF CONTENTS 
Clinical Trial Protocol: K-161-2.01US .......................................................................... 1 
SYNOPSIS ..................................................................................................................... 3 
TABLE OF CONTENTS ............................................................................................. 14 
LIST OF ABBREVIATIONS ...................................................................................... 18 
1 
INTRODUCTION .............................................................................................. 20 
 
Drug Profile from Non-clincial Studies ................................................... 20 
2 
STUDY OBJECTIVES ....................................................................................... 21 
3 
CLINICAL HYPOTHESES ............................................................................... 21 
4 
OVERALL STUDY DESIGN ............................................................................ 21 
5 
STUDY POPULATION ..................................................................................... 22 
 
Number of Subjects (approximate) .......................................................... 22 
 
Study Population Characteristics .............................................................. 22 
 
Inclusion Criteria ...................................................................................... 22 
 
Exclusion Criteria ..................................................................................... 24 
 
Withdrawal Criteria (if applicable) .......................................................... 25 
6 
STUDY PARAMETERS .................................................................................... 26 
 
Efficacy Endpoints ................................................................................... 26 
6.1.1 
Primary Efficacy Endpoints .................................................. 26 
6.1.2 
Important Secondary Efficacy Endpoints ............................. 26 
6.1.3 
Secondary Efficacy Endpoints .............................................. 26 
6.1.4 
Exploratory Efficacy Endpoints ............................................ 27 
 
Safety Measures ....................................................................................... 27 
 
Other Measures ......................................................................................... 27 
 
Clinical Laboratory Measurements .......................................................... 29 
7 
STUDY MATERIALS ....................................................................................... 29 
 
Study Treatments ...................................................................................... 29 
7.1.1 
Masking................................................................................. 29 
7.1.2 
Description of and Justification for the Route of 
Administration, Dosage, Dosage Regimen, and Treatment 
Period. ................................................................................... 29 
7.1.3 
Instructions for Use and Administration ............................... 30 


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Labeling, Packaging, Storage, Accountability, and Return or Disposal of 
Investigational Product ............................................................................. 30 
7.2.1 
Labeling/Packaging............................................................... 30 
7.2.2 
Storage of Investigational Product ........................................ 30 
7.2.3 
Accountability of Investigational Product ............................ 30 
7.2.4 
Return or Disposal of Investigational Product ...................... 31 
 
Other Study Supplies ................................................................................ 31 
8 
STUDY METHODS AND PROCEDURES ...................................................... 31 
 
Subject Entry Procedures ......................................................................... 31 
8.1.1 
Overview ............................................................................... 31 
8.1.2 
Informed Consent.................................................................. 31 
8.1.3 
Washout Intervals ................................................................. 31 
8.1.4 
Procedures for Final Study Entry .......................................... 31 
8.1.5 
Methods for Assignment to Treatment Groups: ................... 31 
 
Concurrent Therapies ............................................................................... 32 
8.2.1 
Prohibited Medications/Treatments ...................................... 32 
8.2.2 
Escape Medications .............................................................. 32 
8.2.3 
Special Diet or Activities ...................................................... 32 
 
Schedule of Visits, Measurements and Dosing ........................................ 41 
8.4.1 
Scheduled Visits.................................................................... 41 
8.4.2 
Unscheduled Visits ............................................................... 41 
 
Compliance with Protocol ........................................................................ 42 
 
Subject Disposition ................................................................................... 42 
8.6.1 
Completed Subjects .............................................................. 42 
8.6.2 
Discontinued Subjects ........................................................... 42 
 
Study Termination .................................................................................... 42 
 
Study Duration ......................................................................................... 43 


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Monitoring and Quality Assurance .......................................................... 43 
9 
ADVERSE EVENTS .......................................................................................... 43 
 
Adverse Event .......................................................................................... 43 
9.1.1 
Severity ................................................................................. 44 
9.1.2 
Relationship to Investigational Product ................................ 44 
9.1.3 
Expectedness ......................................................................... 45 
 
Serious Adverse Events ............................................................................ 45 
 
Procedures for Reporting Serious Adverse Events .................................. 46 
9.3.1 
Reporting a Serious Unexpected Suspected Adverse 
Reaction ................................................................................ 46 
9.3.2 
Reporting a Serious Adverse Event ...................................... 46 
 
Procedures for Unmasking (if applicable) ................................................ 47 
 
Type and Duration of the Follow-up of Subjects after Adverse Events .. 47 
10 
STATISTICAL HYPOTHESES AND METHODS OF ANALYSES ............... 48 
 Analysis Populations ................................................................................ 48 
 Statistical Hypotheses ............................................................................... 48 
 Sample Size .............................................................................................. 49 
 Statistical Analysis ................................................................................... 49 
10.4.1 General Considerations ......................................................... 49 
10.4.2 Unit of Analysis .................................................................... 49 
10.4.3 Missing Data ......................................................................... 50 
10.4.4 Multiplicity Consideration .................................................... 50 
10.4.5 Efficacy Analyses ................................................................. 51 
10.4.6 Safety Variables .................................................................... 51 
10.4.7 Exploratory Safety Analyses................................................. 52 
 
 
 
 
 
10.4.11 Interim Analyses ................................................................... 52 
11 
COMPLIANCE WITH GOOD CLINICAL PRACTICES, ETHICAL 
CONSIDERATIONS, AND ADMINISTRATIVE ISSUES .............................. 53 
 Protection of Human Subjects .................................................................. 53 
11.1.1 Subject Informed Consent..................................................... 53 
11.1.2 Institutional Review Board (IRB) Approval ......................... 53 
 Ethical Conduct of the Study .................................................................... 53 
 Subject Confidentiality ............................................................................. 53 


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 Documentation ......................................................................................... 54 
11.4.1 Retention of Documentation ................................................. 54 
 Recording of Data on Source Documents and Case Reports Forms 
(CRFs) ...................................................................................................... 54 
 Publications .............................................................................................. 54 
12 
REFERENCES ................................................................................................... 55 
13 
APPENDICES .................................................................................................... 56 
Appendix 1: Schedule of Visits and Measurements .................................................... 56 
Appendix 2: Examination Procedures, Tests, & Evaluations ...................................... 58 
Appendix 3: Protocol Amendment Summary .............................................................. 73 
 
Appendix 5: Investigator’s Signature .......................................................................... 75 
 
 


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LIST OF ABBREVIATIONS 
AE 
Adverse event 
CAE 
Controlled adverse environment 
CFR 
Code of Federal Regulations 
CRF 
Case report form 
CRO 
Contract research organization 
DED 
dry eye disease 
eCRF 
electronic case report form 
FDA 
Food and Drug Administration 
GCP 
Good Clinical Practice 
GLP 
Good Laboratory Practice 
HIPAA 
Health Insurance Portability and Accountability Act 
IB 
Investigator’s brochure 
ICF 
informed consent form 
ICH 
International Conference on Harmonisation 
IEC 
Independent Ethics Committee 
IND 
Investigational New Drug Application 
IP 
Investigational product 
IRB 
Institutional Review Board 
ITT 
Intent to treat 
IWRS 
Interactive web response system 
LASIK 
Laser in situ keratomileusis 
LOCF 
Last observation carried forward 


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MedDRA 
Medical Dictionary for Regulatory Activities 
NCS 
Not clinically significant 
ODS 
Ocular Discomfort Score 
OSDI 
Ocular Surface Disease Index 
OTC 
Over the counter 
PK 
Pharmacokinetic 
PP 
Per protocol 
SAE 
Serious adverse event 
SOP 
Standard operating procedure 
TFBUT 
Tear film break-up time 
WHO 
World Health Organization 
 
 


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1 INTRODUCTION 
Dry eye disease (DED) is a multifactorial, progressive disorder of the ocular surface 
resulting from insufficient tear coverage of the surface of the eye in combination with 
ocular surface inflammation. Patients with DED often experience severe pain, visual 
impairment, tear film hyperosmolarity and instability, inflammation, and corneal 
wounding. While the prevalence of DED is difficult to report due to varying 
definitions and diagnostic criteria, the global prevalence of DED is estimated to be 
between 5% and 50%, and increases with age (Bron et al. 2017). In the United States, 
it is estimated that as many as 3.2 million women and 1.7 million men over the age of 
50 have DED, with a projected 40% increase in number of patients affected by 2030 
(Schaumberg et al. 2002, Schaumberg et al. 2003, Schaumberg et al. 2009). 
Current treatment and management of DED consists primarily of tear supplementation 
with lubricants (artificial tears). While artificial tears improve symptoms associated 
with DED, they have no effect on resolving the underlying conditions that lead to 
inflammation of the ocular surface. Three currently available options for treating 
inflammation at the ocular surface are Restasis® (cyclosporine ophthalmic emulsion) 
CEQUA™ (cyclosporine ophthalmic solution), and Xiidra® (lifitegrast ophthalmic 
solution). It has been shown that only 15% of patients respond to Restasis® after 6 
months of treatment, as measured by Schirmer’s test, and many more report ocular 
side-effects such as burning and stinging (Mah et al. 2012). Xiidra® has also been 
shown to be associated with ocular adverse events (AEs); in a clinical study of 
Xiidra® for subjects with DED, subjects reported increased ocular irritation upon 
instillation with Xiidra® compared to placebo (7.8% compared to 1.4% in the placebo 
group) (Tauber et al. 2015). Similarly, common adverse reactions reported after use of 
CEQUA include instillation site pain and conjunctival hyperemia (CEQUA 2018). 
Thus, there remains a medical need for more efficacious treatment options with a 
more favorable safety and comfort profile for patients with DED.  
 Drug Profile from Non-clinical Studies 
 a tyrosine kinase involved in 
cytokine signaling and activation of lymphocytes. 
 have been shown 
to have potent anti-inflammatory activity both in vitro and in vivo (
 
). 
 
was shown to suppress ocular 
surface inflammation and corneal injury in a mouse model of dry eye disease 
(
). Because inflammation is a key component of DED, targeting 
the inflammatory pathway via 
 to reduce cytokine production and/or 
immune cell infiltration at the ocular surface may reduce the signs and symptoms of 
DED. 
 
 
 
 
 
 
 
This will be the first clinical study of K-161 Ophthalmic Solution. 


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2 STUDY OBJECTIVES 
Prior to any changes in a subject’s medical treatment and/or study visit procedures, 
the study will be discussed with each subject and subjects wishing to participate must 
give written informed consent (and/or assent) and sign a Health Insurance Portability 
and Accountability Act (HIPAA) form.  
The objectives of the study are to assess the safety, efficacy, optimum dosage, and 
dosing regimen of K-161 compared to its vehicle from Day 1 (baseline) to Day 29 in 
non-Japanese and Japanese adult subjects with moderate to severe dry eye disease 
both in environmental and Controlled Adverse Environment (CAE) settings. 
3 CLINICAL HYPOTHESES 
The clinical hypotheses for this study is that 
 K-161 Ophthalmic Solution 
 
 (
 is superior to its vehicle (
 for the primary endpoints of signs and 
symptoms of dry eye, as follows:  
 Sign: Post-CAE inferior corneal fluorescein staining score on the Ora Calibra® 
scale, measured by mean change from baseline (Visit 2) to Visit 5 
 Symptom: Post-CAE ocular discomfort scale on the Ora Calibra® scale, 
measured by mean change from baseline (Visit 2) to Visit 5 
4 OVERALL STUDY DESIGN 
This is a Phase 2, multicenter, randomized, double-masked, vehicle-controlled, 
parallel-group design with block enrollment. Subjects will be randomized to one of 
the following treatment groups at Visit 2:  
 
 K-161; 
 (
 (N=~60) 
 
 K-161; 
 
 (N=~60) 
 
 K-161; 
 (
 
 (N=~60)  
 Placebo Ophthalmic Solution (Vehicle); 
 
 (N=~60) 
 
Approximately 240 subjects will be randomly assigned to one of the four treatment 
groups (1:1:1:1). 
 
 Subjects, Sponsor, Contract 
research organization (CRO), and site personnel will be masked to treatment 
assignment. To ensure masking, a dedicated unmasked staff member/technician will 
be delegated to dispense and observe instillation of randomized study drug and collect 
randomized study drug from a subject for drug accountability. The unmasked staff 
member will also collect and review the subject’s daily dosing diary. This person 
cannot perform any other study-related procedures. Additionally, the informed 
consent form (ICF) will not indicate any relationship between dosing regimen and 
treatment. Subjects will be instructed not to discuss their assigned dosing regimen or 
perceived treatment effects with other study participants. 
During the screening period, two 90-minute exposures to the CAE will be conducted 
to ascertain eligibility to enter the study. Subjects who qualify after the initial 
screening visit will enter the run-in phase, where they will self-administer vehicle 
 for approximately 14 days. Those who qualify at Visit 2 (Day 1) will be 
randomized to receive study drug in a double-masked fashion for 28 days. 


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Randomization will be stratified on Visit 2 Post-CAE inferior fluorescein staining and 
Post-CAE ocular discomfort on the Ora Calibra® scale. Subjects will self-administer 
drops either 
 or 
 and will complete daily diary assessments as instructed. 
At Visit 4 (Day 15) and Visit 5 (Day 29), CAE exposure will occur, with pre-CAE, 
during CAE (symptoms only) and post-CAE assessments of ocular signs and 
symptoms. At Visit 3, no CAE exposure will occur but signs and symptoms will be 
assessed. Study drug will be discontinued at Visit 5. Subjects will exit from the study 
at this visit. The follow-up phone call will occur about 7 days after the final day of 
randomized study drug treatment. 
The timing of subject visits and examinations will be consistent throughout the study. 
5 STUDY POPULATION 
 Number of Subjects (approximate) 
It is estimated that approximately 600 subjects will be screened to enroll 
approximately 240 randomized subjects (60 in each group). 
 
 
 
 
 Subjects will be randomized in a 1:1:1:1 ratio of  
 
 K-161; 
 
 
 K-161; 
 
 
 K-161; 
     
 Placebo Ophthalmic Solution (Vehicle); 
  
 Study Population Characteristics 
All subjects must be at least 18 years of age, of either gender, and of any race, and 
must meet all inclusion criteria and none of the exclusion criteria. 
 Inclusion Criteria 
Each subject must: 
1. Be at least 18 years of age at the time of informed consent visit 
2. Have a reported history of dry eye disease in both eyes 
 
 and have a history of eye drop use for dry eye symptoms 
 
 
 
 
 
 
 
 
 
 
 
 
                                                 
 


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 Exclusion Criteria 
Each subject must not: 
1. Have any clinically significant ocular condition 
 
 
 
 
 
 
2. Have a history of 
 
corneal refractive surgery, and/or any other ocular surgical procedure 
 
within 12 months 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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 Withdrawal Criteria (if applicable) 
If at any time during the study the investigator determines that a subject’s safety has 
been compromised, the subject may be withdrawn from the study. 
Subjects may withdraw consent from the study at any time. 
Sponsor and/or investigator may discontinue any subject for non-compliance or any 
valid medical reason (see Section 8.6.2). 
The subject has the right to withdraw from the study at any time. Nevertheless, in this 
study, every attempt will be made to prevent missing data and to obtain complete 
follow up of all subjects during the study period. Investigators will be trained to 
minimize full withdrawals from the study period wherever possible. Subjects who 
discontinue study drug during the study period are not required to withdraw from the 
study. These subjects will be encouraged to remain in the study and asked to conduct 
the remaining study visits as outlined in the protocol through Visit 5. If a subject fails 
to actively maintain contact with the Investigator, reasonable efforts (telephone calls 
to family members or friends, e-mail contacts, etc.) will be made in order to 
encourage the subject to complete the study visits. 


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6 STUDY PARAMETERS 
 Efficacy Endpoints 
6.1.1 Primary Efficacy Endpoints 
The primary efficacy endpoint (sign) is: 
 Change in inferior corneal staining score from Day 1 (baseline) to Day 29 by 
comparing 
 K-161 
 to its vehicle 
 in CAE setting 
The primary efficacy endpoint (symptom) is: 
 Change in Ora Calibra® ODS from Day 1 (baseline) to Day 29 by comparing 
 K-161 
 to its vehicle 
 in CAE setting 
6.1.2 Important Secondary Efficacy Endpoints 
The important secondary endpoints are: 
 Change in Schirmer’s Test value (unanesthetized) from Day 1 (baseline) to 
Day 29 by comparing 
 K-161 
 to its vehicle 
 in 
environmental setting 
 Change in TFBUT from Day 1 (baseline) to Day 29 by comparing 
 K-
161 
 to its vehicle 
 in CAE setting 
6.1.3 Secondary Efficacy Endpoints 
The secondary efficacy endpoints are comparisons of the following associated with 
taking the vehicle 
 and K-161 
 (i.e., 
 K-161 
 and 
 K-161 
 for: 
 Fluorescein staining by region: central, superior, inferior, temporal, nasal and 
corneal sum as assessed by the Ora Calibra® Corneal and Conjunctival 
Staining Scale 
 Lissamine green staining by region: central, superior, inferior, temporal, nasal, 
and conjunctival sum as assessed by the Ora Calibra® Corneal and 
Conjunctival Staining Scale 
 Conjunctival Redness as assessed by the Ora Calibra® Scale 
 TFBUT  
 Tear Osmolarity 
 Schirmer’s Test (unanesthetized) 
 Blink Rate 
 Ora Calibra® Ocular Discomfort Scale  
 Ora Calibra® Ocular Discomfort and 4-Symptom Questionnaire  
 Visual Analog Scale (VAS)   
 Burning/ Stinging 
 Itching 
 Foreign Body Sensation 


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 Blurred Vision 
 Eye Dryness 
 Photophobia 
 Pain 
 OSDI©  
 Daily diary  
6.1.4 
 
 
 
 
 
 
 
 
 
 
 Safety Measures 
The safety measures being evaluated are: 
 
  
 
 
 
AE query 
 
 
 
 
 
 
 
 
 
Maximum dose tolerability by comparing the 
 K-161 
 arm to the 
 and 
 K-161 
 arms 
 Other Measures 
The other measures being evaluated are: 
 
 
 
 
 
 
 
  
 
 
 
  
 
 
 
 


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 Clinical Laboratory Measurements 
The following assessments are being conducted: 
Hematology: 
 
 
   
Clinical chemistry: 
 
 
 
 
 
   
Urinalysis: 
 
 
7 STUDY MATERIALS 
 Study Treatments 
7.1.1 Masking 
All arms will be double-masked. To ensure masking, an unmasked technician 
delegated by the Investigator will perform all study drug instruction, dispensation, 
collection and accountability. This technician cannot perform any other study visit 
procedures. Study Treatments/Formulations 
 
 K-161; 
 
 
 K-161; 
 
 
 K-161; 
    
 Placebo Ophthalmic Solution (Vehicle); 
  
7.1.2 Description of and Justification for the Route of Administration, Dosage, 
Dosage Regimen, and Treatment Period. 
Topical ophthalmic dosing is the optimal route of administration for dry eye 
treatments. The dosage and dosage regimen were selected based on non-clinical 
studies. The proposed treatment period of 4 weeks is based on results from pre-
clinical studies and on the anti-inflammatory mechanism of action of the drug. 


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7.1.3 Instructions for Use and Administration 
Subjects who were randomized to 
 arm must administer study drug 
 
Subjects who were randomized to 
 arm must 
If missed, the subject must not administer the eye drop if the 
next dosing is in less than 2 hours. At Visits 2, 3, 4, and 5, all subjects must visit their 
study sites without administering any topical ophthalmic preparations, including study 
drug, and must not administer topical ophthalmic preparations until all examinations 
are finished. 
Subjects, Sponsor, CRO, and site personnel (with the exception of the following 
person) will be masked to treatment assignment. To ensure masking, a dedicated 
unmasked staff member/technician will be delegated to dispense and observe 
instillation of randomized study drug and collect randomized study drug from a 
subject for drug accountability. This person cannot perform any other study-related 
procedures. Additionally, the ICF will not indicate any relationship between dosing 
regimen and treatment. Subjects will be instructed not to discuss their assigned dosing 
regimen or any perceived treatment effects with other study participants. 
 Labeling, Packaging, Storage, Accountability, and Return or 
Disposal of Investigational Product 
7.2.1 Labeling/Packaging 
Investigational product (IP) will be packaged and labeled into clinical kits. 
Run-in Period 
For the run-in period, 
 
 provide a 
sufficient medication supply.  
Treatment Period 
 Dosing: For the treatment period, 
 
 
provide a sufficient supply of randomized study drug. 
 Dosing: For the treatment period, 
 
 provide a 
sufficient supply of randomized study drug. 
 
7.2.2 Storage of Investigational Product 
The IPs must be stored in a secure area accessible only to the investigator and his/her 
designees. K-161 must be stored at controlled room temperature of 20-25°C (68-
77°F) with excursions permitted between 15°C and 30°C (59-86°F), as indicated on 
the product label.  
7.2.3 Accountability of Investigational Product 
The IP is to only be prescribed by the PI or his/her named Sub-Investigator(s), and is 
to only be used in accordance with this protocol. The IP must only be distributed to 
subjects properly qualified as described in this protocol to receive IP. 


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The investigator must keep an accurate accounting of the IP received from the 
supplier. This includes the amount of IP dispensed to subjects, amount of IP returned 
to the investigator by the subjects, and the amount returned or disposed upon the 
completion of the study. A detailed inventory must be completed for the IP. Study 
drug accountability will be performed by an Unmasked Technician as delegated by 
the PI. To ensure masking, a dedicated unmasked staff member/technician will be 
delegated to dispense and collect randomized study drug from a subject for drug 
accountability. This person cannot perform any other study-related procedures. 
7.2.4 Return or Disposal of Investigational Product 
All IP (used or unused) will be returned to the Sponsor or their designee. Requests for 
the return of IP must be specified in writing. 
 Other Study Supplies 
Other study supplies include 
 Schirmer’s test strips, tear 
meniscometry strips, sodium fluorescein, lissamine green, 
 
tear osmolarity cards,
 
 
8 STUDY METHODS AND PROCEDURES 
 Subject Entry Procedures 
8.1.1 Overview 
Subjects as defined by the criteria in sections 5.2 and 5.3 will be considered for entry 
into this study. 
8.1.2 Informed Consent 
Prior to a subject’s participation in the study (i.e., changes in a subject’s medical 
treatment and/or study related procedures), the study will be discussed with each 
subject, and subjects wishing to participate must give written informed consent using 
an ICF. The ICF must be the most recent version that has received approval/favorable 
review by a properly constituted Institutional Review Board (IRB). 
8.1.3 Washout Intervals 
Prohibited medications, treatments, and activities are outlined in the exclusion criteria 
(Section 5.4). 
8.1.4 Procedures for Final Study Entry 
Subjects must meet all inclusion and none of the exclusion criteria (Section 5.3 and 
5.4). 
8.1.5 Methods for Assignment to Treatment Groups: 
Before the initiation of study run-in at Visit 1, each subject who provides written 
informed consent will be assigned a screening number. All screening numbers will be 
assingned in strict numerical sequence at a site and no numbers will skipped or 
omitted. Each subject who meets all the inclusion and none of the exclusion criteria at 
Visit 1 and Visit 2 will be assigned a randomization number at the end of Visit 2. The 
Interactive Web Response System (IWRS) will be used to assign all randomization 
numbers. 


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For the non-Japanese subjects, randomization will be further stratified by the 
following factors and cut-offs:  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Randomization and kit numbers will be assigned automatically to each subject as they 
are entered into the IWRS.  
The site staff will dispense kit(s) required until the next visit. Both the randomization 
number and the dispensed study drug kit number(s) will be recorded on the subject’s 
source document and electronic case report form (eCRF). Subjects, Sponsor, CRO, 
and site personnel will be masked to treatment assignment. To ensure masking, a 
dedicated unmasked staff member/technician will be delegated to dispense and 
observe instillation of randomized study drug and collect randomized study drug from 
a subject for drug accountability. This person cannot perform any other study-related 
procedures. 
 Concurrent Therapies 
The use of any concurrent medication, prescription or OTC, is to be recorded on the 
subject’s source document and corresponding eCRF along with the reason the 
medication was taken. 
Concurrent enrollment in another investigational drug or medical device study is not 
permitted. 
8.2.1 Prohibited Medications/Treatments 
Disallowed medications/treatments during the study are outlined in the Exclusion 
Criteria (Section 5.4).  
8.2.2 Escape Medications 
No escape medications are required for this study. 
8.2.3 Special Diet or Activities 
No special diets or activities are required for this study. 
 Examination Procedures 
8.3.1 Procedures to be Performed at Each Study Visit with Regard to Study 
Objectives 
Procedures listed below should be performed in the given order. See Appendix 1 for 
the Schedule of Visits and Measurements Appendix 2 for details on methodologies 
and grading systems. 


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8.3.2 Visit 1: Day –14 ± 2 – CAE Screening  
All subjects will undergo the following screening assessments: 
  
 Informed Consent/HIPAA  
 
 
 
 
 
 
 
 
 
  
 Ora Calibra® Ocular Discomfort Scale  
 Ora Calibra® Ocular Discomfort & 4-Symptom Questionnaire  
 OSDI© Questionnaire 
 Visual Analog Scale (VAS) 
 
 
 
  
 Conjunctival Redness 
 TFBUT 
 Fluorescein Staining  
 Lissamine Green Staining  
 At least 15-minute wait between lissamine green staining and Schirmer’s test 
 Schirmer’s test 
 
 
 
 
 
 
 
 
 
 Ora Calibra® Ocular Discomfort Scale  
 Ora Calibra® Ocular Discomfort & 4-Symptom Questionnaire  
 Visual Analog Scale (VAS) 
 
 
 Conjunctival Redness 
 TFBUT 
 Fluorescein Staining 
 Lissamine Green Staining 


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 Dispensation of run-in (Vehicle) for 
 dosing until Visit 2 
o 
 
 
 
 
 Ora Calibra® Drop Comfort Scale 
 Ora Calibra® Drop Comfort Questionnaire 
 Diary and Subject Instructions Dispensation 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 AE Query 
 Subjects will be scheduled for Visit 2. 
8.3.3 Visit 2: Day 1 – CAE Confirmation and Baseline 
  
 Study Diary/Run-in Collection 
 
 
 Medical/medication history update 
 AE query 
 
 
 Ora Calibra® Ocular Discomfort Scale  
 Ora Calibra® Ocular Discomfort & 4-Symptom Questionnaire  
 OSDI© Questionnaire 
 Visual Analog Scale (VAS) 
 
 


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 Conjunctival Redness 
 Blink Rate 
 Tear Osmolarity 
 
 
 TFBUT 
 Fluorescein Staining  
 Lissamine Green Staining  
 At least 15-minute wait between lissamine green staining and Schirmer’s test 
 Schirmer’s test 
 
 
 
 
 
 
 
 
 
 Ora Calibra® Ocular Discomfort Scale  
 Ora Calibra® Ocular Discomfort & 4-Symptom Questionnaire  
 Visual Analog Scale (VAS) 
 
 
 
 
 Conjunctival Redness 
 TFBUT 
 Fluorescein Staining 
 Lissamine Green Staining 
 
  
 Randomization  
 Study Drug Kit Dispensation: All subjects having a positive response and 
meeting all other screening eligibility criteria at the end of Visit 2 will be 
randomized to one of four treatment groups utilizing the IWRS system. 
Subjects will receive their assigned study drug kit with sufficient supply to last 
until Visit 3.  
 
 
  
 Ora Calibra® Drop Comfort Scale 
 Ora Calibra® Drop Comfort Questionnaire 
 
  


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 AE Query 
 Subjects will be scheduled for Visit 3. 
8.3.4 Visit 3: Day 8 ±1  
 Study Drug Diary/Study Drug Collection by unmasked staff member 
 Medical/medication history update 
 AE Query 
 Ora Calibra® Ocular Discomfort Scale  
 Ora Calibra® Ocular Discomfort & 4-Symptom Questionnaire  
 OSDI© Questionnaire 
 Visual Analog Scale (VAS) 
 
 
 
  
 Conjunctival Redness 
 Blink Rate 
 Tear Osmolarity 
 TFBUT 
 Fluorescein Staining  


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 Lissamine Green Staining  
 At least 15-minute wait between lissamine green staining and Schirmer’s test 
 Schirmer’s Test 
 Study Drug Kit Dispensation: Prior to discharge from the study site on Visit 3, 
subjects will be assigned a new study drug kit via the IWRS system for at-
home dosing up to Visit 4. 
 Diary and Subject Instructions Dispensation  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 


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 AE Query 
 Subjects will be scheduled for Visit 4. 
8.3.5 Visit 4: Day 15 ± 2  
 
 Study Drug Diary/Study Drug Collection by unmasked staff member 
 Medical/medication history update 
 AE query 
 Ora Calibra® Ocular Discomfort Scale  
 Ora Calibra® Ocular Discomfort & 4-Symptom Questionnaire  
 OSDI© Questionnaire 
 Visual Analog Scale (VAS) 
 
 
 
  
 Conjunctival Redness 
 Blink Rate 
 Tear Osmolarity 
 TFBUT 
 Fluorescein Staining  
 Lissamine Green Staining  
 At least 15-minute wait between lissamine green staining and Schirmer’s test 
 Schirmer’s Test 
 
 
 
 
 
 
 
 
 
 Ora Calibra® Ocular Discomfort Scale  
 Ora Calibra® Ocular Discomfort & 4-Symptom Questionnaire  
 Visual Analog Scale (VAS) 
 
 
 Conjunctival Redness 
 TFBUT 
 Fluorescein Staining 
 Lissamine Green Staining 


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 Study Drug Kit Dispensation: Prior to discharge from the study site on Visit 4, 
subjects will be assigned a new study drug kit via the IWRS system for at-
home dosing up to Visit 5. 
 Diary and Subject Instructions Dispensation  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 AE Query 
 Subjects will be scheduled for Visit 5. 
8.3.6 Visit 5: Day 29 ± 2 
 
 Study Drug Diary/Study Drug Collection by unmasked staff member 
 Medical/medication history update 
 AE query 
 
 
 
  
 Ora Calibra® Ocular Discomfort Scale  


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 Ora Calibra® Ocular Discomfort & 4-Symptom Questionnaire  
 OSDI© Questionnaire 
 Visual Analog Scale (VAS) 
 
 
 
  
 Conjunctival Redness 
 Blink Rate 
 Tear Osmolarity 
 
 
 TFBUT 
 Fluorescein Staining  
 Lissamine Green Staining  
 At least 15-minute wait between lissamine green staining and Schirmer’s test 
 Schirmer’s Test 
 
 
 
 
 
 
 
 
 
 Ora Calibra® Ocular Discomfort Scale  
 Ora Calibra® Ocular Discomfort & 4-Symptom Questionnaire  
 Visual Analog Scale (VAS) 
 
 
 
 
 Conjunctival Redness 
 TFBUT 
 Fluorescein Staining 
 Lissamine Green Staining 
 
 
 
 
 
 
 AE Query 


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8.3.7 Follow-up phone call Day 36 ± 2 
 Follow-up phone call (about 7 days after the final day of randomized study 
drug treatment) 
 AE query 
 Study exit 
 
Early Termination/Discontinuation  
If a subject is discontinued from the study prior to Visit 5 (Day 29 ± 2), then all safety 
evaluations and 
 evaluations for Visit 5 (Day 29 ± 2) should be performed 
on the day of discontinuation (early termination) or at the discretion of the 
investigator.  
AEs (both elicited and observed) and SAEs will be monitored throughout the study. 
The investigator will promptly review all AEs (both elicited and observed) for 
accuracy and completeness. All AEs will be documented on the appropriate source 
document and case report form. 
 
 
 
 
 
 
 
 Schedule of Visits, Measurements and Dosing 
8.4.1 Scheduled Visits 
Refer to Appendix 1 for a schedule of visits and measurements. 
8.4.2 Unscheduled Visits 
These visits may be performed in order to ensure subject safety. All procedures 
performed at an unscheduled visit will be recorded in the source documents and on 
the Unscheduled Visit eCRF pages. Any procedure indicated in the eCRF that is not 
performed should be indicated as “Not done.” 
Evaluations that may be conducted at an Unscheduled Visit include: 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Assessment of AEs 
 
 


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 Compliance with Protocol 
Subjects will be given written instructions; instructed on proper use of the subject 
daily diary and proper instillation; and instructed on proper storage of the IP at the 
end of Visits 1, 2, 3, and 4. The subject daily diaries, used/unused 
 will be 
collected at each visit from Visit 2 up to and including Visit 5 to assess dosing and 
symptom assessment compliance. Dosing compliance will be based on 
 
 If the subject is less than 80% or more than 125% compliant with 
dosing based on 
 then the subject will be 
deemed non-compliant and a dosing deviation should be recorded in the source 
document.  
In the subject daily diary, if more than 20% of Dose boxes are checked “no”, left 
blank, or missing for a diary period, a subject will be deemed non-compliant and a 
diary deviation will be recorded in the source document. Subjects with more than 20% 
of the total diary symptom assessments missed for that dosing period will be deemed 
non-compliant, and a diary symptom assessment deviation will be recorded in the 
source document. The investigator will use these guidelines to determine subject 
study compliance and deviation compliance.  
 Subject Disposition 
8.6.1 Completed Subjects 
A completed subject is one who has not been discontinued from the study. 
8.6.2 Discontinued Subjects 
Subjects may be discontinued prior to their completion of the study due to: 
 subject request/withdrawal 
 AEs 
 protocol violations 
 administrative reasons (e.g., inability to continue, lost to follow up) 
 sponsor termination of study 
 other 
Note: In addition, any subject may be discontinued for any sound medical reason. 
Notification of a subject discontinuation and the reason for discontinuation will be 
reported to 
 and/or the Sponsor and clearly documented on the electronic case 
report form (eCRF). 
 Study Termination 
The study may be stopped at any time by the investigator, Sponsor, and/or 
 with 
prior notification. 


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 Study Duration 
An individual subject’s participation will involve 5 visits over approximately a 6-
week (~42 days) period (14 days pre-screening, 28 days of treatment) and a follow-up 
phone call. 
 Monitoring and Quality Assurance 
During the course of the study, an 
 monitor, or designee, will make routine site 
visits to review protocol compliance, assess IP accountability, and ensure the study is 
being conducted according to the pertinent regulatory requirements. The review of the 
subjects’ medical records will be performed in a manner that adequately maintains 
subject confidentiality. Further details of the study monitoring will be outlined in a 
monitoring plan. 
Regulatory authorities of domestic and foreign agencies, quality assurance (QA) and 
or its designees may carry out on-site inspections and/or audits which may include 
source data checks. Therefore, direct access to the original source data will be 
required for inspections and/or audits. All inspections and audits will be carried out 
giving consideration to data protection as well as subject confidentiality to the extent 
that local, state, and federal laws apply. 
9 ADVERSE EVENTS 
 Adverse Event 
An AE is defined as any untoward medical occurrence associated with the use of an 
IP in humans, whether or not considered IP-related. An AE can be any unfavorable 
and unintended sign (e.g., an abnormal laboratory finding), symptom, or disease 
temporally associated with the use of an IP, without any judgment about causality. An 
AE can arise from any use of the IP (e.g., off-label use, use in combination with 
another drug or medical device) and from any route of administration, formulation, or 
dose, including an overdose. An AE can arise from any delivery, implantation, or use 
of a medical device, including medical device failure, subject characteristics that may 
impact medical device performance (e.g., anatomical limitations), and therapeutic 
parameters (e.g., energy applied, sizing, dose release, and anatomic fit) associated 
with medical device use. 
All AEs spontaneously reported by the subject and/or in response to an open question 
from study personnel or revealed by observation, physical examination or other 
diagnostic procedures will be recorded in the source document and on the appropriate 
pages of the CRF. Any clinically relevant deterioration in clinical finding is 
considered an AE and must be recorded. When possible, signs and symptoms 
indicating a common underlying pathology will be noted as one comprehensive event. 
Documentation regarding the AE will include the nature, date of onset, end date, 
severity, relationship to IP, action(s) taken, seriousness, and outcome of any sign or 
symptom observed by the investigator or reported by the subject upon indirect 
questioning. Exacerbation of conditions related to the signs and symptoms of DED 
will not be reported as an AE. 


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9.1.1 Severity 
Severity of an AE is defined as a qualitative assessment of the degree of intensity of 
an AE as determined by the investigator or reported by the subject. The assessment of 
severity is made irrespective of relationship to the IP or seriousness of the event and 
will be evaluated according to the following scale: 
 Mild: Event is noticeable to the subject, but is easily tolerated and does not 
interfere with the subject’s daily activities. 
 Moderate: Event is bothersome, possibly requiring additional therapy, and 
may interfere with the subject’s daily activities. 
 Severe: Event is intolerable, necessitates additional therapy or alteration of 
therapy, and interferes with the subject’s daily activities. 
9.1.2 Relationship to Investigational Product 
The relationship of each AE to the IP will be determined by the investigator using 
these explanations: 
 Related: A reasonable possibility exists that the IP caused the AE. A related 
AE can be further defined as follows: 
 Occurs within a reasonable temporal sequence to administration of study 
drug  
 Cannot be explained by concurrent disease or other drugs or chemicals  
 Improves or disappears on stopping or reducing study drug (de-challenge)  
 Reappears on repeated exposure to study drug (re-challenge)  
 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 
 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 IP caused the AE. 
A not related AE can be further defined as follows: 
 Occurs with a temporal relationship to administration of study drug which 
makes a causal relationship improbable 
 Other drugs, chemicals or underlying disease provide plausible 
explanations of causality 
 Is known to be associated with the participant’s clinical condition, or with 
other medication taken by the participant 
Suspected adverse reaction means any AE for which there is a reasonable possibility 
that the IP caused the AE. “Reasonable possibility” means there is evidence to suggest 
a causal relationship between the IP and the AE. Types of evidence that would 
suggest a causal relationship between the IP and the AE event include: a single 
occurrence of an event that is uncommon and known to be strongly associated with IP 
exposure (e.g., angioedema, hepatic injury, Stevens-Johnson Syndrome); one or more 
occurrences of an event that is not commonly associated with IP exposure, but is 
otherwise uncommon in the population exposed to the IP (e.g., tendon rupture); an 


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aggregate analysis of specific events observed in a clinical trial (such as known 
consequences of the underlying disease or condition under investigation or other 
events that commonly occur in the study population independent of drug therapy) that 
indicates those events occur more frequently in the IP-treatment group than in a 
concurrent or historical control group. 
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. 
9.1.3 Expectedness 
The expectedness of an AE should be determined based upon existing safety 
information about the IP using these explanations: 
 Unexpected: An AE that is not listed in the Investigator’s Brochure (IB) or is 
not listed at the specificity or severity that has been observed. 
 Expected: An AE that is listed in the IB at the specificity and severity that has 
been observed. 
 Not applicable: An AE unrelated to the IP. 
AEs that are mentioned in the IB as occurring with a class of products or as 
anticipated from the pharmacological/mechanical (or other) properties of the product, 
but are not specifically mentioned as occurring with the particular product under 
investigation are to be considered unexpected. 
The investigator will initially classify the expectedness of an AE, but the final 
classification is subject to the Medical Monitor’s determination. 
 Serious Adverse Events 
An AE is considered serious if, in the view of either the investigator or Sponsor, it 
results in any of the following outcomes: 
 Death; 
 Is life-threatening; 
Note: An AE is considered “life-threatening” if, in the view of either the 
investigator or sponsor, its occurrence places the subject at immediate risk of 
death. It does not include an AE that, had it occurred in a more severe form, 
might have caused death. 
 Inpatient hospitalization or prolongation of existing hospitalization; 
Note: The term “inpatient hospitalization” refers to any inpatient admission 
(even if less than 24 hours), unless the inpatient admission was pre-planned 
prior to the signing of the informed consent. For chronic or long-term 
inpatients, inpatient admission includes transfer within the hospital to an 
acute/intensive care inpatient unit. Inpatient hospitalization does not include: 
emergency room visits; outpatient/same-day/ambulatory procedures; 
observation/short stay units; rehabilitation facilities; hospice facilities; nursing 
homes; or clinical research/phase 1 units. 
Note: The term “prolongation of existing hospitalization” refers to any 
extension of an inpatient hospitalization beyond the stay anticipated or 


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required for the reason for the initial admission as determined by the 
investigator or treating physician. 
 A persistent or significant incapacity or substantial disruption of the ability to 
conduct normal life functions; 
Note: A serious adverse event (SAE) specifically related to visual threat would 
be interpreted as any potential impairment or damage to the subject’s eyes 
(e.g., hemorrhage, retinal detachment, central corneal ulcer or damage to the 
optic nerve). 
 A congenital anomaly/birth defect. 
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 subject and may require 
medical or surgical intervention to prevent one of the outcomes listed in this 
definition. 
 Procedures for Reporting Serious Adverse Events 
All SAEs and their outcomes, regardless of causality or expectedness, must be 
reported to 
 and the Sponsor as required by the IRB/Independent Ethics 
Committee(IEC), federal, state, or local regulations and governing health authorities 
and recorded on the appropriate CRF. Adverse events will be collected from the time 
of the signing of the ICF until the follow-up phone call (about 7 days after the final 
day of randomized study drug treatment). 
9.3.1 Reporting a Serious Unexpected Suspected Adverse Reaction 
All SAEs that are both ‘suspected’ and ‘unexpected’ are also to be reported to the 
IRB/IEC and the regulatory authorities as required by the IRB/IEC, federal, state, or 
local regulations and governing health authorities. 
9.3.2 Reporting a Serious Adverse Event 
To ensure subject safety, all SAEs, regardless of relationship to the IP, must be 
immediately reported. All information relevant to the SAE must be recorded on the 
appropriate CRFs. The investigator is obligated to pursue and obtain information 
requested by 
 and/or the Sponsor in addition to that information reported on the 
CRF. All subjects experiencing a SAE must be followed up and the outcome reported. 
In the event of a SAE, the investigator will notify 
 and the Sponsor immediately 
using the contact information below; obtain and maintain all pertinent medical 
records, information, and medical judgments from colleagues who assisted in the 
treatment and follow-up of the subject; provide 
 and the Sponsor a complete case 
history, which includes a statement as to whether the event was or was not suspected 
to be related to the use of the IP; and inform the IRB/IEC of the SAE within their 
guidelines for reporting SAEs. 
 
 


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Contact information for reporting SAEs: 
 Procedures for Unmasking (if applicable) 
All subjects, investigators, and study personnel involved with the conduct of the study 
will be masked with regard to treatment assignments. When medically necessary, the 
investigator may need to determine what treatment group has been assigned to a 
subject. When possible (i.e., in non-emergent situations), 
 and/or the Sponsor will 
be notified before unmasking the investigator. 
 and/or the Sponsor must be 
informed immediately about any unmasking event. 
If the investigator identifies a medical need that requires unmasking the treatment 
assignment of a subject, 
 and/or the medical monitor will be contacted prior to 
unmasking the identity of the IP, if possible. 
 will ask the staff to complete and 
send them the Unmasking Request Form. 
 will notify the Sponsor and jointly 
determine if the unmasking request should be granted. In addition, they may consult 
the medical monitor as needed. The result of the request will be documented on the 
Unmasking Request Form. If approval is granted to unmask a subject, written 
permission will be provided on the Unmasking Request Form. The investigator will 
unmask the subject using the interactive web response system (IWRS), complete the 
Unmasking Memo form, include it in the subject’s study file and make a copy for the 
trial master file (TMF). For each unmasked request, the reason, date, signature, and 
name of the person unmasking the subject must be noted in the subject’s study file.  
Unmasked subjects will be discontinued from the study and followed for safety 
monitoring, until resolution of the AE or study completion, whichever occurs last. 
 Type and Duration of the Follow-up of Subjects after Adverse 
Events 
The investigator will follow unresolved AEs to resolution until the subject is lost to 
follow-up, or until the AE is otherwise classified. Resolution means the subject has 
returned to baseline state of health or the investigator does not expect any further 


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improvement or worsening of the AE. If the subject is lost to follow-up, the 
investigator will make 3 reasonable attempts to contact the subject via telephone, 
USPS, or certified mail. All follow-up will be documented in the subject’s source 
document. Non-serious AEs identified during the last scheduled contact must be 
recorded on the AE eCRF with the status noted.  
If the investigator becomes aware of any new information regarding an existing SAE 
(i.e., resolution, change in condition, or new treatment), a new SAE/Unanticipated 
Report Form must be completed and faxed to 
 within 24 hours of the site’s 
awareness of the new information. The original SAE form is not to be altered. The 
report will include a description of the event, treatment, and whether it was resolved 
or continues. 
10 STATISTICAL HYPOTHESES AND METHODS OF 
ANALYSES 
 Analysis Populations 
The following analysis populations will be considered: 
 Intent-to-Treat Population – The intent-to-treat (ITT) population includes all 
randomized subjects. Subjects in the ITT population will be analyzed as 
randomized. 
 Per-Protocol Population – The per-protocol (PP) population includes subjects 
in the ITT population who do not have significant protocol deviations and who 
complete the study. Protocol deviations will be assessed prior to database lock 
and unmasking. Subjects in the PP population will be analyzed as treated. 
 Safety Population – The safety population includes all randomized subjects 
who have received at least one dose of the investigational product. Subjects in 
the Safety population will be analyzed as treated.  
The statistical analysis of safety data will be performed for the safety population. 
The analysis of efficacy data will be performed for the ITT population and on the 
PP population as sensitivity analyses. 
 Statistical Hypotheses 
The following primary hypotheses will be tested against their respective two-sided 
alternative hypotheses in the order: 
H01:  There is no difference in the change from baseline in the post-CAE inferior 
corneal staining score after 28 days of treatment of 
 K-161 
 compared to 
vehicle.   
H02:  There is no difference in the change from baseline in the post-CAE ocular 
discomfort score after 28 days of treatment of 
 K-161 
 compared to vehicle.   
Upon rejecting both H01 and H02, the secondary hypotheses will be tested as detailed 
in Section 10.4.4 in the following order  
H03:  There is no difference in the change from baseline in the pre-CAE Schirmer’s 
test value after 28 days of treatment of 
 K-161 
 compared to vehicle. 
H04:  There is no difference in the change from baseline in the post-CAE TFBUT 
after 28 days of treatment of 
 K-161 
 compared to vehicle. 


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These four hypotheses will be tested hierarchically, each at the alpha = 0.05 level to 
maintain a study-wise Type I error rate at 0.05. 
 Sample Size  
This study is expected to enroll 240 subjects in a 1:1:1:1 ratio across four treatment 
arms, or 60 subjects per treatment arm. In addition, randomization will be stratified 
such that 
 will be randomized in each treatment arm.  
The standard deviation (SD) for change from baseline in post-CAE inferior corneal 
fluorescein staining ranges between 0.68 and 0.81 units. Assuming a common SD of 
0.77, a sample size of 60 subjects per group will have approximately 90% power to 
detect a difference of 0.46 units between the active treatment group and the vehicle 
group using a two-sample t-test at a two-sided significance level of 0.05. Again, it is 
assumed that adjusting for baseline and site will further reduce variability and provide 
>90% power. 
Likewise, the SD for change from baseline scores in the post-CAE ODS at Day 29 is 
assumed a common SD of 0.82, a sample size of 60 subjects per group will have 
approximately 90% power to detect a difference of 0.49 units between the active 
treatment group and the vehicle group using a two-sample t-test at a two-sided 
significance level of 0.05. It is assumed that adjusting for baseline and site will further 
reduce variability and provide >90% power. 
 Statistical Analysis 
10.4.1 General Considerations 
Quantitative variables will be summarized descriptively using number of subjects (n), 
mean, SD, median, minimum, and maximum. Qualitative variables will be 
summarized using counts and percentages. 
All summaries will be presented by treatment group. Summaries will be provided for 
demographics, baseline medical history, concurrent therapies, and subject disposition. 
For the purpose of summarization, medical history, concurrent therapies, and AEs will 
be coded using the MedDRA and WHO drug dictionaries, as appropriate.  
Change from pre-CAE to post-CAE will be calculated as post-CAE value minus pre-
CAE value. Baseline measures are defined as the last non-missing measure prior to 
the initiation of randomized study treatment. Change from baseline will be calculated 
as follow-up visit value minus baseline value. Treatment comparisons between active 
and vehicle will be calculated as active minus vehicle. 
All analyses will be 2-sided at a significance level of 0.05 unless otherwise specified. 
For all efficacy analyses, 95% confidence intervals on the difference between each 
dose of K-161 and vehicle will be provided. 
10.4.2 Unit of Analysis 
Safety endpoints will be analyzed for both eyes. For efficacy endpoints, the unit of 
analysis will be the study eye, or the “worst eye,” as defined by the following:  
Worst Eye: Eyes are eligible for analysis if they meet all of the inclusion criteria. At 
least one eye (the right eye or the left eye) must meet all of the criterial. In the case 
that both eyes are eligible for analysis, the worst eye will be selected as the eye with 
the worst post-CAE inferior corneal staining at Visit 2. If the post-CAE inferior 


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corneal staining at Visit 2 is the same in both eyes then the eye with the worst post-
CAE ODS at Visit 2 will be worst eye. If the post-CAE inferior corneal staining and 
ocular discomfort are the same in both eyes then the right eye will be selected as the 
worst eye. 
10.4.3 Missing Data 
Missing data will be imputed using multiple imputation with a control-based pattern 
mixture model on the ITT population for the primary analyses, the important secondary, 
other secondary, and exploratory comparisons.   
Sensitivity analyses of the primary analyses and important secondary comparisons will 
include the following in order to provide a robust understanding of the impact of 
missing and spurious data:  
 Using complete case data (i.e. observed data only) on the ITT population 
 Using last observation carried forward (LOCF) on the ITT population 
 Multiple imputation under missing at random assumption with Markov Chain 
Monte Carlo (MCMC) techniques on the ITT population 
 Using complete case data on the PP population.  
No imputation will be used for safety endpoints. 
10.4.4 Multiplicity Consideration 
Common factors for multiplicity are multiple arms and multiple endpoints. 
1) Multiple arms 
The primary treatment comparison will be between the 
 K-161 
 treatment arm 
and the vehicle
 treatment arm. 
 
.  
2) Multiple endpoints 
The primary and important secondary endpoints will be tested hierarchically to 
maintain the study-wise Type I error rate of 0.05. First, change from baseline in inferior 
corneal fluorescein staining will be tested at an alpha level of 0.05. The test for change 
from baseline scores in the ODS will be conducted at an alpha level of 0.05 only if the 
previous test demonstrates significance. The test for change from baseline in Schirmer’s 
test will be conducted at an alpha level of 0.05 only if the previous test demonstrates 
significance. The test for change from baseline in TFBUT will be conducted at an alpha 
level of 0.05 only if the previous test demonstrates significance. 
 
 
The hierarchical testing order will be as follows: 
Primary comparisons: 
1. Comparison of the change from baseline in post-CAE inferior corneal staining 
at Day 29 (
 K-161 
 vs vehicle) 
2. Comparison of the change from baseline in post-CAE ocular discomfort at Day 
29 (
 K-161 
 vs vehicle) 
Important Secondary comparisons: 
3. Comparison of the change from baseline in pre-CAE Schirmer’s test value at 
Day 29 (
 K-161 
 vs vehicle) 


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4. Comparison of the change from baseline in post-CAE TFBUT at Day 29 (
 
K-161 
 vs vehicle) 
Thus, the study-wise Type I error rate will be maintained at 0.05 by considering only 
one dose of K-161 as the primary treatment comparison and using a hierarchical testing 
procedure. 
10.4.5 Efficacy Analyses 
Primary Efficacy Analyses 
The primary comparisons of change from baseline in post-CAE inferior corneal 
staining and ocular discomfort between the 
 K-161 
 group and the vehicle 
group at Day 29, will be performed using analysis of covariance (ANCOVA) models. 
The respective baseline post-CAE score will be included as a covariate in each model 
and site will be included as a fixed effect. Treatment by baseline and treatment by site 
interactions will be explored in separate models and, if significant, analyses will be 
performed by baseline stratification and/or site, respectively, to further examine 
significant interactions. The primary analyses will use the ITT population. 
For the primary endpoints, multiple imputation with MCMC techniques will be used. 
Imputation will be performed by treatment arm with imputation terms for baseline and 
Day 29 scores. 
Secondary Efficacy Analyses 
Secondary and exploratory endpoints will be analyzed similarly to the primary 
analyses on the ITT population. Continuous and ordinal variables collected at each 
visit will be summarized descriptively (n, mean, standard deviation, median, 
minimum and maximum), and analyzed with ANCOVA models comparing each K-
161 group to the vehicle group. All visit-based data will be analyzed by visit and for 
each timepoint, if applicable, as well as the change from baseline.  
Data collected pre- and post-CAE will also be analyzed for the change from pre- to 
post-CAE within each visit. Data collected during the CAE will also be analyzed 
using repeated measures models including all of the time points from a CAE 
exposure. Daily subject diary symptom data will be analyzed using each weekly 
average score from the diaries, as well as using repeated measures models across the 
diary collection period.   
For the two important secondary endpoints, other secondary, and exploratory 
endpoints, multiple imputation with MCMC techniques will be used. Imputation will 
be performed by treatment arm with imputation terms for baseline and Day 29 scores. 
 
 
 
 
10.4.6 Safety Variables 
Adverse events will be coded using the MedDRA dictionary. Frequencies and 
percentages of subjects with treatment-emergent adverse events (TEAEs), serious 
TEAEs, and TEAEs causing premature 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 will be given of subjects with TEAEs by 


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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 performed for ocular and non-ocular AEs.  
 
 
 
 
 
 
10.4.7 
 
 
 
 
10.4.8 
 
 
 
 
 
 
Other analyses may be conducted and the details will be included in a separate 
statistical analysis plan. 
10.4.9 
 
 
 
 
10.4.10 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
10.4.11 Interim Analyses 
There will be no interim analyses in this study. 


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11 COMPLIANCE WITH GOOD CLINICAL PRACTICES, 
ETHICAL CONSIDERATIONS, AND ADMINISTRATIVE 
ISSUES 
This study will be conducted in compliance with the protocol, current versions of the 
FDA Good Clinical Practice (GCP) regulations, the International Council for the 
Harmonisation of Technical Requirements for Human Use (ICH) GCP guidance, and 
in general, consistent with the Declaration of Helsinki. In addition, all applicable 
local, state, and federal requirements relevant to the use of IP will be met. 
 Protection of Human Subjects 
11.1.1 Subject Informed Consent 
Informed consent/assent must take place before any study specific procedures are 
initiated. Signed and dated written informed consent must be obtained from each 
subject and/or from the subject’s parent or legal guardian prior to enrollment into the 
study. The subject must also be given a copy of the signed ICF. 
All informed consent forms must be approved for use by the Sponsor and receive 
approval/favorable opinion from an IRB/IEC 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 
 prior to submission to the governing IRB/IEC and that it is read, signed and dated 
by all subjects currently and subsequently enrolled in the study. 
If informed consent is taken under special circumstances (oral informed consent), then 
the procedures to be followed must be determined by 
 and/or the Sponsor and 
provided in writing by 
 and/or the Sponsor prior to the consent process. 
11.1.2 Institutional Review Board (IRB) Approval 
This study is to be conducted in accordance with IRB/IEC regulations (e.g., US FDA 
21 Code of Federal Regulations Part 56.103). The PI must obtain appropriate 
IRB/IEC approval before initiating the study and re-approval at least annually. 
Only an IRB/IEC approved version of the ICF will be used. 
 Ethical Conduct of the Study 
This study will be conducted in accordance with the ethical principles that originated 
with the Declaration of Helsinki. 
 Subject Confidentiality 
All personal study subject data collected and processed for the purposes of this study 
will be maintained by the PI and site staff with adequate precautions as to ensure that 
the confidentiality of the data is in accordance with local, state, and federal laws and 
regulations. 
Monitors, auditors and other authorized representatives of 
 the Sponsor, the 
IRB/IEC approving this study, the FDA, the Department of Health and Human 
Services, other domestic government agencies, and other foreign regulatory agencies 
will be granted direct access to the subject’s original medical and study records for 
verification of the data and/or clinical study procedures. Access to this information 
will be permitted to the aforementioned individuals to the extent permitted by law. 


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A report of the results of this study may be published or sent to the appropriate health 
authorities in any country in which the IP may ultimately be marketed, but the 
subject’s identity will not be disclosed in these documents. 
 Documentation 
Source documents may include a subject’s medical records, hospital charts, clinic 
charts, the study subject files, as well as the results of diagnostic tests such as X-rays, 
laboratory tests, and electrocardiograms. The site’s copy of the CRFs serves as the 
PI’s record of a subject’s study-related data. 
11.4.1 Retention of Documentation 
All study related correspondence, subject records, consent forms, record of the 
distribution and use of all IP, and copies of CRFs must be maintained on file for at 
least two years after the last approval of a marketing application in an ICH region and 
until there are no pending or contemplated marketing applications in an ICH region; 
or until at least two years have elapsed since the formal discontinuation of clinical 
development of the IP. These documents will be retained for a longer period if 
required by the applicable regulatory requirements or by an agreement with the 
Sponsor. It is the responsibility of the Sponsor to inform the PI when these documents 
no longer need to be retained. 
If the PI retires, relocates, or for other reasons withdraws from the responsibility of 
keeping study records, the custody of site study data must be transferred to a person 
who will accept the responsibility. The Sponsor must be notified in writing of the 
name and address of the new custodian. 
 Recording of Data on Source Documents and Case Reports 
Forms (CRFs) 
The PI is responsible for ensuring that study data is completely and accurately 
recorded on each subject’s CRF, source document, and all study-related material. All 
study data should also be attributable, legible, contemporaneous, accurate, complete, 
and original. Recorded data must only be corrected in a manner that does not 
obliterate, destroy, or render illegible the previous entry (e.g., by drawing a single line 
through the incorrect entry and writing the revision next to the corrected data. The  
individual correcting the entry must initial and date it.   
Data entries for all randomized subjects will use software that conforms to 21 CFR 
Part 11 requirements, and will be performed only by staff who have access and have 
been trained on the system. Screen failure data will also be entered in the eCRF. An 
audit trail will be maintained within the electronic system to capture all changes made 
within the eCRF database. After the end of the study and database lock, compact discs 
(CDs) containing copies of all applicable subjects’ eCRFs will be provided to each 
investigator site to be maintained on file by the PI. 
 Publications 
All data derived from the study will be the property of the Sponsor and must be kept 
strictly confidential. The investigator must not submit any of the data from this study 
for publication without prior consent of the Sponsor. The Sponsor will have the final 
decision regarding any manuscript and publication. 
 


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12 REFERENCES 
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Sullivan (2017). "TFOS DEWS II pathophysiology report." Ocul Surf 15(3): 438-510. 
CEQUA (2018). "CEQUA (cyclosporine ophthalmic solution) 0.9% [drug label]. Sun 
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Kudlacz, E., M. Conklyn, C. Andresen, C. Whitney-Pickett and P. Changelian (2008). 
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Mah, F., M. Milner, S. Yiu, E. Donnenfeld, T. M. Conway and D. A. Hollander 
(2012). "PERSIST: Physician's Evaluation of Restasis((R)) Satisfaction in Second 
Trial of topical cyclosporine ophthalmic emulsion 0.05% for dry eye: a retrospective 
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Schaumberg, D. A., R. Dana, J. E. Buring and D. A. Sullivan (2009). "Prevalence of 
dry eye disease among US men: estimates from the Physicians' Health Studies." Arch 
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Schaumberg, D. A., D. A. Sullivan, J. E. Buring and M. R. Dana (2003). "Prevalence 
of dry eye syndrome among US women." Am J Ophthalmol 136(2): 318-326. 
Schaumberg, D. A., D. A. Sullivan and M. R. Dana (2002). "Epidemiology of dry eye 
syndrome." Adv Exp Med Biol 506(Pt B): 989-998. 
Stevenson, W., Z. Sadrai, J. Hua, S. Kodati, J. F. Huang, S. K. Chauhan and R. Dana 
(2014). "Effects of topical Janus kinase inhibition on ocular surface inflammation and 
immunity." Cornea 33(2): 177-183. 
Tauber, J., P. Karpecki, R. Latkany, J. Luchs, J. Martel, K. Sall, A. Raychaudhuri, V. 
Smith, C. P. Semba and O.-. Investigators (2015). "Lifitegrast Ophthalmic Solution 
5.0% versus Placebo for Treatment of Dry Eye Disease: Results of the Randomized 
Phase III OPUS-2 Study." Ophthalmology 122(12): 2423-2431. 
 
 


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13 
APPENDICES 
APPENDIX 1: SCHEDULE OF VISITS AND MEASUREMENTS 
Procedure 
Visit 1 
Day -14 ± 2 
Visit 2 
Day 1 
Visit 3 
Day 8 
± 1 
Visit 4 
Day 15 ± 2 
Visit 5 
Day 29 ± 2 
Follow-up 
Phone Call 
(Day 36 ± 2) 
 
Pre  
CAE 
Post  
CAE 
Pre 
CAE 
Post 
CAE 
Non 
CAE 
Pre 
CAE 
Post 
CAE 
Pre 
CAE 
Post  
CAE 
 
Informed Consent / 
HIPAA 
X 
 
 
 
 
 
 
 
 
 
Medical / Medication 
History and 
Demographics 
X 
 
 
 
 
 
 
 
 
 
Medical / Medication 
Update 
 
 
X 
 
X 
X 
 
X 
 
 
Adverse Event Query 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Ora Calibra® Ocular 
Discomfort Scale 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
Ora Calibra® Ocular 
Discomfort & 4-Symptom 
Questionnaire 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
OSDI© Questionnaire 
X 
 
X 
 
X 
X 
 
X 
 
 
Visual Analog Scale 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
Conjunctival Redness 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
Tear Osmolarity 
 
 
X 
 
X 
X 
 
X 
 
 
TFBUT 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
Fluorescein Staining 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
Lissamine Green Staining 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
Schirmer’s Test 
X 
 
X 
 
X 
X 
 
X 
 
 
Blink Rate 
 
 
X 
 
X 
X 
 
X 
 
 


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Procedure 
Visit 1 
Day -14 ± 2 
Visit 2 
Day 1 
Visit 3 
Day 8 
± 1 
Visit 4 
Day 15 ± 2 
Visit 5 
Day 29 ± 2 
Follow-up 
Phone Call 
(Day 36 ± 2) 
 
Pre  
CAE 
Post  
CAE 
Pre 
CAE 
Post 
CAE 
Non 
CAE 
Pre 
CAE 
Post 
CAE 
Pre 
CAE 
Post  
CAE 
 
Vehicle Run-In 
Dispensation 
 
X 
 
 
 
 
 
 
 
 
Vehicle Run-In 
Instillation 
 
X 
 
 
 
 
 
 
 
 
Vehicle Run-in Collection 
 
 
X 
 
 
 
 
 
 
 
Randomization 
 
 
 
X 
 
 
 
 
 
 
Study Drug Dispensation 
 
 
 
X 
X 
 
X 
 
 
 
Study Drug Collection 
 
 
 
 
X 
X 
 
X 
 
 
Diary Dispensation 
 
X 
 
X 
X 
 
X 
 
 
 
Diary Collection 
 
 
X 
 
X 
X 
 
X 
 
 
Exit Subject from Study 
 
 
 
 
 
 
 
 
 
X 
   
 
 
 
 
 


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APPENDIX 3: PROTOCOL AMENDMENT SUMMARY 
Not Applicable. 
 




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APPENDIX 5: INVESTIGATOR’S SIGNATURE 
 
Protocol Title: 
A Phase 2, Prospective, Double-Masked, 
Randomized, Multi-Center, Vehicle-Controlled, 
Parallel-group, 4-week Administration Study 
Assessing the Safety, Efficacy, and Optimum 
Dosage of K-161 in non-Japanese/Japanese Adult 
Subjects with Moderate to Severe Dry Eye 
Disease Both in Environmental and Controlled 
Adverse Environmental (CAE) Settings 
Protocol Number: K-161-2.01US / 
 
Amendment 1 Date:  
13June2019 
I agree to implement and conduct the study diligently and in strict compliance with 
the protocol, Declaration of Helsinki, Health Insurance Portability and Accountability 
Act, Good Clinical Practice, and all applicable laws and regulations. I agree to 
maintain all information supplied by 
 and the Sponsor in confidence and, when 
this information is submitted to an Institutional Review Board / Independent Ethics  
Committee or another group, it will be submitted with a designation that it is 
confidential. 
I have read this protocol in its entirety, including the above statement, and I agree to 
all aspects. 
 
 
 
Signed: 
 
 
Date:_______________ 
 
 
 
   dd mm yyyy 
 
 
 

Prot_000.pdf: 
K-161-2.01US 
 
 
A Phase 2, Prospective, Double-Masked, Randomized, Multi-Center, Vehicle-Controlled, 
Parallel-group, 4-week Administration Study Assessing the Safety, Efficacy, and 
Optimum Dosage of K-161 in non-Japanese and Japanese Adult Subjects with Moderate 
to Severe Dry Eye Disease Both in Environmental and Controlled Adverse Environmental 
(CAE®) Settings 
 
NCT #: 04084483 
Clinical Trial Protocol 
Ver. 1.0 
 14 September 2018 
 


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Clinical Trial Protocol: K-161-2.01US 
Protocol Title: 
A Phase 2, Prospective, Double-Masked, 
Randomized, Multi-Center, Vehicle-Controlled, 
Parallel-group, 4-week Administration Study 
Assessing the Safety, Efficacy, and Optimum 
Dosage of K-161 in non-Japanese and Japanese 
Adult Subjects with Moderate to Severe Dry Eye 
Disease Both in Environmental and Controlled 
Adverse Environmental (CAE®) Settings 
Protocol Number: 
K-161-2.01US 
Study Phase: 
2 
Investigational Product Name: K-161 
IND/IDE/PMA Number: 
N/A 
Indication: 
Dry eye disease 
Investigators: 
Multi-Center 
Sponsor: 
Kowa Research Institute, Inc. (KRI) 
 
 
 
 
 
 
 
 
 
 
 
 
 
Date 
Original Protocol: 
14 September 2018 
Amendment 1: 
- 
 
 
Confidentiality Statement 
 
This protocol contains confidential, proprietary information of 
. and/or Kowa 
Research Institute, Inc. Further dissemination, distribution or copying of this protocol or 
its contents is strictly prohibited. 
 


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SPONSOR PERSONNEL 
 
 
MEDICAL MONITOR 
 
 


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SYNOPSIS 
Protocol Title: 
A Phase 2, Prospective, Double-Masked, 
Randomized, Multi-Center, Vehicle-Controlled, 
Parallel-group, 4-week Administration Study 
Assessing the Safety, Efficacy, and Optimum 
Dosage of K-161 in non-Japanese and Japanese 
Adult Subjects with Moderate to Severe Dry Eye 
Disease Both in Environmental and Controlled 
Adverse Environmental (CAE) Settings 
Protocol Number: 
K-161-2.01US 
Investigational Product: 
1. K-161 Ophthalmic Solution 
2. Placebo Ophthalmic Solution (Vehicle) 
Study Phase: 
2 
Objective(s): 
The objective of the study is to assess the safety, 
efficacy, optimum dosage, and dosing regimen of K-
161 compared to its vehicle from Day 1 (baseline) to 
Day 29 in non-Japanese and Japanese adult subjects 
with moderate to severe dry eye disease both in 
environmental and CAE settings. 
Overall Study Design: 
Structure: 
Prospective, double-masked, randomized, multi-
center, vehicle-controlled, parallel-group study 
Duration: 
An individual subject’s participation is estimated to 
be approximately 6 weeks (42 days) with a follow-
up phone call. 
Controls: 
Placebo Ophthalmic Solution (Vehicle) 
Dosage/Dose Regimen/ 
Instillation/Application/Use: 
Subjects eligible to be randomized will receive one 
of the following treatments to be administered 
bilaterally for 28 days (from Visit 2 to Visit 5). 
1) 
 K-161 Ophthalmic Solution; 
 
 
2) 
 K-161 Ophthalmic Solution; 
 
 
3) 
 K-161 Ophthalmic Solution; 
 
  
4) Placebo Ophthalmic Solution (Vehicle); 
 
 
During a 14-day study run-in period (for the purpose 
of subject selection) prior to randomization, all 


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subjects will receive Placebo Ophthalmic Solution 
(Vehicle) 
 
Summary of Visit Schedule: 
5 visits over the course of approximately 6 weeks 
with a follow-up phone call. 
• Visit 1 = Day -14 ± 2, CAE Screening  
• Visit 2 = Day 1, CAE Confirmation/ Baseline 
• Visit 3 = Day 8 ± 1 
• Visit 4 = Day 15 ± 2 
• Visit 5 = Day 29 ± 2 
Measures Taken to Reduce 
Bias: 
This is a double-masked, randomized treatment 
assignment study. 
Study Population Characteristics: 
Number of Subjects: 
Approximately 600 subjects will be screened to 
enroll approximately 240 (60 per treatment arm*) 
subjects 
 
Condition/Disease: 
Dry Eye Disease (DED) 
Inclusion Criteria: 
Subjects who meet all of the following criteria will be eligible to participate in the 
study. 
Subjects must: 
1. Be at least 18 years of age at the time of informed consent visit 
2. Have a reported history of dry eye disease in both eyes 
 
 and a history of eye drop use for dry eye symptoms 
 
 
  
 
 
  
 
 
 
  
 
 
 
  
 
 
  
  
 
 


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Exclusion Criteria: 
Subjects who meet any of the following criteria will not be eligible to participate in the 


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study. 
Subjects must not: 
1. Have any ocular condition 
 
 
2. Have a history of 
 
corneal refractive surgery within 12 months prior to Visit 1, and/or any other 
ocular surgical procedure 
 within 12 
months
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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Evaluation Criteria: 
 
Efficacy Measures and 
Endpoints: 
Primary Efficacy Endpoints: 
The primary efficacy endpoint (sign) is: 
• Change in inferior corneal staining score 
from Day 1 (baseline) to Day 29 by 
comparing 
 K-161 
 to its 
vehicle 
 in CAE setting 
The primary efficacy endpoint (symptom) is: 
• Change in Ora Calibra® ODS from Day 1 
(baseline) to Day 29 by comparing 
 K-
161 
 to its vehicle 
 in 
CAE setting 
Important Secondary Efficacy Endpoints: 
The important secondary efficacy endpoints are: 
• Change in Schirmer’s Test value 
(unanesthetized) from Day 1 (baseline) to 
Day 29 by comparing 
 K-161 
 


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 to its vehicle 
 in 
environmental setting 
• Change in TFBUT from Day 1 (baseline) to 
Day 29 by comparing 
 K-161 
 
 to its vehicle 
 in CAE setting 
Secondary Efficacy Endpoints: 
The secondary efficacy endpoints are: 
• Fluorescein staining by region: central, 
superior, inferior, temporal, nasal and 
corneal sum as assessed by the Ora Calibra® 
Corneal and Conjunctival Staining Scale 
• Lissamine green staining by region: central, 
superior, inferior, temporal, nasal, and 
conjunctival sum as assessed by the Ora 
Calibra® Corneal and Conjunctival Staining 
Scale 
• Conjunctival Redness as assessed by the Ora 
Calibra® Scale 
• TFBUT  
• Tear Osmolarity 
• Schirmer’s Test (unanesthetized) 
• Blink Rate 
• Ora Calibra® Ocular Discomfort Scale  
• Ora Calibra® Ocular Discomfort and 4-
Symptom Questionnaire  
• Visual Analog Scale (VAS)   
 Burning/ Stinging 
 Itching 
 Foreign Body Sensation 
 Blurred Vision 
 Eye Dryness 
 Photophobia 
 Pain 
• OSDI©  
• Daily diary  


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Safety Measures: 
 
 
  
 
 
• Adverse event query  
 
  
 
 
 
 
• Maximum dose tolerability by comparing the 
 K-161 
 arm to the 
 and 
 K-161 
 arms 
Other: 
Analysis Populations 
• Intent-to-Treat Population – The intent-to-treat (ITT) population includes all 
randomized subjects. The primary analysis will be performed on the ITT 
population. Subjects in the ITT population will be analyzed as randomized. 
• Per Protocol Population – The per protocol (PP) population includes subjects in 
the ITT population who do not have significant protocol deviations and who 
complete the study. Protocol deviations will be assessed prior to database lock 


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and unmasking. Subjects in the PP population will be analyzed as treated. 
• Safety Population – The safety population includes all subjects who have 
received at least one dose of the investigational product. The safety population 
will be analyzed for all safety assessments. Subjects in the Safety population 
will be analyzed as treated.  
Sample Size 
This study is expected to enroll 240 subjects in a 1:1:1:1 ratio across four treatment 
arms, or 60 subjects per treatment arm. In addition, randomization will be stratified such 
that 
 will be randomized in each treatment arm.  
The standard deviation for change from baseline in post-CAE inferior corneal 
fluorescein staining ranges between 0.68 and 0.81 units. Assuming a common standard 
deviation of 0.77, a sample size of 60 subjects per group will have approximately 90% 
power to detect a difference of 0.46 units between the active treatment group and the 
vehicle group using a two-sample t-test at a two-sided significance level of 0.05. Again, 
it is assumed that adjusting for baseline and site will further reduce variability and 
provide >90% power. 
Likewise, the standard deviation for change from baseline scores in the post-CAE ODS 
at Day 29 is assumed a common standard deviation of 0.82, a sample size of 60 subjects 
per group will have approximately 90% power to detect a difference of 0.49 units 
between the active treatment group and the vehicle group using a two-sample t-test at a 
two-sided significance level of 0.05. It is assumed that adjusting for baseline and site 
will further reduce variability and provide >90% power. 
Multiplicity Consideration: 
Common factors for multiplicity are multiple arms and multiple endpoints. 
1) Multiple arms 
The primary treatment comparison will be between the 
 K-161 
 treatment arm 
and the vehicle 
 treatment arm. Other treatment comparisons will be considered 
secondary or exploratory.  
2) Multiple endpoints 
The primary and important secondary endpoints will be tested hierarchically to maintain 
the study-wise Type I error rate of 0.05. First, change from baseline in inferior corneal 
fluorescein staining will be tested at an alpha level of 0.05. The test for change from 
baseline scores in the ODS will be conducted at an alpha level of 0.05 only if the 
previous test demonstrates significance. The test for change from baseline in Schirmer’s 
test will be conducted at an alpha level of 0.05 only if the previous test demonstrates 
significance. The test for change from baseline in TFBUT will be conducted at an alpha 
level of 0.05 only if the previous test demonstrates significance. All other secondary and 
exploratory endpoints and treatment comparisons will be considered exploratory. 
The hierarchical testing order will be as follows: 
Primary comparisons: 


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1. Comparison of the change from baseline in post-CAE inferior corneal staining at 
Day 29 (
 K-161 
 vs vehicle) 
2. Comparison of the change from baseline in post-CAE ocular discomfort at Day 
29 (
 K-161 
 vs vehicle) 
Important Secondary comparisons: 
3. Comparison of the change from baseline in pre-CAE Schirmer’s test value at 
Day 29 (
 K-161 
 vs vehicle) 
4. Comparison of the change from baseline in post-CAE TFBUT at Day 29 (
 
K-161 
 vs vehicle) 
Thus, the study-wise Type I error rate will be maintained at 0.05 by considering only 
one dose of K-161 as the primary treatment comparison and using a hierarchical testing 
procedure. 
Primary Efficacy Analyses:  
The primary comparisons of change from baseline in post-CAE inferior corneal staining 
and ocular discomfort between the 
 K-161 
 group and the vehicle group at Day 
29, will be performed using analysis of covariance (ANCOVA) models. The respective 
baseline post-CAE score will be included as a covariate in each model and site will be 
included as a fixed effect. Treatment by baseline and treatment by site interactions will 
be explored in separate models and, if significant, analyses will be performed by 
baseline stratification and/or site, respectively, to further examine significant 
interactions. In addition, unadjusted two-sample t-tests and Wilcoxon rank-sum tests 
will be performed for each comparison as sensitivity analyses. The primary analyses 
will use the ITT population. 
For the primary endpoints multiple imputation with a control-based pattern mixture 
model will be used.  
Secondary Efficacy Analyses 
Secondary and exploratory endpoints will be analyzed similarly to the primary analyses 
on the ITT population. Continuous and ordinal variables collected at each visit will be 
summarized descriptively (n, mean, standard deviation, median, minimum and 
maximum), and analyzed with ANCOVA models and two-sample, two-sided t-tests 
comparing each K-161 
 group to the vehicle group. All visit-based data will be 
analyzed by visit and for each timepoint, if applicable, as well as the change from 
baseline.  
Data collected pre- and post-CAE will also be analyzed for the change from pre- to 
post-CAE within each visit. Data collected during the CAE will also be analyzed using 
repeated measures models including all of the time points from a CAE exposure. Daily 
subject diary symptom data will be analyzed using each weekly average score from the 
diaries, as well as using repeated measures models across the diary collection period. 
For the two important secondary endpoints, other secondary, and exploratory endpoints, 
multiple imputation with a control-based pattern mixture model will be used.   


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Safety Variables 
Adverse events (AEs) will be coded using the MedDRA dictionary. Frequencies and 
percentages of subjects with treatment-emergent adverse events (TEAEs), serious 
TEAEs, and TEAEs causing premature 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 will be given of subjects 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 performed for ocular and non-ocular AEs.  
 
 
 
 
 
 
 
 
  
 
 
 
 
 
Other analyses may be conducted and the details will be included in a separate statistical 
analysis plan. 
 
 
 
 
 
 


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TABLE OF CONTENTS 
Clinical Trial Protocol: K-161-2.01US ................................................................................1 
SYNOPSIS ...........................................................................................................................3 
TABLE OF CONTENTS ...................................................................................................14 
LIST OF ABBREVIATIONS ............................................................................................18 
1 
INTRODUCTION ....................................................................................................20 
 
Drug Profile from Non-clinical Studies .........................................................20 
1.1
2 
STUDY OBJECTIVES .............................................................................................21 
3 
CLINICAL HYPOTHESES .....................................................................................21 
4 
OVERALL STUDY DESIGN ..................................................................................21 
5 
STUDY POPULATION ...........................................................................................22 
 
Number of Subjects (approximate) ................................................................22 
5.1
 
Study Population Characteristics ....................................................................22 
5.2
 
Inclusion Criteria ............................................................................................22 
5.3
 
Exclusion Criteria ...........................................................................................24 
5.4
 
Withdrawal Criteria (if applicable) ................................................................25 
5.5
6 
STUDY PARAMETERS ..........................................................................................26 
 
Efficacy Endpoints .........................................................................................26 
6.1
6.1.1 
Primary Efficacy Endpoints ..............................................................26 
6.1.2 
Important Secondary Efficacy Endpoints .........................................26 
6.1.3 
Secondary Efficacy Endpoints ..........................................................26 
6.1.4 
Exploratory Efficacy Endpoints ........................................................27 
 
Safety Measures .............................................................................................27 
6.2
 
Other Measures ...............................................................................................27 
6.3
 
 
 
 
 
 
 
Clinical Laboratory Measurements ................................................................28 
6.7
7 
STUDY MATERIALS .............................................................................................29 
 
Study Treatments ............................................................................................29 
7.1
7.1.1 
Masking.............................................................................................29 
7.1.2 
Description of and Justification for the Route of Administration, 
Dosage, Dosage Regimen, and Treatment Period. ...........................29 


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7.1.3 
Instructions for Use and Administration ...........................................29 
 
Labeling, Packaging, Storage, Accountability, and Return or Disposal of 
7.2
Investigational Product ...................................................................................30 
7.2.1 
Labeling/Packaging...........................................................................30 
7.2.2 
Storage of Investigational Product ....................................................30 
7.2.3 
Accountability of Investigational Product ........................................30 
7.2.4 
Return or Disposal of Investigational Product ..................................30 
 
Other Study Supplies ......................................................................................30 
7.3
8 
STUDY METHODS AND PROCEDURES ............................................................31 
 
Subject Entry Procedures ...............................................................................31 
8.1
8.1.1 
Overview ...........................................................................................31 
8.1.2 
Informed Consent..............................................................................31 
8.1.3 
Washout Intervals .............................................................................31 
8.1.4 
Procedures for Final Study Entry ......................................................31 
8.1.5 
Methods for Assignment to Treatment Groups: ...............................31 
 
Concurrent Therapies .....................................................................................32 
8.2
8.2.1 
Prohibited Medications/Treatments ..................................................32 
8.2.2 
Escape Medications ..........................................................................32 
8.2.3 
Special Diet or Activities ..................................................................32 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Schedule of Visits, Measurements and Dosing ..............................................39 
8.4
8.4.1 
Scheduled Visits................................................................................39 
8.4.2 
Unscheduled Visits ...........................................................................40 
 
Compliance with Protocol ..............................................................................40 
8.5
 
Subject Disposition .........................................................................................40 
8.6


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8.6.1 
Completed Subjects ..........................................................................40 
8.6.2 
Discontinued Subjects .......................................................................41 
 
Study Termination ..........................................................................................41 
8.7
 
Study Duration ...............................................................................................41 
8.8
 
Monitoring and Quality Assurance ................................................................41 
8.9
9 
ADVERSE EVENTS ................................................................................................41 
 
Adverse Event ................................................................................................41 
9.1
9.1.1 
Severity .............................................................................................42 
9.1.2 
Relationship to Investigational Product ............................................42 
9.1.3 
Expectedness .....................................................................................43 
 
Serious Adverse Events ..................................................................................44 
9.2
 
Procedures for Reporting Serious Adverse Events ........................................44 
9.3
9.3.1 
Reporting a Serious Unexpected Suspected Adverse Reaction ........45 
9.3.2 
Reporting a Serious Adverse Event ..................................................45 
 
Procedures for Unmasking (if applicable) ......................................................46 
9.4
 
Type and Duration of the Follow-up of Subjects after Adverse Events ........47 
9.5
10 
STATISTICAL HYPOTHESES AND METHODS OF ANALYSES .....................47 
 Analysis Populations ......................................................................................47 
10.1
 Statistical Hypotheses .....................................................................................47 
10.2
 Sample Size ....................................................................................................48 
10.3
 Statistical Analysis .........................................................................................48 
10.4
10.4.1 General Considerations .....................................................................48 
10.4.2 Unit of Analysis ................................................................................49 
10.4.3 Missing Data .....................................................................................49 
10.4.4 Multiplicity Consideration ................................................................49 
10.4.5 Efficacy Analyses .............................................................................50 
10.4.6 Safety Variables ................................................................................51 
10.4.7 Exploratory Safety Analyses.............................................................51 
 
 
 
10.4.11 Interim Analyses ...............................................................................52 


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11 
COMPLIANCE WITH GOOD CLINICAL PRACTICES, ETHICAL 
CONSIDERATIONS, AND ADMINISTRATIVE ISSUES ....................................52 
 Protection of Human Subjects ........................................................................52 
11.1
11.1.1 Subject Informed Consent.................................................................52 
11.1.2 Institutional Review Board (IRB) Approval .....................................53 
 Ethical Conduct of the Study ..........................................................................53 
11.2
 Subject Confidentiality ...................................................................................53 
11.3
 Documentation ...............................................................................................53 
11.4
11.4.1 Retention of Documentation .............................................................53 
 Recording of Data on Source Documents and Case Reports Forms (CRFs) .54 
11.5
 Publications ....................................................................................................54 
11.6
12 
REFERENCES .........................................................................................................55 
13 
APPENDICES ..........................................................................................................56 
Appendix 1: Schedule of Visits and Measurements ..........................................................56 
Appendix 2: Examination Procedures, Tests, & Evaluations ............................................58 
Appendix 3: Protocol Amendment Summary ....................................................................73 
 
Appendix 5: Investigator’s Signature ................................................................................75 
 
 


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LIST OF ABBREVIATIONS 
AE 
adverse event 
 
 
 
 
CAE 
controlled adverse environment 
CFR 
Code of Federal Regulations 
 
 
 
 
CRF 
case report form 
CRO 
contract research organization 
 
 
DED 
dry eye disease 
eCRF 
electronic case report form 
 
 
 
 
FDA 
Food and Drug Administration 
 
 
GCP 
Good Clinical Practice 
GLP 
Good Laboratory Practice 
HIPAA 
Health Insurance Portability and Accountability Act 
IB 
Investigator’s brochure 
ICF 
informed consent form 
ICH 
International Conference on Harmonisation 
IEC 
Independent Ethics Committee 
 
 
 
 
IND 
investigational new drug application 
 
 
IP 
investigational product 
IRB 
institutional review board 
ITT 
intent to treat 
IWRS 
interactive web response system 
 
 
LASIK 
laser in situ keratomileusis 
LOCF 
last observation carried forward 
 
 
 
 
MedDRA 
Medical Dictionary for Regulatory Activities 


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NCS 
not clinically significant 
ODS 
Ocular Discomfort Score 
OSDI 
Ocular Surface Disease Index 
 
 
PP 
per protocol 
 
 
SAE 
serious adverse event 
 
 
SOP 
standard operating procedure 
 
 
TFBUT 
tear film break-up time 
 
 
 
 
 
 
 
 
 
 
 
 
 


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1 INTRODUCTION 
Dry eye disease is a multifactorial, progressive disorder of the ocular surface resulting 
from insufficient tear coverage of the surface of the eye in combination with ocular 
surface inflammation. Patients with DED often experience severe pain, visual 
impairment, tear film hyperosmolarity and instability, inflammation, and corneal 
wounding. While the prevalence of DED is difficult to report due to varying definitions 
and diagnostic criteria, the global prevalence of DED is estimated to be between 5% and 
50%, and increases with age (Bron et al. 2017). In the United States, it is estimated that 
as many as 3.2 million women and 1.7 million men over the age of 50 have DED, with a 
projected 40% increase in number of patients affected by 2030 (Schaumberg et al. 2002, 
Schaumberg et al. 2003, Schaumberg et al. 2009). 
Current treatment and management of DED consists primarily of tear supplementation 
with lubricants (artificial tears). While artificial tears improve symptoms associated with 
DED, they have no effect on resolving the underlying conditions that lead to 
inflammation of the ocular surface. Three currently available options for treating 
inflammation at the ocular surface are Restasis® (cyclosporine ophthalmic emulsion) 
CEQUA™ (cyclosporine ophthalmic solution), and Xiidra® (lifitegrast ophthalmic 
solution). It has been shown that only 15% of patients respond to Restasis® after 6 
months of treatment, as measured by Schirmer’s test, and many more report ocular side-
effects such as burning and stinging (Mah et al. 2012). Xiidra® has also been shown to be 
associated with ocular adverse events; in a clinical study of Xiidra® for subjects with 
DED, subjects reported increased ocular irritation upon instillation with Xiidra® 
compared to placebo (7.8% compared to 1.4% in the placebo group) (Tauber et al. 2015). 
Similarly, common adverse reactions reported after use of CEQUA include instillation 
site pain and conjunctival hyperemia (CEQUA 2018). Thus, there remains a medical need 
for more efficacious treatment options with a more favorable safety and comfort profile 
for patients with DED.  
 Drug Profile from Non-clinical Studies 
1.1
 a tyrosine kinase involved in 
cytokine signaling and activation of lymphocytes. 
 have been shown to 
have potent anti-inflammatory activity both in vitro and in vivo 
 
. 
 
 was shown to suppress ocular surface inflammation 
and corneal injury in a mouse model of dry eye disease (
). Because 
inflammation is a key component of DED, targeting the inflammatory pathway via 
 
 to reduce cytokine production and/or immune cell infiltration at the ocular 
surface may reduce the signs and symptoms of DED. 
 
 


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This will be the first clinical study of K-161 Ophthalmic Solution. 
2 STUDY OBJECTIVES 
Prior to any changes in a subject’s medical treatment and/or study visit procedures, the 
study will be discussed with each subject and subjects wishing to participate must give 
written informed consent (and/or assent) and sign a HIPAA form.  
The objectives of the study are to assess the safety, efficacy, optimum dosage, and dosing 
regimen of K-161 compared to its vehicle from Day 1 (baseline) to Day 29 in non-
Japanese and Japanese adult subjects with moderate to severe dry eye disease both in 
environmental and Controlled Adverse Environment (CAE) settings. 
3 CLINICAL HYPOTHESES 
The clinical hypotheses for this study is that 
 K-161 Ophthalmic Solution 
 
 (
 is superior to its vehicle (
 for the primary endpoints of signs and 
symptoms of dry eye, as follows:  
• Sign: Post-CAE inferior corneal fluorescein staining score on the Ora Calibra® 
scale, measured by mean change from baseline (Visit 2) to Visit 5 
• Symptom: Post-CAE ocular discomfort scale on the Ora Calibra® scale, measured 
by mean change from baseline (Visit 2) to Visit 5 
4 OVERALL STUDY DESIGN 
This is a Phase 2, multicenter, randomized, double-masked, vehicle-controlled, parallel-
group design with block enrollment. Subjects will be randomized to one of the following 
treatment groups at Visit 2:  
• 
 K-161; 
 (
 
 (N=~60) 
• 
 K-161; 
 
 (N=~60) 
• 
 K-161; 
 (
 
 (N=~60)  
• Placebo Ophthalmic Solution (Vehicle); 
 
 (N=~60) 
Approximately 240 subjects will be randomly assigned to one of the four treatment 
groups (1:1:1:1).
 
 Subjects, Sponsor, Contract research 
organization (CRO), and site personnel will be masked to treatment assignment. To 
ensure masking, a dedicated unmasked staff member/technician will be delegated to 
dispense and observe instillation of randomized study drug and collect randomized study 
drug from a subject for drug accountability. This person cannot perform any other study-
related procedures. Additionally, the informed consent form (ICF) will not indicate any 
relationship between dosing regimen and treatment. Subjects will be instructed not to 
discuss their assigned dosing regimen or perceived treatment effects with other study 
participants. 


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During the screening period, two 90-minute exposures to the CAE will be conducted to 
ascertain eligibility to enter the study. Subjects who qualify after the initial screening visit 
will enter the run-in phase, where they will self-administer vehicle 
 for 
approximately 14 days. Those who qualify at Visit 2 (Day 1) will be randomized to 
receive study drug in a double-masked fashion for 28 days. Randomization will be 
stratified on Visit 2 Post-CAE inferior fluorescein staining and Post-CAE ocular 
discomfort on the Ora Calibra® scale. Subjects will self-administer drops either 
 or 
 and will complete daily diary assessments as instructed. 
At Visit 4 (Day 15) and Visit 5 (Day 29), CAE exposure will occur, with pre-CAE, 
during CAE (symptoms only) and post-CAE assessments of ocular signs and symptoms. 
At Visit 3, no CAE exposure will occur but signs and symptoms will be assessed. Study 
drug will be discontinued at Visit 5. Subjects will exit from the study at this visit. The 
follow-up phone call will occur about 7 days after the final day of randomized study drug 
treatment. 
The timing of visit including each examinations should be consistent in each subject 
through the study phase. 
5 STUDY POPULATION 
 Number of Subjects (approximate) 
5.1
It is estimated that approximately 600 subjects will be screened to enroll approximately 
240 randomized subjects (60 in each group). 
 
Subjects will 
be randomized in a 1:1:1:1 ratio of  
• 
 K-161; 
 
• 
 K-161; 
 
• 
 K-161; 
     
• Placebo Ophthalmic Solution (Vehicle); 
  
 Study Population Characteristics 
5.2
All subjects must be at least 18 years of age, of either gender, and of any race, and must 
meet all inclusion criteria and none of the exclusion criteria. 
 Inclusion Criteria 
5.3
Each subject must: 
1. Be at least 18 years of age at the time of informed consent visit 
2. Have a reported history of dry eye disease in both eyes 
 
 and have a history of eye drop use for dry eye symptoms 
 
 
  
 


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 Exclusion Criteria 
5.4
Each subject may not: 
1. Have any ocular condition
 
 
 
 
2. Have a history of 
 
corneal refractive surgery within 12 months prior to Visit 1, and/or any other 
ocular surgical procedure 
 within 12 months 
 
 
 
 
 
 
 
 
 
 
 
 
 


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 Withdrawal Criteria (if applicable) 
5.5
If at any time during the study the investigator determines that a subject’s safety has been 
compromised, the subject may be withdrawn from the study. 
Subjects may withdraw consent from the study at any time. 
Sponsor and/or investigator may discontinue any subject for non-compliance or any valid 
medical reason (see Section 8.6.2). 
The subject has the right to withdraw from the study at any time. Nevertheless, in this 
study, every attempt will be made to prevent missing data and to obtain complete follow 
up of all subjects during the study period. Investigators will be trained to minimize full 
withdrawals from the study period wherever possible. Subjects who discontinue study 
drug during the study period are not required to withdraw from the study. These subjects 


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will be encouraged to remain in the study and asked to conduct the remaining study visits 
as outlined in the protocol through Visit 5. If a subject fails to actively maintain contact 
with the Investigator, reasonable efforts (telephone calls to family members or friends, e-
mail contacts, etc.) will be made in order to encourage the subject to complete the study 
visits. 
6 STUDY PARAMETERS 
 Efficacy Endpoints 
6.1
6.1.1 Primary Efficacy Endpoints 
The primary efficacy endpoint (sign) is: 
• Change in inferior corneal staining score from Day 1 (baseline) to Day 29 by 
comparing 
 K-161 
 to its vehicle 
 in CAE setting 
The primary efficacy endpoint (symptom) is: 
• Change in Ora Calibra® ODS from Day 1 (baseline) to Day 29 by comparing 
 K-161 
 to its vehicle 
 in CAE setting 
6.1.2 Important Secondary Efficacy Endpoints 
The important secondary endpoints are: 
• Change in Schirmer’s Test value (unanesthetized) from Day 1 (baseline) to Day 
29 by comparing 
 K-161 
 to its vehicle 
 in 
environmental setting 
• Change in TFBUT from Day 1 (baseline) to Day 29 by comparing 
 K-161 
 to its vehicle 
 in CAE setting 
6.1.3 Secondary Efficacy Endpoints 
The secondary efficacy endpoints are compared between vehicle 
 and K-161 
 
(i.e., 
 K-161 
 and 
 K-161 
) for: 
• Fluorescein staining by region: central, superior, inferior, temporal, nasal and 
corneal sum as assessed by the Ora Calibra® Corneal and Conjunctival Staining 
Scale 
• Lissamine green staining by region: central, superior, inferior, temporal, nasal, 
and conjunctival sum as assessed by the Ora Calibra® Corneal and Conjunctival 
Staining Scale 
• Conjunctival Redness as assessed by the Ora Calibra® Scale 
• TFBUT  
• Tear Osmolarity 
• Schirmer’s Test (unanesthetized) 
• Blink Rate 


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• Ora Calibra® Ocular Discomfort Scale  
• Ora Calibra® Ocular Discomfort and 4-Symptom Questionnaire  
• Visual Analog Scale (VAS)   
 Burning/ Stinging 
 Itching 
 Foreign Body Sensation 
 Blurred Vision 
 Eye Dryness 
 Photophobia 
 Pain 
• OSDI©  
• Daily diary  
6.1.4 
 
 
 
 
 
 
 
 
 
 
 
 
 Safety Measures 
6.2
The safety measures being evaluated are: 
 
  
 
 
• 
AE query 
 
 
 
 
 
 
 
 
• 
Maximum dose tolerability by comparing the 
 K-161 
 arm to the 
 and 
 K-161 
 arms 
 Other Measures 
6.3
The other measures being evaluated are: 


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6.4
 
 
 
 
6.5
 
 
 
  
 
 
 
 
   
 
 
6.6
 
 
 
 
 Clinical Laboratory Measurements 
6.7
The following assessments are being conducted: 
Hematology: 
 
 
  
Clinical chemistry:
 
 
 


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Urinalysis: 
 
 
7 STUDY MATERIALS 
 Study Treatments 
7.1
7.1.1 Masking 
All arms will be double-masked. To ensure masking, an unmasked technician delegated 
by the Investigator will perform all study drug instruction, dispensation, collection and 
accountability. This technician cannot perform any other study visit procedures. Study 
Treatments/Formulations 
• 
 K-161; 
 
• 
 K-161; 
 
• 
 K-161; 
    
• Placebo Ophthalmic Solution (Vehicle); 
  
7.1.2 Description of and Justification for the Route of Administration, Dosage, 
Dosage Regimen, and Treatment Period. 
Topical ophthalmic dosing is the optimal route of administration for dry eye treatments. 
The dosage and dosage regimen were selected based on non-clinical studies. The 
proposed treatment period of 4 weeks is based on results from pre-clinical studies and on 
the anti-inflammatory mechanism of action of the drug. 
7.1.3 Instructions for Use and Administration 
Subjects who were randomized to 
 arm must administer study drug at 
 
. Subjects who were randomized to 
 arm must at 
 If missed, the subject must not administer the eye drop if the next dosing is in 
less than 2 hours. At Visits 2, 3, 4, and 5, all subjects must visit their study sites without 
administering any topical ophthalmic preparations, including study drug, and must not 
administer topical ophthalmic preparations until all examinations are finished. Subjects, 
Sponsor, CRO, and site personnel (with the exception of the following person) will be 
masked to treatment assignment. To ensure masking, a dedicated unmasked staff 
member/technician will be delegated to dispense and observe instillation of randomized 
study drug and collect randomized study drug from a subject for drug accountability. This 
person cannot perform any other study-related procedures. Additionally, the informed 
consent form (ICF) will not indicate any relationship between dosing regimen and 
treatment. Subjects will be instructed not to discuss their assigned dosing regimen or any 
perceived treatment effects with other study participants. 


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 Labeling, Packaging, Storage, Accountability, and Return or 
7.2
Disposal of Investigational Product 
7.2.1 Labeling/Packaging 
Investigational product (IP) will be packaged and labeled into clinical kits. 
Run-in Period 
For the run-in period,
 
 to provide a sufficient 
medication supply.  
Treatment Period 
 For the treatment period, 
 
 to provide a 
sufficient supply of randomized study drug. 
 For the treatment period, 
 
 to provide a 
sufficient supply of randomized study drug. 
7.2.2 Storage of Investigational Product 
The study drugs must be stored in a secure area accessible only to the investigator and 
his/her designees.K-161 drug product must be stored at controlled room temperature of 
20-25°C (68-77°F) with excursions permitted between 15°C and 30°C (59-86°F) as 
indicated on the drug label.  
7.2.3 Accountability of Investigational Product 
The IP is to only be prescribed by the principal investigator or his/her named sub-
investigator(s), and is to only be used in accordance with this protocol. The IP must only 
be distributed to subjects properly qualified under this protocol to receive IP. 
The investigator must keep an accurate accounting of the IP received from the supplier. 
This includes the amount of IP dispensed to subjects, amount of IP returned to the 
investigator by the subjects, and the amount returned or disposed upon the completion of 
the study. A detailed inventory must be completed for the IP. Study drug accountability 
will be performed by an Unmasked Technician as delegated by the Investigator. To 
ensure masking, a dedicated unmasked staff member/technician will be delegated to 
dispense and collect randomized study drug from a subject for drug accountability. This 
person cannot perform any other study-related procedures. 
7.2.4 Return or Disposal of Investigational Product 
All IP (used or unused) will be returned to the sponsor or their designee. The return of IP 
will be specified in writing. 
 Other Study Supplies 
7.3
Other study supplies include 
 Schirmer’s test strips, Tear 
meniscometry strips, sodium fluorescein, lissamine green, 
 Tear 


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Osmolarity cards and
 
 
8 STUDY METHODS AND PROCEDURES 
 Subject Entry Procedures 
8.1
8.1.1 Overview 
Subjects as defined by the criteria in sections 5.2 and 5.3 will be considered for entry into 
this study. 
8.1.2 Informed Consent 
Prior to a subject’s participation in the study (i.e., changes in a subject’s medical 
treatment and/or study related procedures), the study will be discussed with each subject, 
and subjects wishing to participate must give written informed consent using an informed 
consent form. The informed consent form must be the most recent version that has 
received approval/favorable review by a properly constituted Institutional Review Board 
(IRB). 
8.1.3 Washout Intervals 
Prohibited medications, treatments, and activities are outlined in the exclusion criteria 
(Section 5.4). 
8.1.4 Procedures for Final Study Entry 
Subjects must meet all inclusion and none of the exclusion criteria (Section 5.3 and 5.4). 
8.1.5 Methods for Assignment to Treatment Groups: 
Before the initiation of study run-in at Visit 1, each subject who provides written 
informed consent will be assigned a screening number. All screening numbers will be 
assingned in strict numerical sequence at a site and no numbers will skipped or omitted. 
Each subject who meets all the inclusion and none of the exclusion criteria at Visit 1 and 
Visit 2 will be assigned a randomization number at the end of Visit 2. The Interactive 
Web Response System (IWRS) will be used to assign all randomization numbers. 
 
For the non-Japanese subjects, randomization will be further stratified by the following 
factors and cut-offs:  
 
 
 
 
 
 
 
 
 
 
 
 
 


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Randomization and kit numbers will be assigned automatically to each subject as they are 
entered into the IWRS.  
The site staff will dispense kit(s) required until the next visit. Both the randomization 
number and the dispensed study drug kit number(s) will be recorded on the subject’s 
source document and electronic case report form (eCRF). Subjects, Sponsor, CRO, and 
site personnel will be masked to treatment assignment. To ensure masking, a dedicated 
unmasked staff member/technician will be delegated to dispense and observe instillation 
of randomized study drug and collect randomized study drug from a subject for drug 
accountability. This person cannot perform any other study-related procedures. 
 Concurrent Therapies 
8.2
The use of any concurrent medication, prescription or OTC, is to be recorded on the 
subject’s source document and corresponding eCRF along with the reason the medication 
was taken. 
Concurrent enrollment in another investigational drug or medical device study is not 
permitted. 
8.2.1 Prohibited Medications/Treatments 
Disallowed medications/treatments during the study are outlined in the Exclusion Criteria 
(Section 5.4).  
8.2.2 Escape Medications 
No escape medications are required for this study. 
8.2.3 Special Diet or Activities 
No special diets or activities are required for this study. 
 Examination Procedures 
8.3
8.3.1 Procedures to be Performed at Each Study Visit with Regard to Study 
Objectives 
Procedures listed below should be performed in the given order. See Appendix 1 for the 
Schedule of Visits and Measurements Appendix 2 for details on methodologies and 
grading systems. 
8.3.2 Visit 1: Day –14 ± 2 – CAE Screening  
All subjects will undergo the following screening assessments: 
  
• Informed Consent/HIPAA  
 
 
 
 
 
 


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• 
 
 
• Ora Calibra® Ocular Discomfort Scale  
• Ora Calibra® Ocular Discomfort & 4-Symptom Questionnaire  
• OSDI© 
• Visual Analog Scale (VAS) 
 
 
 
  
• Conjunctival Redness 
• TFBUT 
• Fluorescein Staining  
• Lissamine Green Staining  
• At least 15-minute wait between lissamine green staining and Schirmer’s test 
• Schirmer’s test 
 
 
 
 
 
 
 
 
• Ora Calibra® Ocular Discomfort Scale  
• Ora Calibra® Ocular Discomfort & 4-Symptom Questionnaire  
• Visual Analog Scale (VAS) 
 
 
• Conjunctival Redness 
• TFBUT 
• Fluorescein Staining 
• Lissamine Green Staining 
 
 
 
 
 
 
 
  


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• Run-in Instillation at the Study Site: All subjects having a positive response and 
meeting all other screening eligibility criteria at the end of Visit 1 will receive 
run-in drops for dosing.
 
 
• Ora Calibra® Drop Comfort Scale 
• 
Ora Calibra® Drop Comfort Questionnaire 
• Run-in (Vehicle) and Diary Dispensation: Prior to discharge from the study site 
on Day –14, subjects will be dispensed sufficient Run-in supply to last until Visit 
2 and will be educated in diary recording and self–administration of vehicle run-
in. 
 
 
  
• AE Query 
• Subjects will be scheduled for Visit 2. 
8.3.3 Visit 2: Day 1 – CAE Confirmation and Baseline 
  
• Study Diary/Run-in Collection 
 
 
• Medical/medication history update 
• AE query 
 
 
• Ora Calibra® Ocular Discomfort Scale  
• Ora Calibra® Ocular Discomfort & 4-Symptom Questionnaire  
• OSDI© 
• Visual Analog Scale (VAS) 
 
 
 
  
• Conjunctival Redness 
• Blink Rate 
• Tear Osmolarity 
 
 
• TFBUT 
• Fluorescein Staining  
• Lissamine Green Staining  


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• At least 15-minute wait between lissamine green staining and Schirmer’s test 
• Schirmer’s test 
 
 
 
 
 
 
 
 
• Ora Calibra® Ocular Discomfort Scale  
• Ora Calibra® Ocular Discomfort & 4-Symptom Questionnaire  
• Visual Analog Scale (VAS) 
 
 
 
 
• Conjunctival Redness 
• TFBUT 
• Fluorescein Staining 
• Lissamine Green Staining 
 
  
• Randomization  
• Study Drug Instillation at the Study Site: All subjects having a positive response 
and meeting all other screening eligibility criteria at the end of Visit 2 will be 
randomized to one of four treatment groups utilizing the IWRS system. 
 
  
• Ora Calibra® Drop Comfort Scale 
• Ora Calibra® Drop Comfort Questionnaire 
• Study Drug Diary/Study Drug Dispensation: Prior to discharge from the study site 
on Visit 2 (Day 1), randomized subjects will be educated in study drug diary 
recording and self–administration of study drug.
 
 
  
• AE Query 
• Subjects will be scheduled for Visit 3. 


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8.3.4 Visit 3: Day 8 ±1  
• Study Drug Diary/Study Drug Collection 
• Medical/medication history update 
• AE Query 
• Ora Calibra® Ocular Discomfort Scale  
• Ora Calibra® Ocular Discomfort & 4-Symptom Questionnaire  
• OSDI© 
• Visual Analog Scale (VAS) 
 
 
 
  
• Conjunctival Redness 
• Blink Rate 
• Tear Osmolarity 
• TFBUT 
• Fluorescein Staining  
• Lissamine Green Staining  
• At least 15-minute wait between lissamine green staining and Schirmer’s test 
• Schirmer’s test 
 Study Drug Diary/Study Drug Dispensation: Prior to discharge from the study site 
on Visit 3, subjects will be assigned a new study drug kit via the IWRS system for 
at-home dosing up to Visit 4. Subjects will again be educated in study drug diary 
recording and self–administration of study drug.
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 


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• 
 
 
• AE Query 
• Subjects will be scheduled for Visit 4. 
8.3.5 Visit 4: Day 15 ± 2  
 
• Study Drug Diary/Study Drug Collection 
• Medical/medication history update 
• AE query 
• Ora Calibra® Ocular Discomfort Scale  
• Ora Calibra® Ocular Discomfort & 4-Symptom Questionnaire  
• OSDI© 
• Visual Analog Scale (VAS) 
 
 
 
  
• Conjunctival Redness 
• Blink Rate 
• Tear Osmolarity 
• TFBUT 
• Fluorescein Staining  
• Lissamine Green Staining  
• At least 15-minute wait between lissamine green staining and Schirmer’s test 
• Schirmer’s test 
 
 
 
 
 
 
 
 
• Ora Calibra® Ocular Discomfort Scale  
• Ora Calibra® Ocular Discomfort & 4-Symptom Questionnaire  
• Visual Analog Scale (VAS) 
 
 


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• Conjunctival Redness 
• TFBUT 
• Fluorescein Staining 
• Lissamine Green Staining 
 Study Drug Diary/Study Drug Dispensation: Prior to discharge from the study site 
on Visit 4, subjects will be assigned a new study drug kit via the IWRS system for 
at-home dosing up to Visit 5. Subjects will again be educated in study drug diary 
recording and self–administration of study drug.
 
 
• 
 
 
 
 
 
 
• AE Query 
• Subjects will be scheduled for Visit 5. 
8.3.6 Visit 5: Day 29 ± 2 
 
• Study Drug Diary/Study Drug Collection 
• Medical/medication history update 
• AE query 
 
 
 
  
• Ora Calibra® Ocular Discomfort Scale  
• Ora Calibra® Ocular Discomfort & 4-Symptom Questionnaire  
• OSDI© 
• Visual Analog Scale (VAS) 
 
 
 
  
• Conjunctival Redness 
• Blink Rate 
• Tear Osmolarity 
 
 


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• TFBUT 
• Fluorescein Staining  
• Lissamine Green Staining  
• At least 15-minute wait between lissamine green staining and Schirmer’s test 
• Schirmer’s test 
 
 
 
 
 
 
 
 
• Ora Calibra® Ocular Discomfort Scale  
• Ora Calibra® Ocular Discomfort & 4-Symptom Questionnaire  
• Visual Analog Scale (VAS) 
 
 
 
 
• Conjunctival Redness 
• TFBUT 
• Fluorescein Staining 
• Lissamine Green Staining 
 
 
 
 
 
 
• AE Query 
8.3.7 Follow-up phone call 
• Follow-up phone call (about 7 days after the final day of randomized study drug 
treatment) 
• AE query 
• Study exit 
 Schedule of Visits, Measurements and Dosing 
8.4
8.4.1 Scheduled Visits 
Refer to Appendix 1 for a schedule of visits and measurements. 


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8.4.2 Unscheduled Visits 
These visits may be performed in order to ensure subject safety. All procedures 
performed at an unscheduled visit will be recorded in the source documents and on the 
Unscheduled Visit eCRF pages. Any procedure indicated in the eCRF that is not 
performed should be indicated as “Not done.” 
Evaluations that may be conducted at an Unscheduled Visit include: 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
• Assessment of AEs 
 
 
• Any other assessments needed in the judgment of the investigator. 
 Compliance with Protocol 
8.5
Subjects will be instructed on proper use of the subject daily diary and proper instillation 
and storage of study drug at the end of Visits 1, 2, 3, and 4, and given written 
instructions. The subject daily diaries, used and unused 
 will be 
collected at each visit from Visit 2 up to and including Visit 5 to assess dosing and 
symptom assessment compliance. Dosing compliance will be based on the used and 
. If the subject is less than 80% or more than 125% compliant with 
dosing based on 
 then the subject will be deemed 
non-compliant and a dosing deviation should be recorded.  
In the subject daily diary, if more than 20% of Dose boxes are checked “no”, left blank, 
or missing for a diary period, a subject will be deemed non-compliant and a diary 
deviation will be recorded. If more than 20% of the total diary symptom assessments for 
that dosing period are missed, these subjects will be deemed non-compliant and a diary 
symptom assessment deviation will be recorded. These guidelines will be used by the 
Investigator for determining the subject’s necessary compliance for the study and for 
recording deviations from this compliance. 
 Subject Disposition 
8.6
8.6.1 Completed Subjects 
A completed subject is one who has not been discontinued from the study. 


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8.6.2 Discontinued Subjects 
Subjects may be discontinued prior to their completion of the study due to: 
• subject request/withdrawal 
• AEs 
• protocol violations 
• administrative reasons (e.g., inability to continue, lost to follow up) 
• sponsor termination of study 
• other 
Note: In addition, any subject may be discontinued for any sound medical reason. 
Notification of a subject discontinuation and the reason for discontinuation will be made 
to 
 and/or sponsor and will be clearly documented on the eCRF. 
 Study Termination 
8.7
The study may be stopped at any time by the investigator, the sponsor, and/or 
 with 
appropriate notification. 
 Study Duration 
8.8
An individual subject’s participation will involve 5 visits over approximately a 6-week 
(~42 days) period (14 days pre-screening, 28 days of treatment) and a follow-up phone 
call. 
 Monitoring and Quality Assurance 
8.9
During the course of the study an 
 monitor, or designee, will make routine site visits 
to review protocol compliance, assess IP accountability, and ensure the study is being 
conducted according to the pertinent regulatory requirements. The review of the subjects’ 
medical records will be performed in a manner that adequately maintains subject 
confidentiality. Further details of the study monitoring will be outlined in a monitoring 
plan. 
Regulatory authorities of domestic and foreign agencies, quality assurance and or its 
designees may carry out on-site inspections and/or audits which may include source data 
checks. Therefore direct access to the original source data will be required for inspections 
and/or audits. All inspections and audits will be carried out giving consideration to data 
protection as well as subject confidentiality to the extent that local, state, and federal laws 
apply. 
9 ADVERSE EVENTS 
 Adverse Event 
9.1
An AE is defined as any untoward medical occurrence associated with the use of an IP in 
humans, whether or not considered IP-related. An AE can be any unfavorable and 


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unintended sign (e.g., an abnormal laboratory finding), symptom, or disease temporally 
associated with the use of an IP, without any judgment about causality. An AE can arise 
from any use of the IP (e.g., off-label use, use in combination with another drug or 
medical device) and from any route of administration, formulation, or dose, including an 
overdose. An AE can arise from any delivery, implantation, or use of a medical device, 
including medical device failure, subject characteristics that may impact medical device 
performance (e.g., anatomical limitations), and therapeutic parameters (e.g., energy 
applied, sizing, dose release, and anatomic fit) associated with medical device use. 
All AEs spontaneously reported by the subject and/or in response to an open question 
from study personnel or revealed by observation, physical examination or other 
diagnostic procedures will be recorded in the source document and on the appropriate 
pages of the CRF. Any clinically relevant deterioration in clinical finding is considered 
an AE and must be recorded. When possible, signs and symptoms indicating a common 
underlying pathology should be noted as one comprehensive event. 
Documentation regarding the AE should be made as to the nature, date of onset, end date, 
severity, and relationship to IP, action(s) taken, seriousness, and outcome of any sign or 
symptom observed by the physician or reported by the subject upon indirect questioning. 
Exacerbation of conditions related to the signs and symptoms of DED will not be 
reported as an AE. 
9.1.1 Severity 
Severity of an AE is defined as a qualitative assessment of the degree of intensity of an 
AE as determined by the investigator or reported to him/her by the subject. The 
assessment of severity is made irrespective of relationship to IP or seriousness of the 
event and should be evaluated according to the following scale: 
• Mild: Event is noticeable to the subject, but is easily tolerated and does not 
interfere with the subject’s daily activities. 
• Moderate: Event is bothersome, possibly requiring additional therapy, and may 
interfere with the subject’s daily activities. 
• Severe: Event is intolerable, necessitates additional therapy or alteration of 
therapy, and interferes with the subject’s daily activities. 
9.1.2 Relationship to Investigational Product 
The relationship of each AE to the IP should be determined by the investigator using 
these explanations: 
• Related: A reasonable possibility exists that the IP caused the AE. A related AE 
can be further defined as follows: 
 Occurs within a reasonable temporal sequence to administration of study drug  
 Cannot be explained by concurrent disease or other drugs or chemicals  
 Improves or disappears on stopping or reducing study drug (de-challenge)  
 Reappears on repeated exposure to study drug (re-challenge)  


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 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 
 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 IP caused the AE. A 
not related AE can be further defined as follows: 
 Occurs with a temporal relationship to administration of study drug which 
makes a causal relationship improbable 
 Other drugs, chemicals or underlying disease provide plausible explanations 
of causality 
 Is known to be associated with the participant’s clinical condition, or with 
other medication taken by the participant 
Suspected adverse reaction means any AE for which there is a reasonable possibility that 
the IP caused the AE. “Reasonable possibility” means there is evidence to suggest a 
causal relationship between the IP and the AE. Types of evidence that would suggest a 
causal relationship between the IP and the AE event include: a single occurrence of an 
event that is uncommon and known to be strongly associated with IP exposure (e.g., 
angioedema, hepatic injury, Stevens-Johnson Syndrome); one or more occurrences of an 
event that is not commonly associated with IP exposure, but is otherwise uncommon in 
the population exposed to the IP (e.g., tendon rupture); an aggregate analysis of specific 
events observed in a clinical trial (such as known consequences of the underlying disease 
or condition under investigation or other events that commonly occur in the study 
population independent of drug therapy) that indicates those events occur more 
frequently in the IP-treatment group than in a concurrent or historical control group. 
The investigator should 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. 
9.1.3 Expectedness 
The expectedness of an AE should be determined based upon existing safety information 
about the IP using these explanations: 
• Unexpected: An AE that is not listed in the Investigator’s Brochure (IB) or is not 
listed at the specificity or severity that has been observed. 
• Expected: An AE that is listed in the IB at the specificity and severity that has 
been observed. 
• Not applicable: An AE unrelated to the IP. 
AEs that are mentioned in the IB as occurring with a class of products or as anticipated 
from the pharmacological/mechanical (or other) properties of the product, but are not 
specifically mentioned as occurring with the particular product under investigation are to 
be considered unexpected. 


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The investigator should initially classify the expectedness of an AE, but the final 
classification is subject to the Medical Monitor’s determination. 
 Serious Adverse Events 
9.2
An AE is considered serious if, in the view of either the investigator or sponsor, it results 
in any of the following outcomes: 
• Death; 
• Is life-threatening; 
Note: An AE is considered “life-threatening” if, in the view of either the 
investigator or sponsor, its occurrence places the subject at immediate risk of 
death. It does not include an AE that, had it occurred in a more severe form, might 
have caused death. 
• Inpatient hospitalization or prolongation of existing hospitalization; 
Note: The term “inpatient hospitalization” refers to any inpatient admission (even 
if less than 24 hours), unless the inpatient admission was pre-planned prior to the 
signing of the informed consent. For chronic or long-term inpatients, inpatient 
admission includes transfer within the hospital to an acute/intensive care inpatient 
unit. Inpatient hospitalization does not include: emergency room visits; 
outpatient/same-day/ambulatory procedures; observation/short stay units; 
rehabilitation facilities; hospice facilities; nursing homes; or clinical 
research/phase 1 units. 
Note: The term “prolongation of existing hospitalization” refers to any extension 
of an inpatient hospitalization beyond the stay anticipated or required for the 
reason for the initial admission as determined by the investigator or treating 
physician. 
• A persistent or significant incapacity or substantial disruption of the ability to 
conduct normal life functions; 
Note: A serious adverse event (SAE) specifically related to visual threat would be 
interpreted as any potential impairment or damage to the subject’s eyes (e.g., 
hemorrhage, retinal detachment, central corneal ulcer or damage to the optic 
nerve). 
• A congenital anomaly/birth defect. 
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 subject and may require medical or 
surgical intervention to prevent one of the outcomes listed in this definition. 
 Procedures for Reporting Serious Adverse Events 
9.3
All SAEs and their outcomes, regardless of causality or expectedness, must be reported to 
 and the sponsor as required by the IRB/IEC, federal, state, or local regulations and 
governing health authorities and recorded on the appropriate CRF. Adverse events will be 


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collected from the time of the signing of the Informed Consent until the follow-up phone 
call (about 7 days after the final day of randomized study drug treatment). 
9.3.1 Reporting a Serious Unexpected Suspected Adverse Reaction 
All SAEs that are both ‘suspected’ and ‘unexpected’ are also to be reported to the 
IRB/IEC and the regulatory authorities as required by the IRB/IEC, federal, state, or local 
regulations and governing health authorities. 
9.3.2 Reporting a Serious Adverse Event 
To ensure subject safety, all SAEs, regardless of relationship to the IP, must be 
immediately reported. All information relevant to the SAE must be recorded on the 
appropriate CRFs. The investigator is obligated to pursue and obtain information 
requested by 
 and/or the sponsor in addition to that information reported on the CRF. 
All subjects experiencing a SAE must be followed up and the outcome reported. 
In the event of a SAE, the investigator must notify 
 and the sponsor immediately 
using the contact information below; obtain and maintain in his/her files all pertinent 
medical records, information, and medical judgments from colleagues who assisted in the 
treatment and follow-up of the subject; provide 
 and the sponsor with a complete case 
history, which includes a statement as to whether the event was or was not suspected to 
be related to the use of the IP; and inform the IRB of the SAE within their guidelines for 
reporting SAEs. 
 
 


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Contact information for reporting SAEs: 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Procedures for Unmasking (if applicable) 
9.4
All subjects, investigators, and study personnel involved with the conduct of the study 
will be masked with regard to treatment assignments. When medically necessary, the 
investigator may need to determine what treatment group has been assigned to a subject. 
When possible (i.e., in non-emergent situations), 
 and/or the study sponsor should be 
notified before unmasking study drug. 
 and/or the study sponsor must be informed 
immediately about any unmasking event. 
If an investigator identifies a medical need for unmasking the treatment assignment of a 
subject, he/she should contact 
 and/or the medical monitor prior to unmasking the 
identity of the IP, if possible. 
 will ask the site to complete and send them the 
Unmasking Request Form. 
 will notify the sponsor, and jointly will determine if the 
unmasking request should be granted. They may consult the medical monitor as needed. 
The result of the request will be documented on the Unmasking Request Form. If 
approval is granted to unmask a subject, written permission via the Unmasking Request 
Form will be provided to the investigator. The investigator will unmask the subject using 
IWRS. The investigator will complete the Unmasking Memo form and include it in the 
subject’s study file and provide a copy for the TMF. For each unmasked request, the 
reason, date, signature, and name of the person who unmasked the subject must be noted 
in the subject’s study file.  
Unmasked subjects will be discontinued from the study. Unmasked subjects will be 
followed for safety monitoring until resolution of the adverse event or study completion, 
whichever occurs last. 


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 Type and Duration of the Follow-up of Subjects after Adverse 
9.5
Events 
The investigator will follow unresolved AEs to resolution until the subject is lost to 
follow-up or until the AE is otherwise classified. Resolution means the subject has 
returned to baseline state of health or the investigator does not expect any further 
improvement or worsening of the AE. If the subject is lost to follow-up, the investigator 
should make 3 reasonable attempts to contact the subject via telephone, post, or certified 
mail. All follow-up will be documented in the subject’s source document. Non-serious 
AEs identified on the last scheduled contact must be recorded on the AE eCRF with the 
status noted.  
If the investigator becomes aware of any new information regarding an existing SAE 
(i.e., resolution, change in condition, or new treatment), a new SAE/Unanticipated Report 
Form must be completed and faxed to 
 within 24 hours of the site’s awareness of the 
new information. The original SAE form is not to be altered. The report should describe 
whether the event has resolved or continues and how the event was treated. 
10 STATISTICAL HYPOTHESES AND METHODS OF ANALYSES 
 Analysis Populations 
10.1
The following analysis populations will be considered: 
• Intent-to-Treat Population – The intent-to-treat (ITT) population includes all 
randomized subjects. Subjects in the ITT population will be analyzed as 
randomized. 
• Per-Protocol Population – The per-protocol (PP) population includes subjects in 
the ITT population who do not have significant protocol deviations and who 
complete the study. Protocol deviations will be assessed prior to database lock 
and unmasking. Subjects in the PP population will be analyzed as treated. 
• Safety Population – The safety population includes all randomized subjects who 
have received at least one dose of the investigational product. Subjects in the 
Safety population will be analyzed as treated.  
The statistical analysis of safety data will be performed for the safety population. The 
analysis of efficacy data will be performed for the ITT population and on the PP 
population as sensitivity analyses. 
 Statistical Hypotheses 
10.2
The following primary hypotheses will be tested against their respective two-sided 
alternative hypotheses in the order: 
H01:  There is no difference in the change from baseline in the post-CAE inferior corneal 
staining score after 28 days of treatment of 
 K-161 
 compared to vehicle.   
H02:  There is no difference in the change from baseline in the post-CAE ocular 
discomfort score after 28 days of treatment of 
 K-161 
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Upon rejecting both H01 and H02, the secondary hypotheses will be tested as detailed in 
Section 10.4.4 in the following order  
H03:  There is no difference in the change from baseline in the pre-CAE Schirmer’s test 
value after 28 days of treatment of 
 K-161 
 compared to vehicle. 
H04:  There is no difference in the change from baseline in the post-CAE TFBUT after 
28 days of treatment of 
 K-161 
 compared to vehicle. 
These four hypotheses will be tested hierarchically, each at the alpha = 0.05 level to 
maintain a study-wise Type I error rate at 0.05. 
 Sample Size  
10.3
This study is expected to enroll 240 subjects in a 1:1:1:1 ratio across four treatment arms, 
or 60 subjects per treatment arm. In addition, randomization will be stratified such that 
will be randomized in each treatment arm.  
The standard deviation for change from baseline in post-CAE inferior corneal fluorescein 
staining ranges between 0.68 and 0.81 units. Assuming a common standard deviation of 
0.77, a sample size of 60 subjects per group will have approximately 90% power to detect 
a difference of 0.46 units between the active treatment group and the vehicle group using 
a two-sample t-test at a two-sided significance level of 0.05. Again, it is assumed that 
adjusting for baseline and site will further reduce variability and provide >90% power. 
Likewise, the standard deviation for change from baseline scores in the post-CAE ODS at 
Day 29 is assumed a common standard deviation of 0.82, a sample size of 60 subjects per 
group will have approximately 90% power to detect a difference of 0.49 units between 
the active treatment group and the vehicle group using a two-sample t-test at a two-sided 
significance level of 0.05. It is assumed that adjusting for baseline and site will further 
reduce variability and provide >90% power. 
 Statistical Analysis 
10.4
10.4.1 General Considerations 
Quantitative variables will be summarized descriptively using number of subjects (n), 
mean, standard deviation, median, minimum, and maximum. Qualitative variables will be 
summarized using counts and percentages. 
All summaries will be presented by treatment group. Summaries will be provided for 
demographics, baseline medical history, concurrent therapies, and subject disposition. 
For the purpose of summarization, medical history, concurrent therapies, and AEs will be 
coded to MedDRA and WHO Drug dictionaries, as appropriate.  
Change from pre-CAE to post-CAE will be calculated as post-CAE value minus pre-CAE 
value. Baseline measures are defined as the last non-missing measure prior to the 
initiation of randomized study treatment. Change from baseline will be calculated as 
follow-up visit value minus baseline value. Treatment comparisons between active and 
vehicle will be calculated as active minus vehicle. 


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All analyses will be 2-sided at a significance level of 0.05 unless otherwise specified. For 
all efficacy analyses, 95% confidence intervals on the difference between each dose of K-
161 and vehicle will be provided. 
10.4.2 Unit of Analysis 
Safety endpoints will be analyzed for both eyes. For efficacy endpoints, the unit of 
analysis will be the study eye, or the “worst eye,” as defined by the following:  
Worst Eye: Eyes are eligible for analysis if they meet all of the inclusion criteria. At least 
one eye (the right eye or the left eye) must meet all of the criterial. In the case that both 
eyes are eligible for analysis, the worst eye will be selected as the eye with the worst 
post-CAE inferior corneal staining at Visit 2. If the post-CAE inferior corneal staining at 
Visit 2 is the same in both eyes then the eye with the worst post-CAE ODS at Visit 2 will 
be worst eye. If the post-CAE inferior corneal staining and ocular discomfort are the 
same in both eyes then the right eye will be selected as the worst eye. 
10.4.3 Missing Data 
Missing data will be imputed using multiple imputation with a control-based pattern 
mixture model on the ITT population for the primary analyses, the important secondary, 
other secondary, and exploratory comparisons.   
Sensitivity analyses of the primary analyses and important secondary comparisons will 
include the following in order to provide a robust understanding of the impact of missing 
and spurious data:  
• Using complete case data (i.e. observed data only) on the ITT population 
• Using last observation carried forward (LOCF) on the ITT population 
• Multiple imputation under missing at random assumption with Markov Chain 
Monte Carlo (MCMC) techniques on the ITT population 
• Using complete case data on the PP population.  
No imputation will be used for safety endpoints. 
10.4.4 Multiplicity Consideration 
Common factors for multiplicity are multiple arms and multiple endpoints. 
1) Multiple arms 
The primary treatment comparison will be between the 
 K-161 
 treatment arm 
and the vehicle 
 treatment arm. 
 
  
2) Multiple endpoints 
The primary and important secondary endpoints will be tested hierarchically to maintain 
the study-wise Type I error rate of 0.05. First, change from baseline in inferior corneal 
fluorescein staining will be tested at an alpha level of 0.05. The test for change from 
baseline scores in the ODS will be conducted at an alpha level of 0.05 only if the 
previous test demonstrates significance. The test for change from baseline in Schirmer’s 
test will be conducted at an alpha level of 0.05 only if the previous test demonstrates 
significance. The test for change from baseline in TFBUT will be conducted at an alpha 


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level of 0.05 only if the previous test demonstrates significance. 
 
The hierarchical testing order will be as follows: 
Primary comparisons: 
1. Comparison of the change from baseline in post-CAE inferior corneal staining at 
Day 29 (
 K-161 
 
) 
2. Comparison of the change from baseline in post-CAE ocular discomfort at Day 29 
(
 K-161 
 
 
Important Secondary comparisons: 
3. Comparison of the change from baseline in pre-CAE Schirmer’s test value at Day 
29 (
 K-161 
) 
4. Comparison of the change from baseline in post-CAE TFBUT at Day 29 (
 
K-161 
) 
Thus, the study-wise Type I error rate will be maintained at 0.05 by considering only one 
dose of K-161 as the primary treatment comparison and using a hierarchical testing 
procedure. 
10.4.5 Efficacy Analyses 
Primary Efficacy Analyses 
The primary comparisons of change from baseline in post-CAE inferior corneal staining 
and ocular discomfort between the 
 K-161 
 group and the vehicle group at Day 
29, will be performed using analysis of covariance (ANCOVA) models. The respective 
baseline post-CAE score will be included as a covariate in each model and site will be 
included as a fixed effect. Treatment by baseline and treatment by site interactions will be 
explored in separate models and, if significant, analyses will be performed by baseline 
stratification and/or site, respectively, to further examine significant interactions. In 
addition, unadjusted two-sample t-tests and Wilcoxon rank-sum tests will be performed 
for each comparison as sensitivity analyses. The primary analyses will use the ITT 
population. 
For the primary endpoints, multiple imputation with MCMC techniques will be used. 
Imputation will be performed by treatment arm with imputation terms for baseline and 
Day 29 scores. 
Secondary Efficacy Analyses 
Secondary and exploratory endpoints will be analyzed similarly to the primary analyses 
on the ITT population. Continuous and ordinal variables collected at each visit will be 
summarized descriptively (n, mean, standard deviation, median, minimum and 
maximum), and analyzed with ANCOVA models and two-sample two-sided t-tests 
comparing each K-161 group to the vehicle group. All visit-based data will be analyzed 
by visit and for each timepoint, if applicable, as well as the change from baseline.  
Data collected pre- and post-CAE will also be analyzed for the change from pre- to post-
CAE within each visit. Data collected during the CAE will also be analyzed using 


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repeated measures models including all of the time points from a CAE exposure. Daily 
subject diary symptom data will be analyzed using each weekly average score from the 
diaries, as well as using repeated measures models across the diary collection period.   
For the two important secondary endpoints, other secondary, and exploratory endpoints, 
multiple imputation with MCMC techniques will be used. Imputation will be performed 
by treatment arm with imputation terms for baseline and Day 29 scores. 
 
 
 
10.4.6 Safety Variables 
Adverse events will be coded using the MedDRA dictionary. Frequencies and 
percentages of subjects with treatment-emergent adverse events (TEAEs), serious 
TEAEs, and TEAEs causing premature 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 will be given of subjects 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 performed for ocular and non-ocular AEs.  
 
 
 
 
 
 
 
 
 
 
 
 
Other analyses may be conducted and the details will be included in a separate statistical 
analysis plan. 
 
 
 


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10.4.11 Interim Analyses 
There will be no interim analyses in this study. 
11 COMPLIANCE WITH GOOD CLINICAL PRACTICES, 
ETHICAL CONSIDERATIONS, AND ADMINISTRATIVE 
ISSUES 
This study will be conducted in compliance with the protocol, current Good Clinical 
Practices (GCPs), including the International Conference on Harmonisation (ICH) 
Guidelines, and in general, consistent with the Declaration of Helsinki. In addition, all 
applicable local, state, and federal requirements relevant to the use of IP in the countries 
involved will be addressed. 
 Protection of Human Subjects 
11.1
11.1.1 Subject Informed Consent 
Informed consent/assent must take place before any study specific procedures are 
initiated. Signed and dated written informed consent must be obtained from each subject 
and/or from the subject’s parent or legal guardian prior to enrollment into the study.  
All informed consent forms must be approved for use by the sponsor and receive 
approval/favorable opinion from an IRB prior to their use. If the consent form requires 
revision (e.g., due to a protocol amendment or significant new safety information), it is 
the investigator’s responsibility to ensure that the amended informed consent is reviewed 
and approved by 
 prior to submission to the governing IRB and that it is read, signed 
and dated by all subjects subsequently enrolled in the study as well as those currently 
enrolled in the study. 
If informed consent is taken under special circumstances (oral informed consent), then 
the procedures to be followed must be determined by 
 and/or sponsor and provided in 
writing by 
 and/or sponsor prior to the consent process. 


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11.1.2 Institutional Review Board (IRB) Approval 
This study is to be conducted in accordance with IRB regulations (U.S. 21 CFR Part 
56.103). The investigator must obtain appropriate IRB approval before initiating the 
study and re-approval at least annually. 
Only an IRB approved version of the informed consent form will be used. 
 Ethical Conduct of the Study 
11.2
This study will be conducted in accordance with the ethical principles that originated 
with the Declaration of Helsinki. 
 Subject Confidentiality 
11.3
All personal study subject data collected and processed for the purposes of this study 
should be maintained by the investigator and his/her staff with adequate precautions as to 
ensure that the confidentiality of the data is in accordance with local, state, and federal 
laws and regulations. 
Monitors, auditors and other authorized representatives of 
 the sponsor, the IRB/IEC 
approving this study, the FDA, the Department of Health and Human Services, other 
domestic government agencies, and other foreign regulatory agencies will be granted 
direct access to the subject’s original medical and study records for verification of the 
data and/or clinical study procedures. Access to this information will be permitted to the 
aforementioned individuals to the extent permitted by law. 
A report of the results of this study may be published or sent to the appropriate health 
authorities in any country in which the IP may ultimately be marketed, but the subject’s 
identity will not be disclosed in these documents. 
 Documentation 
11.4
Source documents may include a subject’s medical records, hospital charts, clinic charts, 
the investigator’s study subject files, as well as the results of diagnostic tests such as X-
rays, laboratory tests, and EKGs. The investigator’s copy of the CRFs serves as the 
investigator’s record of a subject’s study-related data. 
11.4.1 Retention of Documentation 
All study related correspondence, subject records, consent forms, record of the 
distribution and use of all IP, and copies of CRFs should be maintained on file for at least 
two years after the last approval of a marketing application in an ICH region and until 
there are no pending or contemplated marketing applications in an ICH region; or until at 
least two years have elapsed since the formal discontinuation of clinical development of 
the IP. These documents will be retained for a longer period if required by the applicable 
regulatory requirements or by an agreement with the sponsor. It is the responsibility of 
the sponsor to inform the investigator/institution as to when these documents no longer 
need to be retained. 
If the responsible investigator retires, relocates, or for other reasons withdraws from the 
responsibility of keeping study records, custody must be transferred to a person who will 


K-161 
Sponsor: Kowa Research Institute (KRI) 
Clinical Trial Protocol No.: K-161-2.01US 
 
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accept the responsibility. The sponsor must be notified in writing of the name and address 
of the new custodian. 
 Recording of Data on Source Documents and Case Reports Forms 
11.5
(CRFs) 
The investigator is responsible for ensuring that study data is completely and accurately 
recorded on each subject’s CRF, source document, and all study-related material. All 
study data should also be attributable, legible, contemporaneous, and original. Recorded 
datum should only be corrected in a manner that does not obliterate, destroy, or render 
illegible the previous entry (e.g., by drawing a single line through the incorrect entry and 
writing the revision next to the corrected data). An individual who has corrected a data 
entry should make clear who made the correction and when, by adding to the correction 
his/her initials as well as the date of the correction. 
Data entry of all enrolled and randomized subjects will use software that conforms to 21 
CFR Part 11 requirements, and will be performed only by staff who have been trained on 
the system and have access to the system. Data will be entered in eCRF for screen failure 
subjects. An audit trail will be maintained within the electronic system to capture all 
changes made within the eCRF database. After the end of the study and database lock, 
compact discs (CDs) containing copies of all applicable subjects’ eCRFs will be provided 
to each Investigator Site to be maintained on file by the Investigator. 
 Publications 
11.6
All data derived from the study will be the property of the sponsor and must be kept 
strictly confidential. The investigator must not submit any of the data from this study for 
publication without prior consent of the sponsor. The sponsor will have the final decision 
regarding any manuscript and publication. 
 


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Clinical Trial Protocol No.: K-161-2.01US 
 
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12 REFERENCES 
Bron, A. J., C. S. de Paiva, S. K. Chauhan, S. Bonini, E. E. Gabison, S. Jain, E. Knop, M. 
Markoulli, Y. Ogawa, V. Perez, Y. Uchino, N. Yokoi, D. Zoukhri and D. A. Sullivan 
(2017). "TFOS DEWS II pathophysiology report." Ocul Surf 15(3): 438-510. 
CEQUA (2018). "CEQUA (cyclosporine ophthalmic solution) 0.9% [drug label]. Sun 
Pharmaceuticals." 
Kudlacz, E., M. Conklyn, C. Andresen, C. Whitney-Pickett and P. Changelian (2008). 
"The JAK-3 inhibitor CP-690550 is a potent anti-inflammatory agent in a murine model 
of pulmonary eosinophilia." Eur J Pharmacol 582(1-3): 154-161. 
Mah, F., M. Milner, S. Yiu, E. Donnenfeld, T. M. Conway and D. A. Hollander (2012). 
"PERSIST: Physician's Evaluation of Restasis((R)) Satisfaction in Second Trial of topical 
cyclosporine ophthalmic emulsion 0.05% for dry eye: a retrospective review." Clin 
Ophthalmol 6: 1971-1976. 
 
 
 
 
 
Schaumberg, D. A., R. Dana, J. E. Buring and D. A. Sullivan (2009). "Prevalence of dry 
eye disease among US men: estimates from the Physicians' Health Studies." Arch 
Ophthalmol 127(6): 763-768. 
Schaumberg, D. A., D. A. Sullivan, J. E. Buring and M. R. Dana (2003). "Prevalence of 
dry eye syndrome among US women." Am J Ophthalmol 136(2): 318-326. 
Schaumberg, D. A., D. A. Sullivan and M. R. Dana (2002). "Epidemiology of dry eye 
syndrome." Adv Exp Med Biol 506(Pt B): 989-998. 
Stevenson, W., Z. Sadrai, J. Hua, S. Kodati, J. F. Huang, S. K. Chauhan and R. Dana 
(2014). "Effects of topical Janus kinase inhibition on ocular surface inflammation and 
immunity." Cornea 33(2): 177-183. 
Tauber, J., P. Karpecki, R. Latkany, J. Luchs, J. Martel, K. Sall, A. Raychaudhuri, V. 
Smith, C. P. Semba and O.-. Investigators (2015). "Lifitegrast Ophthalmic Solution 5.0% 
versus Placebo for Treatment of Dry Eye Disease: Results of the Randomized Phase III 
OPUS-2 Study." Ophthalmology 122(12): 2423-2431. 
 
 


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Clinical Trial Protocol No.: K-161-2.01US 
 
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13 
APPENDICES 
APPENDIX 1: SCHEDULE OF VISITS AND MEASUREMENTS 
Procedure 
Visit 1 
Day -14 ± 2 
Visit 2 
Day 1 
Visit 3 
Day 8 
± 1 
Visit 4 
Day 15 ± 2 
Visit 5 
Day 29 ± 2 
Follow-up 
Phone Call 
(Day 36 ± 2) 
 
Pre  
CAE 
Post  
CAE 
Pre 
CAE 
Post 
CAE 
Non 
CAE 
Pre 
CAE 
Post 
CAE 
Pre 
CAE 
Post  
CAE 
 
Informed Consent / 
HIPAA 
X 
 
 
 
 
 
 
 
 
 
Medical / Medication 
History and Demographics 
X 
 
 
 
 
 
 
 
 
 
Medical / Medication 
Update 
 
 
X 
 
X 
X 
 
X 
 
 
Adverse Event Query 
 
X 
X 
X 
X 
X 
X 
X 
X 
X 
Ora Calibra® Ocular 
Discomfort Scale 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
Ora Calibra® Ocular 
Discomfort & 4-Symptom 
Questionnaire 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
OSDI© Questionnaire 
X 
 
X 
 
X 
X 
 
X 
 
 
Visual Analog Scale 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
Conjunctival Redness 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
Tear Osmolarity 
 
 
X 
 
X 
X 
 
X 
 
 
TFBUT 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
Fluorescein Staining 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
Lissamine Green Staining 
X 
X 
X 
X 
X 
X 
X 
X 
X 
 
Schirmer’s Test 
X 
 
X 
 
X 
X 
 
X 
 
 
Blink Rate 
 
 
X 
 
X 
X 
 
X 
 
 


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Clinical Trial Protocol No.: K-161-2.01US 
 
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Procedure 
Visit 1 
Day -14 ± 2 
Visit 2 
Day 1 
Visit 3 
Day 8 
± 1 
Visit 4 
Day 15 ± 2 
Visit 5 
Day 29 ± 2 
Follow-up 
Phone Call 
(Day 36 ± 2) 
 
Pre  
CAE 
Post  
CAE 
Pre 
CAE 
Post 
CAE 
Non 
CAE 
Pre 
CAE 
Post 
CAE 
Pre 
CAE 
Post  
CAE 
 
Vehicle Run-In 
Dispensation 
 
X 
 
 
 
 
 
 
 
 
Vehicle Run-In Instillation 
 
X 
 
 
 
 
 
 
 
 
Vehicle Run-in Collection 
 
 
X 
 
 
 
 
 
 
 
Randomization 
 
 
 
X 
 
 
 
 
 
 
Study Drug Dispensation 
 
 
 
X 
X 
 
X 
 
 
 
Study Drug Collection 
 
 
 
 
X 
X 
 
X 
 
 
Diary Dispensation 
 
X 
 
X 
X 
 
X 
 
 
 
Diary Collection 
 
 
X 
 
X 
X 
 
X 
 
 
Exit Subject from Study 
 
 
 
 
 
 
 
 
 
X 
   
 
 
 
 
 


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Clinical Trial Protocol No.: K-161-2.01US 
 
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Clinical Trial Protocol No.: K-161-2.01US 
 
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Clinical Trial Protocol No.: K-161-2.01US 
 
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Clinical Trial Protocol No.: K-161-2.01US 
 
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Clinical Trial Protocol No.: K-161-2.01US 
 
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Sponsor: Kowa Research Institute (KRI) 
Clinical Trial Protocol No.: K-161-2.01US 
 
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Clinical Trial Protocol No.: K-161-2.01US 
 
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Clinical Trial Protocol No.: K-161-2.01US 
 
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Clinical Trial Protocol No.: K-161-2.01US 
 
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Clinical Trial Protocol No.: K-161-2.01US 
 
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Sponsor: Kowa Research Institute (KRI) 
Clinical Trial Protocol No.: K-161-2.01US 
 
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Clinical Trial Protocol No.: K-161-2.01US 
 
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Sponsor: Kowa Research Institute (KRI) 
Clinical Trial Protocol No.: K-161-2.01US 
 
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Clinical Trial Protocol No.: K-161-2.01US 
 
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APPENDIX 3: PROTOCOL AMENDMENT SUMMARY 
Not Applicable. 


K-161 
Sponsor: Kowa Research Institute (KRI) 
Clinical Trial Protocol No.: K-161-2.0 I US 
APPENDIX 4: SPONSOR AND 
 APPROVALS 
Protocol Title: 
A Phase 2, Prospective, Double-Masked, 
Randorrized, Multi-Center, Vehicle-Controlled, 
Parallel-group, 4-week Administration Study 
Assessing the Safety, Efficacy, and Optimum Dosage 
ofK-161 in non-Japanese/Japanese Adult Subjects 
with Moderate to Severe Dry Eye Disease Both in 
Environmental and Controlled Adverse 
Environmental (CAE) Settings 
Protocol Number: K-161-2.01 US 
Final Date: 
This clinical study protocol was subject to critical review and has been approved by the sponsor. 
The following personnel contributed to writing and/or approving this protocol. 
Confidential 
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1\,-]61
Clinical Trial Protocol No.: K-161-2.0IUS
Sponsor: KOW3 Research lnstilUle (KRI)
APPENDIX 5: INVESTIGATOR'S
SIGNATURE
Pretocol Title:
A Phase 2. Prospective. Double-Masked.
Randomized.
Multi-Center.
Vehicle-Controlled.
Parallel-group.
4-week Administration
Study
Assessing the Safety. Efficacy. and Optimum
Dosage
of K-) 6) in non-Japanese/Japanese
Adult Subjects
with Moderate to Severe Dry Eye Disease Both in
Environmental
and Controlled Adverse
Environmental
(CAE) Settings
Protocol Number: K-161-2.0 IUS
Final Date:
I agree to implement and conduct the study diligently and in strict compliance with the
protocol. good clinical practices and all applicable laws and regulations.
I agree to
maintain all information
supplied by
and the sponsor in confidence and, when this
information
is submitted to an Institutional
Review Board (lRB). Ethical Review
Committee
(ERC) or another group. it win be submitted with a designation
that the
material is confidential.
I have read this protocol in its entirety. including the above statement, and I agree to all
aspects.
Confidential
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