Conditions: Pterygium Ocular Pain Ocular Inflammation Post-surgical Inflammation
Keywords: zebesten ocular anti-inflammatory ocular analgesic pterygium anti-inflammatory non-steroidal ophthalmic
Allocation: RANDOMIZED | Intervention model: PARALLEL
Enrollment: 166
Healthy volunteers: no

Brief summary:
Title of the study Efficacy and safety of PRO-155 (Zebesten ofteno®) on inflammation of the conjunctival surface in subjects with grade I-III pterygium vs placebo.

Hypothesis H0. The Zebesten® ophthalmic solution (bromfenac 0.09%) is less effective and safe than placebo in reducing conjunctival hyperemia in subjects with grade I-III pterygium.

H1 The Zebesten® ophthalmic solution (bromfenac 0.09%) is more effective and safe than placebo in reducing conjunctival hyperemia in subjects with grade I-III pterygium.

Objective

To evaluate the efficacy and safety of PRO-155 (bromfenac 009%) ophthalmic solution in the treatment of conjunctival hyperemia and ocular surface inflammation in a clinical model of pterygium grade I to III.

Detailed description:
Variables to be evaluated Visual ability Intraocular pressure. Ocular surface Exploration of the previous segment. Exploration of the posterior segment. Lacrimal rupture time. Corneal de-epithelialization Conjunctival de-epithelialization Adverse events.

PHARMACOLOGICAL INTERVENTION

The pharmacological intervention will consist of the instillation of the ophthalmological solution in the conjunctival cul-de-sac, during the waking period, to any of the following study groups:

* Group 1:

  * Sodium hyaluronate 0.4% \[Lagricel ofteno®\] 1 drop 3 times a day in the period of vigil in the conjunctival sac fund (the following application scheme is suggested: start: 7:00 ± 1 hours, continuation: 15:00 ± 1 hour and term: at 19:00 ± 1 hours) for 20 days
  * Pro-155 1 drop 2 times a day in the period of vigil in the conjunctival cul-de-sac (the following application scheme is recommended: start: 7:15 ± 1 hours and term: at 19:15 ± 1 hours) during 20 days
* Group 2:

  * Sodium hyaluronate 0.4% \[Lagricel ofteno®\] 1 drop 3 times a day in the period of vigil in the conjunctival sac fund (the following application scheme is suggested: start: 7:00 ± 1 hours, continuation: 15:00 ± 1 hour and term: at 19:00 ± 1 hours) for 20 days
  * Placebo 1 drop 2 times a day in the period of vigil in the conjunctival cul-de-sac (the following application scheme is recommended: start: 7:15 ± 1 hours and term: at 19:15 ± 1 hours) for 20 days

Arms:
arm 1: Pro-155: 1 drop 2 times a day in the period of vigil in the conjunctival cul-de-sac for 20 days arm 2: Placebo 1 drop 2 times a day in the period of vigil in the conjunctival cul-de-sac

Interventions: intervention 1: PRO-155 intervention 2: Placebo
Intervention descriptions: intervention 1: PRO-155 (Zebesten ofteno®) Active agent: bromfenac 0.90 mg / mL, dropper bottle of low density polyethylene for multidose administration in the form of an ophthalmic solution of 5 mL (milliliters). Sanitary registry in Mexico: 108M2014

Sodium hyaluronate 0.4% \[Lagricel ofteno®\] 1 drop 3 times a day in the period of vigil in the conjunctival cul-de-sac intervention 2: The placebo is constituted by agents, additives and vehicles, of the formulation PRO-155 without pharmacological activity. It is dispensed in dropper bottle of low density polyethylene for multi-dose administration in the form of ophthalmic solution of 5 mL

Sodium hyaluronate 0.4% (Lagricel ofteno®) 1 drop 3 times a day in the period of vigil in the conjunctival cul-de-sac

Protocol document:
Prot_SAP_000.pdf: 
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Zebesten ® (Bromfenac 0.09 %) efficacy and safety on inflammation 
of the conjunctival surface in subjects with grade I-III Pterygium 
vs placebo 
 
 
 
 
 
Drug Product Code: 
PRO-155 
Study Drug: 
Bromfenac 0.09 % 
Therapeutic Indication:  
Ophthalmic non-steroid anti-inflammatory  
Development Phase: 
Phase IV 
Protocol Code: 
SOPH155-0415/IV 
Sponsor: 
Laboratorios Sophia, S.A. de C.V. 
Version: 
 
Date: 
2 
 
June 2016 


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1. INDEX 
 
1. INDEX................................................................................................................................................ 2 
2. GLOSSARY ....................................................................................................................................... 5 
3. BACKGROUND ................................................................................................................................. 6 
4. JUSTIFICATION ................................................................................................................................ 9 
5. PURPOSES ..................................................................................................................................... 10 
5.1 General purpose: ........................................................................................................................ 10 
5.1.1 Specific purpose 1: .............................................................................................................. 10 
5.1.2 Specific objective 2: ............................................................................................................. 10 
6. SUMMARY ...................................................................................................................................... 11 
7. MATERIALS AND METHODS ......................................................................................................... 12 
7.1 Study design .............................................................................................................................. 12 
7.2 Sample ....................................................................................................................................... 12 
7.3 Blinding ...................................................................................................................................... 12 
7.4 Pharmacological approach ......................................................................................................... 13 
7.5 Distribution into treatment groups ............................................................................................... 14 
7.6 Ethical considerations ................................................................................................................ 14 
7.6.1 Research Ethics Committee ................................................................................................. 15 
7.6.2 Modifications to the “informed consent” ................................................................................ 16 
7.7 Confidentiality – use of information ............................................................................................. 17 
7.8 Organization of the center .......................................................................................................... 18 
8. STUDY DRUG PRODUCT ............................................................................................................... 18 
8.1 Codes, labelling, storage ............................................................................................................ 18 
8.1.1 
Primary packaging .......................................................................................................... 19 
8.1.2 
Secondary packaging ..................................................................................................... 19 
8.2 
Study Drug Product ............................................................................................................... 20 
8.3 
Study Drug Handling .............................................................................................................. 20 
9. 
STUDY SCHEDULE ..................................................................................................................... 23 
9.1 
Annotations to Activities Schedule: ........................................................................................ 23 
10. DESCRIPTION OF THE PROCEDURES ...................................................................................... 24


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10.1 General and Ophthalmic Medical Record .............................................................................. 24 
10.2 Pregnancy Test ........................................................................................................................ 25 
10.3 Ophthalmic Exploration .......................................................................................................... 25 
10.3.1. Visual Capacity Measurement ........................................................................................... 25 
10.3.2 
Previous Biomicroscopy ................................................................................................. 27 
10.3.3 Measurement of Intraocular Pressure ................................................................................ 31 
10.3.4 Posterior Segment Exploration ........................................................................................... 31 
10.4 Ocular Symptomology ........................................................................................................... 32 
10.5 OSDI Questionnaire ............................................................................................................... 32 
10.6 Subject's Diary Submission and Review ................................................................................... 32 
10.7 Adverse Events Evaluation ....................................................................................................... 32 
10.8 Evaluation of Concomitant Drugs ............................................................................................. 32 
11. PROCEDURES TO BE PERFORMED ON EACH VISIT ................................................................ 33 
11.1 Baseline Visit ............................................................................................................................ 33 
11.2 Visits 1 and 2 [Days 7 and 15 (±2 Days]) ............................................................................... 34 
11.3 Final Visit [Day 21 (+2 Days)] ................................................................................................ 34 
11.4 Follow-up Phone Call [Day 36 (±2)] ....................................................................................... 34 
12. POPULATION CHARACTERISTICS ............................................................................................. 34 
12.1 Inclusion Criteria ....................................................................................................................... 35 
12.2 Exclusion Criteria ..................................................................................................................... 35 
12.2.1 General Criteria:................................................................................................................. 35 
12.2.2 Exclusion criteria related to ophthalmologic conditions: ..................................................... 36 
12.2.3 Elimination criteria of the subject included in the study: ...................................................... 37 
12.3 PROHIBITED DRUG PRODUCTS ........................................................................................... 38 
12.4 SAMPLE SIZE CALCULATION ................................................................................................ 39 
13. STUDY VARIABLES ...................................................................................................................... 40 
13.1 Tolerability study ...................................................................................................................... 41 
13.2 Security evaluation ................................................................................................................... 41 
13.3 Efficacy assessment ................................................................................................................. 42 
14. PROPOSED STATISTICAL ANALYSIS ......................................................................................... 43 
15. Results report ................................................................................................................................ 44 
16. IDENTIFICATION PROCEDURES, SECURITY AND THERAPEUTIC ADHERENCE OF THE 
INVESTIGATION SUBJECTS .............................................................................................................. 44


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16.1 Recruitment .............................................................................................................................. 44 
16.2 Subject identification ................................................................................................................ 44 
16.3 Subject discontinuation ............................................................................................................. 45 
16.4 Research products recall .......................................................................................................... 46 
16.5 Adherence to the treatment ...................................................................................................... 46 
17. ADVERSE EVENTS ...................................................................................................................... 47 
17.1 Adverse event, definition and communication ........................................................................... 47 
17.1.1 Overview ............................................................................................................................ 47 
17.2 Classification and severity ........................................................................................................ 48 
17.2.1 Classification ...................................................................................................................... 48 
17.2.2 Severity of the Adverse Events .......................................................................................... 48 
17.3 Report of non-serious adverse events ...................................................................................... 49 
17.4 Characteristics of the report of serious adverse events ............................................................ 49 
17.5 Causality .................................................................................................................................. 50 
17.5.1 Definitely related: ............................................................................................................... 50 
17.5.2 Probably related: ................................................................................................................ 50 
17.5.3 Possibly related:................................................................................................................. 51 
17.5.4 Not related: ........................................................................................................................ 51 
17.5.5 Unknown: ........................................................................................................................... 51 
17.5.6 Reporte de los Eventos Adversos Serios ........................................................................... 51 
17.5.7 Pharmacovigilance responsible: ......................................................................................... 52 
18. MONITORING AND AUDITING PROCEDURES. .......................................................................... 53 
19. BIOSAFETY CONSIDERATIONS .................................................................................................. 54 
20. ATTACHMENTS ............................................................................................................................ 55 
21. REFERENCES .............................................................................................................................. 56 
 
 


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2. GLOSSARY 
 
 
ABC 
Area under the curve 
AINE 
Non-steroid anti-inflammatory  
BAK 
Benzalkonium chloride 
Cmax 
Maximum concentration  
COX1 
Cyclooxygenase 1 
COX2 
Cyclooxygenase 2 
FDA 
Food and Drug Administration 
HFB 
Hydroxyfluoroprednisolone  
PGE2 
Prostaglandin E2 
PIO 
Intraocular pressure 
T1/2 
Half life 
Tmax 
Time to reach the maximum concentration  
OSDI 
Ocular Surface Disease Index  
TRL 
Tear film breakup time  
mmHg 
Millimeter of mercury 
FRC 
Case report form 
UV rays 
Ultraviolet rays  
LOCS III 
Lens Opacities Classification System  


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3. BACKGROUND 
 
The manipulation of the ocular structures during surgery, infectious phenomena, trauma in the ocular 
globe, allergies, etc., are events that cause an inflammatory cascade, due to the release of a large 
number of chemical mediators, after cell lysis, and induce the expression of cyclooxygenase 1 and 2 
(COX1 and 2). The COX-2 products are prostaglandins, which have different effects on the damaged 
tissue (see figure 1).  
 
 
 
Figure 1. The loss of integrity of the cellular membrane as consequence of the surgical manipulation of the ocular structures 
causes an increase in the bioavailability of membrane phospholipids, which are biotransformed by phospholipids into 
arachidonic acid. 5-lipooxygenase acts on the arachidonic acid and synthesizes leukotrienes, which increase the vascular 
permeability and vasoconstriction. Cyclooxygenases, upon acting on the arachidonic acid, synthesize prostaglandins and 
thromboxanes, which 
 
 
 
Prostaglandins cause the filtration of fluid from the perifoveal capillary networks to the extracellular space 
of the macular region. Some of the main ocular signs and symptoms in which prostaglandins have been 
involved are inflammation, pain, conjunctival hyperemia, posterior synechiae, opacity of the posterior 
capsule, changes in ocular tension, glaucoma, and cystic macular edema.  
Cellular membrane 
phospholipids  
Leukotrienes 
Prostaglandins 
Thromboxanes 
5-lipooxygenase 
Phospholipases 
Cyclooxygenase 
Arachidonic acid 
Vasoconstriction  
Increases 
permeability 
Vasoconstriction  
Platelet 
aggregation 
Vasodilation  
Edema potency   


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Considering the role taken on by the inflammation in the development of this process, the use of two 
groups of drugs to prevent the deteriorating effects of its onset has been proposed:  
 
1. Non-steroid anti-inflammatory agents that directly inhibit COX1 and COX2 enzymes.  
2. Topical corticoids that act on the A2 phospholipase level, inhibiting the release of prostaglandins.  
 
Non-steroid anti-inflammatories present higher safety in chronic dosing schedules compared to corticoid 
anti-inflammatories; however, in terms of anti-inflammatory potency they are superior to the latter.  
 
Currently, there are four FDA-approved ophthalmic AINES for treatment of inflammation following 
cataract surgery: diclofenac 0.1 % solution, ketorolac 0.5 % suspension, nepafenac 0.1 % suspension, 
and bromfenac 0.09 % solution. Bromfenac is a non-steroid anti-inflammatory byproduct of phenylacetic 
acid related to diclofenac. Its unique chemical structure confers high lipophilicity, quick penetration, and 
higher immediate and sustained bioavailability in all ocular tissue.1 
 
Bromfenac 0.9 mg/ mL eyewash is intended for treating post-surgery ocular inflammation after the 
extraction of cataracts in adults, based on good preclinical and clinical results.  
 
The ophthalmic bromfenac 0.09 % solution has demonstrated its safety and efficacy as a topical ocular 
AINE, specifically, in a controlled inflammation model such as surgical trauma in the anterior chamber 
(phacoemulsification); said study demonstrated its efficacy in reducing the swelling of different structures 
in the post-surgery period, such as corneal edema, conjunctival hyperemia, chemosis, intracameral 
cellularity, and retinal edema.2 
 


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In comparison with other AINES available on the market, it was also demonstrated that its efficacy is 
similar and its tolerability is satisfactory as well as its safety.  
 
Currently, thanks to the diversity of available drug products for the treatment of ocular inflammation, we 
as ophthalmologists can be more precise in the treatment scheme granted to the subject; that is to say, 
we can choose, depending on the gravity of the inflammatory symptoms, the anti-inflammatory with the 
desired effect and the lowest number of possible adverse events.  
 
Chronic pathologies with an inflammatory component, such as Pterygium, occur with recurrent 
aggravations in which symptoms and signs that, while they may not permanently affect the structure of 
the eye, do diminish the visual quality, are exacerbated.  
 
The ideal AINE is that which reaches therapeutic concentrations in the anterior and posterior segment 
levels, has an excellent anti-inflammatory activity, is analgesic, safe, and well-tolerated. Different types 
of AINES are formulated and sold for their use in ophthalmology: indomethacin 1 %, diclofenac 0.1 %, 
ketorolac 0.5 %, nepafenac 0.1 %, and bromfenac 0.09 %; among these the most innovative are 
nepafenac and bromfenac. All are organic acids except nepafenac, which is an amide analog and is 
formulated as a suspension instead of a solution. All of them reach therapeutic concentrations in the 
aqueous humor, iris, and ciliary body. However, most are not able to reach the posterior pole. Only the 
next-generation AINES – bromfenac and nepafenac – are able to reach therapeutic concentrations in the 
posterior segment and are the most inhibitory for COX2, which has the highest expression at the retina 
level.  
 


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4. JUSTIFICATION 
 
Steroids are considered the “golden standard” for treating inflammation and may cause multiple adverse 
events such as: increase in intraocular pressure, susceptibility to infection, delay in the healing of corneal 
injuries, glaucoma, and posterior subcapsular cataracts, among others; for which reason AINEs represent 
a safer alternative for the treatment of long-term post-surgery inflammation. 
 
Most AINEs are weak acids and are ionized with the tear pH, limiting their permeability towards the 
anionic cornea. Due to their pharmacological characteristics, AINES must be combined with insoluble 
cationically-charged complexes, as is the case with benzalkonium chloride, to facilitate their penetration 
and solubility.  
 
Currently, four topical non-steroid anti-inflammatories are approved by the Food and Drug Administration 
(FDA) for the treatment of inflammation: diclofenac 0.1 %, ketorolac 0.5 %, nepafenac 0.1 %, and 
bromfenac 0.09 %. Of these, bromfenac is the only one approved at a dosage of twice a day and which 
is currently used to treat post-surgery inflammation, blepharitis, conjunctivitis, and escleritis.3 
 
The use of topical ocular AINES was limited to their chronic use, which also presents adverse events 
such as corneal abrasion, tear film dysfunction, or even corneal melting. Recent evidence regarding 
bromfenac being used for 3 weeks indicates that its dosage of twice a day appears to be safe for the 
ocular surface.  
 
There is a report by Frucht J, et al. which compares the use of indomethacin 0.1 % versus 
dexamethasone 0.1 % to handle ocular signs and symptoms associated with Pterygium and Pinguecula, 
under a dosing schedule of 1 drop 6 times a day for 3 days, followed by 1 drop 4 times a day for 11 days 
for both drug products.  
 


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Although the authors assert that both drug products are efficient and safe, the dosing schedule entails 
the frequent administration of the drug products, which represents an increase in the risk of the subject’s 
failure to follow the treatment, for which reason we propose bromfenac as a useful drug in the control of 
clinical signs such as hyperemia in an inflammatory disease model that requires a drug with less adverse 
events and a lower frequency of administration that other AINES.4 
 
5. PURPOSES 
 
5.1 General purpose: 
Evaluate the efficacy and safety of Zebesten ® (bromfenac 0.09 %) ophthalmic solution in the treatment 
of conjunctival hyperemia and ocular surface inflammation in a clinical grade I to III Pterygium model.  
 
5.1.1 Specific purpose 1: 
Evaluate the efficacy of Zebesten ® in the control of conjunctival hyperemia in subjects with Pterygium 
through its qualitative assessment through the validated analogous scale of the cornea unit and contact 
lenses of the University of South Wales.5 
 
5.1.2 Specific objective 2: 
Evaluate the safety of Zebesten ® through the evaluation of the corneal and conjunctival epithelium 
through fluorescein and lissamine green staining, the measurement of intraocular pressure, and the Tear 
film breakup time.  
 


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6. SUMMARY 
Drug Product Code: 
PRO155 
Study Drug: 
BROMPHENAC 0.09 % OPHTHALMIC SOLUTION 
Therapeutic Indication: 
Ocular non-steroid anti-inflammatory  
Protocol Code: 
SOPH155-0415/IV 
Sponsor: 
Laboratorios Sophia, S.A. de C.V. 
Version: 
Date: 
2 
June 2016 
Study Title: 
Evaluation of the efficacy and safety of Zebesten ® (Bromfenac 0.09 %) 
ophthalmic solution on the treatment of conjunctival hyperemia and 
inflammation of the ocular surface in a clinical grade I-III Pterygium model  
Study Design: 
Controlled, randomized, double blind, masked clinical study, comparing 
the safety and efficacy of Zebesten ® for the treatment of conjunctival 
hyperemia in grade I to III Pterygium compared to placebo  
Variables to Evaluate: 
Primary outcome 
- 
Conjunctival hyperemia 
- 
Tear film breakup time 
- 
Adverse events 
Secondary outcome 
- 
Ocular symptomatology 
o Burning sensation 
o Foreign body sensation 
o Photophobia  
- 
OSDI questionnaire scoring 
- 
Evaluation of epithelial defects with fluorescent dye (cornea and 
conjunctival)  
- 
Evaluation of epithelial defects with lissamine green dye (cornea 
and conjunctival) 
- 
Visual capacity  
- 
Intraocular pressure  
Groups 
Subjects diagnosed with grade I to III Pterygium will be included in 2 study 
groups. 
Group 1 will receive Zebesten ® ophthalmic solution together with Na 
hyaluronate.  
Group 2 will receive placebo plus Na hyaluronate.  


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7. MATERIALS AND METHODS 
 
7.1 Study design 
Multicentric, controlled, randomized, double blind clinical study, which compares the safety and efficacy 
of Zebesten ® for the treatment of conjunctival hyperemia in grade I to III Pterygium compared to placebo.  
 
7.2 Sample 
The total population will be 166 cases, which will be randomly included and distributed in 2 study groups. 
Both with diagnosis of grade I to III Pterygium. 
 
Subjects with bilateral Pterygium, in which both eyes meet the selection criteria, can participate with both 
eyes, taking each eye as one case.  
Group 1 will receive Zebesten ® ophthalmic solution together with Na hyaluronate.  
Group 2 will receive placebo (formulation with no drug substance) together with Na hyaluronate.  
 
7.3 Blinding 
The double blind study is a procedure in which the subject and treating physician do not know which 
study subjects were assigned to which treatment group. To achieve blind conditions for the drug product, 
the investigational drug product and the placebo are both packaged in identical bottles with the same 
legends on the label. The blinding codes are kept by an individual uninvolved in the study designated by 
the sponsor. The codes are also available in the research center (completely sealed), so the Researcher 
may refer to them should a subject present a serious adverse event, after being authorized by the study 
sponsor. The blind conditions are strictly upheld during the data analysis.  
 


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7.4 Pharmacological approach 
The pharmacological approach consists in the instillation of the ophthalmic solution in the bottom of the 
conjunctival sac during the waking period in any of the following study groups: 
• 
Group 1: 
o Sodium hyaluronate 0.4 % [Lagricel Ofteno ®] 1 drop 3 times a day in the waking period 
in the bottom of the conjunctival sac (the following application method is recommended: 
start: 7:00 ± 1 h; following: 15:00 ± 1 h; end: 19:00 ± 1 h) for 20 days 
o Bromphenac 0.09 % [Zebesten ®] 1 drop 2 times a day in the waking period in the bottom 
of the conjunctival sac (the following application method is recommended: start: 7:15 ± 1 
h; end: 19:15 ± 1 h) for 20 days 
• 
Group 2: 
o Sodium hyaluronate 0.4 % [Lagricel Ofteno ®] 1 drop 3 times a day in the waking period 
in the bottom of the conjunctival sac (the following application method is recommended: 
start: 7:00 ± 1 h; following: 15:00 ± 1 h; end: 19:00 ± 1 h) for 20 days 
o Placebo 1 drop 2 times a day in the waking period in the bottom of the conjunctival sac 
(the following application method is recommended: start: 7:15 ± 1 h; end: 19:15 ± 1 h) for 
20 days 
 


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7.5 Distribution into treatment groups 
The subjects are distributed into the study groups on the visit indicated in the study timetable, through 
simple 1:1 randomization, closed envelope technique, through a specialized software that uses random 
number tables to achieve a uniform distribution in each of the treatment groups.  
 
 
Fig. 1. DISTRIBUTION OF STUDY SUBJECTS. Shows the randomized distribution of the study subjects in the research protocol 
using a computing system through the closed envelope technique. 
 
7.6 Ethical considerations 
This protocol follows the Good Clinical Practices (GCP) and the principles originated in the 18th Medical 
Assembly of Helsinki, Finland in 1964 and the modifications carried out in Tokyo, Japan in 1975, Venice, 
Italy in 1983, Hong Kong in 1989, and the 48th General Assembly in Somerset West, South Africa in 
1996. 59th General Assembly in Seoul, South Korea, 2008, 64th General Assembly in Fortaleza, Brazil, 
2013, where the medical investigation (clinical investigation) was discussed. 
 
Also, the protocol follows the specifications of the General Health Law of Mexico as regards research in 
the healthcare field, which as per article 17 considers this study, under subsection III, as having a risk 
higher than the minimum and the administration of drugs. Under said legal framework, the integrity of the 
individuals, their life, and their safety is respected.  
 
Study subjects 
with grade I-III 
Pterygium that 
present 
conjunctival 
hyperemia  
1:1 closed 
envelope 
randomization 
Zebesten Ofteno ® 
group (PRO-155 + 
Na hyaluronate) 
1 drop 2 times a 
day for 20 days 
Placebo group 
(Vehicle + Na 
hyaluronate) 
1 drop 2 times a day 
for 20 days 
Evaluation:  
Efficacy in reducing 
swelling 
Control of conjunctival 
hyperemia 
Safety 
Evaluation:  
Efficacy in reducing 
swelling 
Control of conjunctival 
hyperemia 
Safety 


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We also follow National Mexican Standard NOM-012-SSA3-2012, which establishes the criteria to carry 
out investigational projects in the field of human healthcare.  
 
7.6.1 Research Ethics Committee  
The main researcher shall submit the study protocol, informed consent, researcher’s manual, materials 
to be handed to the subjects, recruiting materials, and necessary documents to an investigational ethics 
committee approved by the National Bioethics Commission and currently registered before the Federal 
Commission for Protection against Sanitary Risks (COFEPRIS), as per local requirements.  
 
The study shall not be initiated in the research center without prior approval of the relevant investigational 
ethics committees and research committee, compliance with the local regulatory requirements, signing 
of the confidentiality agreements, economic proposal, and signing of the contracts of each of the main 
medical researchers.  
 
7.6.1.1 Information for subjects and informed consent form 
The informed consent must be obtained before the subject undergoes any procedure indicated in the 
protocol.  
The written consent documents shall incorporate the informed consent elements described in the 
Declaration of Helsinki and the ICH Good Clinical Practices Guide and shall comply with all applicable 
laws and regulations. 
 
The main researcher (or a physician who is a member of the site’s research team, duly specified by the 
main researcher as far as delegation of responsibility) shall provide the possible participant with all the 
information regarding the study characteristics, potential risks, benefits, objectives, and procedures. This 
information shall be communicated in a language the subject can comprehend, and the subject will be 
informed that they have the right to interrupt their participation in the study at any time,


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without it affecting the relationship with the researcher and/ or their future support. The informed consent 
shall be given to the possible participant for their consideration, and they must be given enough time to 
analyze each of the previously mentioned aspects. Should they have any doubts, these must be clarified 
by the person responsible for obtaining the informed consent. Once the participant agrees to participate 
in the study, they must sign and date the informed consent letter in the presence of two witnesses that 
may or may not have a relationship with the study subject, who shall participate during the informed 
consent process and sign affirming that the process was carried out before any study procedure, that the 
study information was clearly explained, and that doubts (if any) were clarified.  
 
If a subject is illiterate, their agreement shall be indicated with their fingerprint, and should the subject not 
be able to grant their adequate written informed consent, a “legally authorized” representative of the 
subject may provide said consent on behalf of the subject, as per applicable laws and regulations.  
 
The main researcher must also sign and date this consent.  
 
The informed consent must be signed in duplicate by all involved parties and two witnesses. A copy shall 
be archived in the researcher’s files and another shall be provided to the participant. The researcher must 
document the date on which the informed consent was signed within the subject’s medical record.  
 
After having obtained the informed consent, a unique identification number shall be assigned to the 
subject, which will be used during the entirety of the study for the purpose of identification of the 
participants.  
7.6.2 Modifications to the “informed consent” 
Any change to the “informed consent” constitutes a modification to this document and must be presented 
for approval before the Research Ethics Committees and, if applicable, before the competent authorities.  


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In the modification, a copy of the new version shall be included in the country’s language or languages.  
Said modifications may be implemented only after having obtained written approval of the Research 
Ethics Committee and having complied with the local regulatory requirements, except for modifications 
required to eliminate an immediate danger for the study subjects.  
 
Each subject affected by the modification must fill out, date, and sign two original copies of the new 
version. The subject will receive a signed original copy of the modification and the researcher will keep 
the second original copy.  
 
7.7 Confidentiality – use of information  
All documents and information provided to the researcher by the sponsor are strictly confidential. The 
researcher expressly agrees that the information regarding their professional and clinical experience 
provided to the sponsor physically and stored in the computer are only for use related to their activities 
with the clinical study sponsor, according to the Good Clinical Practices. The researcher accepts that 
they and the members of their team will only use the information within the study framework to carry out 
the protocol. This agreement is obligatory while the confidential information has not been disseminated 
to the public by the sponsor. The clinical study protocol provided to the researcher may be used by them 
and their colleagues to obtain the subjects’ informed consent for the study. The clinical study protocol, 
as with any information taken from it, shall not be revealed to other parties without the sponsor’s written 
authorization.  
The researcher shall not reveal any information without the prior written consent of Laboratorios Sophia 
S.A. de C.V., except to representatives of the competent authorities and only upon their request. In this 
last case, the researcher is required to inform Laboratorios Sophia S.A. de C.V., before revealing the 
information to the authorities. The researcher shall fill out and maintain a subject screening logbook, as 
well as the identification and recruitment listing of each of the subjects.  
 


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The researcher agrees to grant access to the site to the auditor and/ or representatives of the competent 
authorities. The information shall be handled in compliance with trade confidentiality.  
 
The subject screening logbook shall begin to be filled out starting from the moment in which the 
researcher determines that a subject can participate in the study (through an assessment of the subject’s 
medical record during a visit or review of the medical file), once the research center is opened.  
 
7.8 Organization of the center 
All individuals to whom the researcher delegates part of the follow-up of the study under their 
responsibility (co-researcher, sub-researcher, nurse) and any other person participating in this center’s 
study (cardiologist, pharmacist, …) must appear in the delegation of responsibility form. This document 
must be submitted at the start of the study and updated if there are changes in any of the individuals 
participating in the center’s study.  
 
8. STUDY DRUG PRODUCT 
 
8.1 Codes, labelling, storage 
The dropper bottles shall be issued in their primary and secondary packaging to the various participating 
research centers, identified with the protocol code, under the specific dosage form and contents in 
milliliters, as shown in the following image, among others: 


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8.1.1 Primary packaging 
 
PRO 155 
CAUTION: STUDY DRUG  
FOR RESEARCH 
PURPOSES ONLY 
Subject No. 
Initials: 
 
ME No.: 
Batch: 
Cad: 
Ophthalmic solution 
Content: 5 mL 
 
8.1.2 Secondary packaging 
 
Drug products No. 
Batch: 
Expiration date: 
0.09 
Protocol: SOPH155-0415/IV 
Subject No.: 
 
Subject initials: 
 
Researcher: 
 
 
Ophthalmic route. Give as per the 
protocol. 
Storage at room temperature at not more 
than 30 ºC. Do not freeze. 
Sample for clinical research. 
Investigational drug product 
 
Not for sale. 
Keep out of reach of children. 
 
“Return this container and unused drug 
products” 
Laboratorios Sophia S.A. de C.V. 
Av. Paseo del Norte No. 5255, Col. 
Guadalajara 
Technology Park 
C.P. 45010. Zapopan, Jalisco, México. 
Tel. +52 (33) 3001-4200. 
 
Content: 1 bottle 
REMOVE LABEL 
PRO-155 
Protocol: SOPH155-0415/IV 
Drug products No.: 
 
Subject initials: 
 
Researcher: 
 
PRO-155 
Protocol: SOPH155-0415/IV 
Drug products No.: 
 
Subject initials: 
 
Researcher: 
 
 


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8.2 
Study Drug Product 
• 
The formulation of Zebesten® is composed of the following active agent: Bromfenac 0.09 mg/mL, 
and inactive agents: povidone, boric acid, sodium borate decahydrate, sodium sulfite, polysorbate 
80, disodium edetate dihydrate, benzalkonium chloride, sodium hydroxide, hydrochloric acid, 
water for injection. It is dispensed in low-density polyethylene dropper bottles for multidose 
administration as a 5 mL ophthalmic solution. Sanitary record: 108M2014. 
• 
Drug product Lagricel Ofteno® is composed of the following active agent: sodium hyaluronate 0.4 
mg (4 mg/mL). It is dispensed in a dropper bottle (with a container closure system that allows to 
preserve the solution) for unit-dose administration as a 0.5 mL preservative-free ophthalmic 
solution. Sanitary record: 0208C99 SSA 
• 
Placebo is composed of Zebesten® formulation additives: povidone, boric acid, sodium borate 
decahydrate, sodium sulfite, polysorbate 80, disodium edetate dihydrate, benzalkonium chloride, 
sodium hydroxide, hydrochloric acid, water for injection. It is dispensed in low-density 
polyethylene dropper bottles for multidose administration as a 5 mL ophthalmic solution. 
8.3 
Study Drug Handling 
Previously weighted and packed drug products will be sent from the storage center located at 
Laboratorios Sophia S.A. de C.V. 
The main researcher at the research center is responsible of handling the study drug, including: 
- Receipt and storage of the study drug (ME). The receipt of the study drug will be acknowledged by 
signature and return of the relevant form. The study drug must be kept in a safe area with restricted 
access. Some special 


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storage conditions are requested, such as storage at room temperature ≤ 30 ºC, do not freeze, and no 
refrigeration required. The researcher must have a thermohygrometer that records: 
• 
Current temperature 
• 
Minimum temperature 
• 
Maximum temperature 
• 
Percentage of relative humidity 
- The main researcher or designated pharmacist must read daily the 4 parameters indicated and record 
them in the corresponding documentation. 
-The expiration date will appear on each box and label. 
- The researcher or pharmacist of the research center must use the provided treatment only for subjects 
participating in the study. 
- The study drug must be kept locked and with restricted access throughout the period it remains at the 
research center. 
- Study drug count: 
- The researcher and/or pharmacist of the research center and/or a designated team member must fill on 
real time all the documents provided by the sponsor for the study drug hamdling. 
The study monitor will verify regularly the study drug handling and count. 
- At the end of the study, the researcher and study monitor will make a final inventory of the drug products 
and will record it in the relevant form. 
After counting the amount of remaining study drug products returned in every container, the study monitor 
will pick them for storage and subsequent destruction. 
 
 


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Any defect or deterioration of the study drug or their packaging must be notified to the study monitor. The 
researcher will notify the monitor all the complaints received from the subjects. 
If the study drug is returned to the sponsor before expected (batch withdrawal), the sponsor will prepare 
an informative letter addressed to the researcher and/or pharmacist of the research center. Local persons 
responsible of the study will sent this letter to each one of the study centers. When receiving the letter, 
the researcher and/or pharmacist will identify the subjects that own the treatment when the incident is 
observed and will contact them immediately. The monitor will organize the return of the study drug to 
destroy it. 
 


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9. 
STUDY SCHEDULE 
Procedure 
SCHEDULE 
(window periods) 
Baseline 
visit 
Visit 1 
Visit 2 
Final visit 
Follow-up 
call 
Day 1 
Day 7 
(± 2) 
Day 15 
(± 2) 
Day 21 
(± 2) 
Day 36 
(± 2) 
Eligibility criteria (inclusion and exclusion) 
X 
 
 
 
 
Pregnancy test (if applicable) 
X 
 
 
X 
 
Informed consent signature 
X 
 
 
 
 
General and ophthalmic medical record 
X 
 
 
 
 
Ocular symptomatology (A, B, C) 
X 
X 
X 
X 
 
OSDI questionnaire 
X 
X 
X 
X 
 
Subject code assignment 
X 
 
 
 
 
Visual capacity 
X 
X 
X 
X 
 
Previous biomicroscopy (D) 
X 
X 
X 
X 
 
Testing of epithelial defects with fluorescein dye 
X 
X 
X 
X 
 
Testing of epithelial defects with lissamine green 
dye 
X 
X 
X 
X 
 
Breakup time 
X 
X 
X 
X 
 
PIO measurement 
X 
 
 
X 
 
Posterior ophthalmoscopy under mydriasis 
X 
 
 
X 
 
Treatment delivery 
X 
 
 
 
 
Start of drug application 
X 
 
 
 
 
End of drug application 
 
 
 
X1 
 
Drug return 
 
 
 
X 
 
Subject diary submission 
X 
 
 
 
 
Subject diary review 
 
X 
X 
X 
 
Evaluation of adverse events 
 
X 
X 
X 
X 
Evaluation of concomitant drug 
X 
X 
X 
X 
 
Follow-up call 
 
 
 
 
X 
 
9.1 
Annotations to Activities Schedule: 
A. Burning 
B. Foreign body sensation 
C. Photophobia 
D. Includes testing of conjunctival hyperemia variable 


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1 The application ends one day before to fulfill the 20 days indicated in the treatment. 
10. DESCRIPTION OF THE PROCEDURES 
10.1 
General and Ophthalmic Medical Record 
It refers to a systems review highlighting the medical and surgical history, indicating the start, evolution 
and, if applicable, the end of previous conditions. 
List the drug products taken and the dates of the last dose; specify their administration route. 
A general clinical examination will be performed, including vital signs (blood pressure, body temperature, 
breaths per minute and heart rate) and anthropometric parameters (weight, size, complexion). 
Patients will be asked about previous, chronic or acute ocular conditions, specifying onset or diagnosis 
time, and their evolution. 
If applicable, the optical correction devices used by the subject will be listed, such as frame glasses, 
contact lenses, magnifying glass, etc. Similarly, the evolution time and use period will be stated. 
Then, topical drug products used in eyes and eye adnexa will be investigated. In the case of any systemic 
drug product directly related to a condition of the eyes or eye adnexa (eyelids, eye socket, lacrimal duct, 
glands, etc.), it must also be recorded in this section. 
Any finding that prevents the protocol procedures from being carried out or the subject from remaining in 
the study must be recorded. Yes/ No must be indicated in the FRC. In the case of any finding, it must be 
specified. 
 


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It must also be recorded if the subject performs outdoor activities for more than 8 hours (Yes/ No) and if 
they perform activities in a place with air conditioning for more than 8 hours a day (Yes/ No). 
The grade of pterygium must be recorded according to the above classification. 
10.2 Pregnancy Test 
A urine pregnancy test will be performed in the same facilities of the contracted research center, where 
the participant of the study will be provided with a home pregnancy test-type device for private use. The 
subject will be indicated to pour the urine on the absorbing end for 10 seconds, and then to place the 
included plastic cover and let it stand for 3 minutes on a flat surface with the results window facing 
upwards. It is important to mention that the device must not be moved during this period. 
The result will appear after 3 to 15 minutes. A line will appear in the control window indicating that it is 
working correctly. Then, a pink line will appear in the results window. Its intensity may vary, but if it 
appears it indicates that pregnancy is very probable. 
The test must be recorded in the FRC, indicating it was performed, the date and results (positive/ 
negative). If the test is not performed, the reason must be specified. 
10.3 
Ophthalmic Exploration 
10.3.1. Visual Capacity Measurement 
Basal visual acuity must be tested without using optical correction devices, using a Snellen card in a 
room with adequate natural or artificial lighting. The result must be documented in the form of a fraction 
according to the number of lines that the subject was able to read. This information will be reported as 
visual acuity. 
Afterwards, the subject's visual acuity will be tested using the best optical refraction and it will also be 
recorded in the form of a fraction in the Snellen card. Both values will be reported for statistical purposes 
(LogMAR). A fraction conversion table is attached to LogMAR. 
 


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In the FRC, the result will be recorded as 20 / number for Snellen and as decimal for LogMAR. 
 
• 
Visual Examination Standardization 
- At a distance of 3 meters in a well-lit room the research subject will be evaluated as follows: 
- This examination will be performed within the research center 
- The subject will be asked to sit always at the same place and their visual acuity (AV) will be tested using 
the LogMAR chart. If this chart is not available, the conversion must be performed (Fig. 10.3.1.1). The 
research subject must keep both eyes open. 
- The research subject must gently cover an eye with the occluder provided by Laboratorios Sophia S.A. 
de C.V., (all the research subjects must use the same occluder to cover their eye) while they read aloud 
the smallest line of letters they are able to see. This examination is performed in each eye, one at a time, 
starting with the right eye (OD). 
- The physician must point to the line the research subject must read. 
- The same steps are applied for the visual capacity test.


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LogMAR 
VAR 
Snellen (m) 
Decimal Snellen (ft) 
 
 
 
 
Fig. No. 10.3.1.1. LogMAR conversion table 
10.3.2 Previous Biomicroscopy 
This test will be performed in consecutively from the eyelids and eyes adnexa to the ocular surface and 
anterior chamber. The following items must be tested: 
❖ Description of eyelids, eyelashes and adnexa glands. 
❖ Description of lid wiper, bulbar and fornix: in this item, the qualitative characteristics will be 
classified as follows. 
❖ Conjunctival hyperemia: 
o Bulbar hyperemia: it will be compared to the images of Fig. 10.3.3.1, which shows different 
grades of venous turgor: very slight, slight, moderate and severe. 
VERY SLIGHT 
SLIGHT 
MODERATE 
SEVERE 
 
 
Fig. 10.3.3.1 10 


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o Tarsal hyperemia: similarly, tarsal hyperemia will be compared with the images shown in 
Fig. 10.3.3.2, which shows the venous turgor in the palpebral mucosa. 
o Documentation in the FRC: the most severe hyperemia must be recorded. 
VERY SLIGHT 
SLIGHT 
MODERATE 
SEVERE 
 
 
 
Fig. 10.3.3.2 10 
10.3.2.1 Anterior Segment: 
❖ The photometer and consensual pupilar reflexes must be reviewed, as well as the iris constitution, 
highlighting pathological aspects, such as inflammatory membranes, anterior and posterior 
synechiae, among others. 
❖ The width of the anterior chamber will be qualitatively graded using the Van Herick technique, 
which consists of grading the space between the iris and posterior side of the cornea by subjective 
appreciation, locating the beam of light of a slit lamp in the external third of the anterior chamber: 
Example: Van Herick II 
 
 
 
 
 
❖ Lens: the items to be evaluated are the integrity of the anterior capsule of the lens and its 
composition characteristics, highlighting only pathological aspects, for example: 
pseudoexfoliation, pigment, synechiae, etc.


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❖ Opacities: will be analyzed, if applicable, according to the LOCS II scale. 
It will be recorded in FRC as normal/abnormal. If abnormal, it must be specified if this finding affects the 
protocol procedures and if it prevents the subject from remaining in the study. 
 
 
 
 
 
 
 
 
Image 2. LOCS III 6 
10.3.2.2 Fluorescein Dye 
Sodium fluorescein dye dissolved in tetracaine will be used on the ocular surface (billiard conjunctiva and 
cornea). After staining the surface, the following explorations will be performed: 
10.3.2.2.1 Tear Film Breakup Time 
It will be measured after blinking once and the patient will be asked to not blink again until the tear film 
breaks on the cornea. If it is more than 10" it will be regarded as normal. The whole number value will be 
recorded on the FRC. 
 


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Example: 
10.3.2.2.2 Epithelial Defects 
After the TRL test, the grade of epithelial staining in the cornea and conjunctiva will be tested according 
to the Oxford University scale, as it has been shown to be the scale closest to the OSDI score.7 The 
record in the FRC must correspond to this scale. It must be recorded in the FRC with the roman numeral 
corresponding to the grade. 
10.3.2.3 Lissamine Green Dye 
Lissamine green dye dissolved with tetracaine will be used on the ocular surface (bulbar conjunctive and cornea). 
Once the surface is stained, the cornea and conjunctive epithelium will be testes according to the Oxford 
University scale. It must be recorded in the FRC with the roman numeral corresponding to the grade. 
Panel 
Grade 
Criteria 
A  
0 
Equal or less than panel 
A 
B 
I 
Equal or less than panel 
B, more than A 
C 
II 
Equal or less than panel 
C, more than B 
D 
III 
Equal or less than panel 
D, more than C 
 


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E  
IV Equal or less than panel 
E, more than D 
> E 
V 
More than panel E 
 
10.3.3 Measurement of Intraocular Pressure 
After testing the ocular surface using fluorescein dye, PIO will be measured using a Goldman tonometer 
and cobalt-blue filter. 
The whole number value will be recorded in the FRC. 
 
10.3.4 Posterior Segment Exploration 
The posterior segment will be reviewed to verify that there are no pathological processes requiring 
attention and/or preventing the participation of the subject in the clinical trial. 
The posterior segment and the rest of the retina will be explored under medicinal mydriasis, recording 
the following aspects: 
1. 
Appearance of vitreous humor  
2. 
Retina completely applied 
3. 
Vascular alterations 
4. 
Appearance of clinical macular area  
5. 
Appearance of the foveolar area  
6. 
Characteristics of the optical nerve  
a) 
Emergence of vessels  
a. 
Neuroretinal rim 
b. 
Cup-to-disc ratio expressed in decimals 
7. 
Report any other clinical finding in the retina. 
It must be reported in the FRC as normal/abnormal. If it is abnormal, it should be specified if this finding 
affects the protocol procedures preventing the subject from remaining in the study. 
The optical nerve must be reported in decimals. 


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10.4 
Ocular Symptomology 
It refers to the enquiry performed by the researcher for the presence or absence of the following 
symptoms: burning, foreign body sensation and photophobia, related to pterygium. It must be recorded 
as present or absent. Symptomology directly related to the administration of the drug product must not 
be reported in this section. Post-instillation symptoms shall be recorded in the instrument “subject's diary”. 
10.5 
OSDI Questionnaire 
It refers to the application of the OSDI questionnaire. The obtained score must be recorded. The score 
is obtained as follows: 
𝑂𝑆𝐷𝐼=
(𝑠𝑐𝑜𝑟𝑒 𝑠𝑢𝑚)25
# 𝑜𝑓 𝑎𝑛𝑠𝑤𝑒𝑟𝑒𝑑 𝑞𝑢𝑒𝑠𝑡𝑖𝑜𝑛𝑠 
10.6 Subject's Diary Submission and Review 
During the baseline visit, the subject will be provided with the instrument “subject's diary” and it will be 
explained how to fill it out. 
During the following visits, the completeness of the diary will be reviewed, and questions that might have 
arisen during its completion will be answered. 
10.7 Adverse Events Evaluation 
It refers to the evaluation performed by the main researcher for the presence of adverse events according 
to item 17. Adverse Events. 
If the subject presents any adverse event it must be recorded in the file and FRC. 
10.8 Evaluation of Concomitant Drugs 
The main researcher will question the subject on the use of drug products other than those indicated in 
the protocol. 
If the subject uses any other drug it will be documented in the file and FRC. 


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11. PROCEDURES TO BE PERFORMED ON EACH VISIT 
The procedures to be performed on each visit are listed below. The study day on which the visit must be 
performed appears in brackets and the permitted window period in parentheses. 
11.1 Baseline Visit 
1. 
During this visit it will be evaluated if the subject meets the eligibility criteria. 
2. 
First, the informed consent will be reviewed clarifying any doubt the subject wishes to review, 
and documenting in the clinical note the subject's possible questions and the answers given to 
them. This procedure will be performed strictly by the healthcare personnel, preferably by the 
main researcher. 
a. 
Afterwards, the informed consent will be signed, jointly with two witnesses (if 
applicable). 
3. 
If applicable (female subject in reproductive age), pregnancy test. 
4. 
The medical staff will generate a medical record based on the systems review of the subject, 
specifying signs and symptoms related to systemic inflammatory diseases. A complete 
ophthalmic medical record will be generated, including at least the items required in the case 
report form plus the items required by the usual medical record used for the first time in the 
subject's research center. 
5. 
OSDI questionnaire will be applied. 
6. 
Ocular symptomology enquiry. 
7. 
Complete ophthalmic exploration, indicating pterygium. 
8. 
Subject code designation (as per item 16. Identification Procedures). 
9. 
Treatment deliverance (as per item 8. Study Drugs). 
10. 
Start of the treatment. 
11. 
Subject diary submission. 
12. 
Concomitant drug products assessment. 
13. 
Scheduling subsequent visits. 


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11.2 
Visits 1 and 2 [Days 7 and 15 (±2 Days]) 
1. 
Ophthalmic physical exploration: 
a. Visual capacity testing 
b. Previous biomicroscopy 
2. 
OSDI questionnaire application 
3. 
Enquiry regarding ocular symptomology 
4. 
Subject diary review 
5. 
Adverse events evaluation 
6. 
Concomitant drug products assessment 
11.3 
Final Visit [Day 21 (+2 Days)] 
1. 
If applicable (female subject in reproductive age), pregnancy test 
2. 
OSDI questionnaire application 
3. 
Ocular symptomology enquiry 
4. 
Complete ophthalmic exploration 
5. 
Return of drug 
6. 
Adverse events evaluation 
8. 
Concomitant drug products assessment 
11.4 
Follow-up Phone Call [Day 36 (±2)] 
1. 
Investigate any adverse events related to the drug. 
12. POPULATION CHARACTERISTICS 
❖ 
Adults ≥ 18 years and < 90 years. 
❖ 
Both sexes. 
❖ 
Clinical diagnosis of pterygium grade I to III (temporary and/or nasal). 
❖ 
Enrollment duration of 6 months. 


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❖ Enrollment potential: once the research centers are opened, it is estimated that during the 
first month, inclusion will cover 30% of the size of the total sample. 
12.1 Inclusion Criteria 
❖ 
Age ≥18 and <90 years 
❖ 
Both sexes 
❖ 
Clinical diagnosis of pterygium grade I to III (temporal and/or nasal). According to the 
classification proposed by Johnston.9 (See attachment) 
❖ 
Availability to attend check-ups when indicated. 
 
12.2 Exclusion Criteria 
12.2.1 General Criteria: 
1. 
Subjects with topical or systemic medication that interferes significantly with the study results, 
such as topical immunomodulators, AINEs, antihistamines, corticosteroids, artificial tears with 
preservative, vasoconstrictors, etc. (see list of prohibited drug products). 
2. Subjects (female) with an active sex life that do not use a hormonal contraceptive method, 
intrauterine device or bilateral tubal occlusion. 
3. Female subjects that are pregnant or lactating.  
4. Female subjects that tested positive in a urine base pregnancy test.  
5. Positive for addiction* (verbal interview). 
6. Subjects that have participated in any research clinical study in the last 40 days.  
7. Legally or mentally incapacitated subjects unable to give their informed consent for their 
participation in this study.   
8. Subjects that cannot keep appointments or follow through with all the protocol requirements.  
*Definition: routine consumption of one or several psychoactive substances, till the point where the 
consumer (known as addict) periodically intoxicates themselves or does so in a constant manner, 


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shows a compulsive desire of using the preferred substance (or the substances), suffers an 
enormous difficulty to interrupt voluntarily or modify the consumption of the substance and seems 
determined to obtain it at any cost. –OMS definition*. 
** Addiction explanatory note: in the case of socially accepted drugs like tobacco and alcohol, their 
repetitive or continuous use is considered as addiction as well. In case of it being occasional (less 
than once per week) it must be completely suspended during a month prior to the study and during 
the study. In the case of ex-smokers (with more than one year without smoking) they shall not use 
substitutes like nicotine patches nor electronic cigarettes. In the case that there was another 
condition please consult the scientific committee of Laboratorios Sophia S.A. de C.V. to analyze 
each case in particular.  
12.2.2 Exclusion criteria related to ophthalmologic conditions: 
Grade IV pterygium. According to the classification proposed by Jonhston9. (See addendum) 
Dellen of the cornea. 
Ocular surface neoplasia  
Symblepharon. 
Any type of corneal ulcers  
Ocular surface disorders that result in scarring. 
Metaplastic lesions in the ocular surface or adnexa. 
History of autoimmune diseases that potentially can present ocular manifestations, like: rheumatoid 
arthritis, juvenile rheumatoid arthritis, Sjörgen syndrome, seronegative spondyloarthropathies, 
Systemic lupus erythematosus, multiple sclerosis, arthritis of giant cells, Graves’ disease, among 
others.  
Infectious diseases  
 
Ophthalmologic diseases that can potentially require treatment in the following 3 months.   


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Ocular surgical procedures (in the last 3 months) 
Diseases in the previous segment that require treatment or endanger the visual prognosis (posterior 
uveitis, diabetic retinopathy, macular degeneration, etc.) 
History of penetrating corneal transplantation. 
History of scarring inflammatory diseases such as Steven-Johnson syndrome, pemphigus etc.  
History of ocular allergic reaction and/or adnexa. 
 
12.2.3 Elimination criteria of the subject included in the study: 
 1. Corneal damage clinically perceptible or evidenced in the staining of the surface (lissamine green 
and fluorescence) for example: 
(a) Corneal de-epithelisation grade V (according to the Oxford scale)  
(b) Corneal Melting. 
(c) Corneal Dellen. 
2. Added ocular surface diseases that require a treatment different to Zebesten ® or added 
treatments that are indicated for the new diagnostic.  
3 Opacities in ocular transparent mediums (cornea, clear, vitreous body) that prevents the 
assessment of the anterior chamber or the following segment.  
4. The subject’s own decision.  
5. Unable to keep the follow-up appointments. 
6. Added not authorized treatment or self-medicated 
7. Herbal treatments that affect the course of the disease or that produce other complications not 
related to the disease.   
8. Systematic diseases that require immunomodulatory treatment or biologics that affect each line of 
the inflammatory cascade.   


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9. Retinal diseases secondary to chronic-degenerative diseases that require treatment to preserve 
the function and/or anatomy.  
10. Inflammatory retinal diseases  
11. Installation of uveitic picture in any ocular uveal level. 
12. Uveitic picture that mean an ophthalmologic emergency that requires immediate treatment.  
13. Ocular diseases that require surgical treatment. 
14. Ocular diseases that require intravitreal injections.  
 
12.3 PROHIBITED DRUG PRODUCTS 
For purposes of this protocol, all drug products belonging to the groups listed in the 12.3.1 table are 
considered as prohibited, the drug product in the prototype column are examples of the most 
representative drug product of the group, however, they are not the only ones that are prohibited.  
  
Table 12.3.1  
Drug product group 
Prototype 
Route of 
administration 
Resting period 
Non-steroidal anti-
inflammatory  drugs 
Ketorolac 
Diclofenac 
Topical 
8 weeks 
Steroidal anti-
inflammatory  drugs 
Dexamethasone, 
Prednisolone, 
Fluorometholone. 
Topical and systematic 
8 weeks 
prostaglandin analogue 
Latanoprost, 
Travaprost 
Topical 
12 weeks 
 
 


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Immune modulators 
Ciclosporin 
Topical 
12 months 
Vasoconstrictive 
Naphazoline 
Topical and systematic 
2 weeks 
Alpha 2 agonists 
Brimonidine 
Topical 
4 weeks 
Beta blockers 
Timolol, betaxolol 
Topical 
4 weeks 
Carbonic anhydrase: 
Dorozlamide 
brinzolamide 
Topical 
4 weeks 
Lubricants with 
conservatives 
Hypromellose, 
Propylene glycol 
Topical 
2 weeks 
 
12.4 SAMPLE SIZE CALCULATION 
Sample size protocol SOPH155-0415/IV 
According to the objectives of the study to evaluate the Zebesten ® effect in subjects with primary 
pterygum, the variables of primary outcome stipulated in the design were:  
• 
Conjunctival hyperemia 
• 
TRL 
Both variables are considered, using similar literature, to perform the calculation of the sample size to 
meet with the study objectives.  
 
Conjunctival hyperemia 
The sample size was calculated according to the formula for the continuous quantitative variables: 
𝑛= 2 (𝑍∝ −𝑍1 − 𝛽)(𝛿)
𝑑2
 
With a statistical trust of 95% that corresponds to the type I error, and is the same as 1.96, with a potency 
of 80% that corresponds to the type II error, and equals to 0.84. It is considered as a standard deviation 
for the increase of 0.4 degrees of severity1 in the scale of conjunctival hyperemia after a pterygium 
surgery, with an expected difference of at least 2.9 degrees of severity. 


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Based on the previous the result was 69 cases (eyes) per group, which was incremented 20% by 
consideration of the losses (14 subjects), with a total of 83 cases per group, with a total population of 
study of 166 eyes to treat.8 
 
Tear film breakup time  
The sample size was calculated according to the formula for continuous quantitative variables: 
𝑛= 2 (𝑍∝ −𝑍1 − 𝛽)(𝛿)
𝑑2
 
With a statistical trust of 95% that corresponds to the type I error, and is the same as 1.96, with a potency 
of 80% that corresponds to the type II error, and equals to 0.84. It’s considered as a standard deviation 
for the increase of 1.47 seconds 2 in the tear film breakup time posterior to 60 days of ciclosporin 
application A, with an expected difference of at least 10.2 seconds.  
Based on the previous the result was of 120 cases per group, which was incremented 20% per 
consideration to the losses (24 cases), with a total of 144 cases per group, with a total population of 
study of 288 eyes to treat.    
 
13. STUDY VARIABLES  
 
Independent variables 
• 
Pharmacological intervention  
o Zebesten® + Sodium hyaluronate 4 mg/ml 
o Placebo (vehicle + Sodium hyaluronate 4 mg/ml) 
 
Dependent variable 
• 
Primary outcome variable  
o Conjunctival hyperemia 
o  Tear film breakup time 
o  Adverse events 


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• 
Secondary outcome variable  
o burning 
o Foreign body sensation  
o Photophobia  
o Questionnaire score OSDI  
o Fluorescein stain  
o Visual capacity 
o Intraocular pressure  
Intervening variables 
• 
Work activity with sun exposure without ocular protection.  
• 
Areas with air conditioner. 
• 
Use of ocular devises that modify the lubrication.  
 
13.1 Tolerability study 
The security variables of the use of Zebesten ® will be evaluated in the appointed visits in the 
chronogram, by means of the following parameters.  
 
1. burning 
2. Foreign body sensation 
3. Photophobia 
 
13.2 Security evaluation 
The security variables of the use of Zebesten ® will be evaluated in the appointed visits in the 
chronogram, by means of the following parameters.  
1. Tear film breakup time 
2. Visual capacity 
3. Intraocular pressure 
4. Epithelial defects  
5. Adverse events. 


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13.3 Efficacy assessment  
The efficacy variables of Zebesten® use will be evaluated in the appointed visits in the chronogram, by 
means of the following parameters: 
1.  Conjunctival hyperemia 
2. OSDI score  
 
Table of scales and variables measurement method 
Variable 
Unit 
Symbol 
Type 
Measurement 
method 
Normal value 
Age 
Years 
-- 
Continuous 
Calculated as 
of the date of 
birth  
NA 
Gender 
Female 
Male 
F/M 
Nominal  
Direct 
questioning  
NA 
Pterygum  
Grade 0 
Grade I 
Grade II 
Grade III 
Grade IV 
-- 
Ordinal  
Direct 
observation  
Grade 0  
Adverse 
events 
Number of 
cases 
N 
Discreet 
Counting  
NA 
Intraocular 
pressure 
Mercury 
millimeters 
MmHg 
Continuous 
Goldman 
applanation 
tonometry 
11-21 
Visual 
capacity  
Fraction 
Snellen  
Nominal  
Card 
 
Tear film 
breakup time 
Seconds 
s 
Continuous  
Direct 
counting 
> 10 
OSDI 
questionnaire  
Points 
-- 
Discreet  
Questionnaire  
 
epithelial 
defects 
Grade I 
Grade II 
Grade III 
Grace IV 
Grade V 
-- 
Discreet 
Direct 
observation 
with 
fluorescent 
staining and 
lissamine 
green 
Oxford scale  


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Signs and ophthalmologic symptoms  
conjunctival 
hyperemia 
Very mild 
Mild 
Moderate 
Severe 
-- 
Ordinal  
Direct 
observation. 
Efron 
classification.  
Normal 
burning 
Present  
absent 
-- 
Nominal 
Direct 
questioning  
Absent 
Foreign body 
sensation  
Present  
Absent 
-- 
Nominal 
Direct 
questioning 
Absent 
Photophobia  
Present  
Absent 
-- 
Nominal 
Direct 
questioning 
Absent 
Prior segment  
Normal  
Abnormal  
-- 
Nominal 
Direct 
observation  
Normal 
 
14. PROPOSED STATISTICAL ANALYSIS  
The statistical analysis will be performed by a researcher blinded to the intervention groups.   
The continuous quantitative variables will be expressed and presented via measures of central 
tendencies and of dispersion (media, standard deviation and ranges). 
 The nominal qualitative variables and ordinals will be presented via frequencies and proportions.  
The Kolmogorov-Smirnov test will be performed in order to know the normal distribution or not of the 
obtained results in each study group. Also, the Levene test will be performed in order to know if the 
variables are the same or different.  
 
Assuming a normal distribution of the data, the intra-group differences will be determined via the t test 
for paired samples, in the case of the quantitative variables. For the quantitative variables the χ2 test (chi 
squared) will be used and in case that the expected frequencies are less than 5 the exact Fisher test will 
be used.  
The differences among the groups will be analyzed via the t test in case of quantitative variables. For the 
quantitative variables tables of contingency 2x2 will be made and the differences will be calculated via χ2 
(chi squared) with Yates correction in case that the expected frequencies are less than 5 the exact Fisher 
test will be used). 


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The level of significance will be alpha of 0.05 or less.  
A final statistical analysis will be included to all the subjects that complete 3 visits in the chronogram of 
activities.  
 
15. Results report  
The results obtained during the development of the investigation’s protocol will be the responsibility of 
the sponsor, who is under obligation of reporting them to the pertinent authorities. Plus each one of the 
participating researchers will receive a results report.  
The objective is to achieve the publication of the study on an international magazine with the objective of 
disseminate the scientific knowledge obtained.  
 
16. IDENTIFICATION PROCEDURES, SECURITY AND THERAPEUTIC ADHERENCE OF THE 
INVESTIGATION SUBJECTS  
16.1 Recruitment  
 The subject will be recruited in the ophthalmologic consultation of the participating research centers, in 
which a goal of scrutinized and randomized subjects are contemplated according to their scrutiny and 
recruitment capacity.  
 
16.2 Subject identification  
All the subject of the study will be identified through a number and their initials.  


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In the scrutiny stage a number will be assigned to the participant in a consecutive manner, employing 3 
digits and once included the subject will be assigned with the subject’s number (CFR number) which will 
be conformed of 3 digits of the molecule, 2 of the center’s number, and 3 digits of the consecutive number 
assigned at the research center.  
 
For example: 
 
155/01/001 (molecule number/ center’s number/ subject’s number at the 
center). 
 
 16.3 Subject discontinuation  
 The following are the reasons why a subject may leave the study prematurely: 
 
Subject’s decision. The subject that desires to leave the study for any reason is allowed to do so at any 
moment, but they must inform the researcher. In all cases, the researcher musty try to establish contact 
with the subject as soon as possible for a final evaluation with the purpose of: 
Documenting the subject’s decision in clinical notes, obtaining the motive/s of the departure and writing 
them down in the exit format of the CRF, evaluate the clinical state of the subject, take timely therapeutic 
measures if required: handling of an adverse event or concomitant illness.  
 
Researcher’s decision. Especially if adverse events occur and the researcher considers that this can risk 
the subject’s health, the indications in the adverse events section must be followed, or if an important 
disease occurs that needs medical prescription incompatible with the objective of the study. It will be 
reported in the clinical notes and a reporting format of the serious adverse events will be filled and the 
Ethics committee will be informed, clinical monitor and pharmacovigilance of Laboratorios Sophia. 


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An erroneous inclusion according to the protocol. The decision on whether the subject will remain in the 
study will be made conjunctly by the researcher and the sponsor.  
Other motives (insufficient response, need of another treatment) 
In all the cases, the available data will be kept for the security analysis (intention-to-treat population)  
 
16.4 Research products recall  
In case of research products recall (decided by the competent authorities of the sponsor) the sponsor will 
immediately inform the researcher.  
 
The researcher in collaboration with the sponsor’s representatives (clinical monitor) must with haste: 
❖ Interrupt the supply of the affected research products to the subjects.  
❖ Inform the involved subjects that they must stop the application of these research products 
immediately and take them to the center.  
❖ The monitor will organize the return in order to carry on with the destruction of the study drug, 
both the used as the not used to Laboratorios Sopihia S.A. de C.V., according to procedures.  
16.5 Adherence to the treatment 
Compliance of the administration of the study drugs by the subjects will be evaluated at the facilities of 
Laboratorios Sophia once the dropper bottle of each subject are returned by the researcher. Each bottle 
with be weighed in an analytical balance and the difference with respect to the initial weight of the bottle; 
all values above 70% will be considered as adequate adherence to the treatment with respect to the 
posology described in the present protocol for Zebesten® and the buyer. It will also be evaluated in the 
research center by the researching physician  
 


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In the event that the adherence to the study drug is under 70 %, it will be considered that the results 
obtained from the participant are analyzed by intention to treat, see the section for the statistical 
analysis.  
17. ADVERSE EVENTS 
17.1 Adverse event, definition and communication 
17.1.1 Overview  
 
Adverse events (EA) may appear during the study, these may be associated or not with the study drug. 
If at any time any of the subjects may present any adverse event classified as serious that is derived from 
the drug’s administration, the guidelines of the Official Mexican Norm 220 SSA1 2012 Installation and 
Operation of the Pharmacovigilance shall apply. The administration of the drug will be interrupted and 
the administration of an alternative therapy will be prescribed, as per the judgement of the main 
researcher. 
An adverse event is any medical occurrence in a subject or subjects of a medical research, to whom a 
pharmaceutical product was administered and that does not necessarily have a causal relation with this 
treatment. Therefore. An EA can be any unfavorable and unintended sign (including an abnormal 
laboratory finding), symptom or disease temporally associated with the use of a medicinal (research) 
product, whether it is or not related to this. 
The researcher must report the adverse events occurred during the study from the moment in which the 
subject signs the informed consent to be included in the clinical trial until the conclusion of the last 
procedure described in the approved version of the study protocol.   
 


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In all cases the etiology must be identified as far as possible and the sponsor must be notified. An 
“unexpected adverse event” is understood as any EA that is not identified in the nature, severity or 
frequency in the Researcher’s Manual or in the information of the risks described in this protocol. 
17.2 Classification and severity  
17.2.1 Classification  
The adverse events are divided in two categories according to their importance: “serious” and “not 
serious”, this classification determines the procedures that must be used to report and document the 
adverse event. 
A serious adverse event is that which: 
❖ Threatens the life or causes the death of the subject. 
❖ Makes it necessary to hospitalize or prolong the hospital stay 
❖ It is the cause for persistent or meaningful incapacity  
❖ It is the cause of alterations or malformations in the newly born 
A non-serious adverse event is that which does not comply with any of the previous criteria. 
17.2.2 Severity of the Adverse Events 
The grade of severity of the adverse events must be evaluated by the researcher in charge or the person 
delegated for such task, as per the intensity of the clinical manifestations. 
❖ Mild intensity is considered for those adverse events that do not interfere with everyday 
activities; these that may or may not require the suspension of the drug’s administration. 
❖ Moderate intensity is considered for those adverse events that interfere with everyday activities; 
(may provoke sick leave at work or school), but do not directly threaten the subject’s life, they 
may or not require the suspension of the drug’s administration. 


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❖ Severe intensity is considered for those adverse events that prevent the subject from performing 
their everyday activities. 
 
17.3 Report of non-serious adverse events  
The reports of adverse events classified as “non-serious” must be reported in the specific section of the 
case report form of the clinical protocol, as per what is indicated in the guide for the filling of the case 
report form. 
During each monitoring visit, the correct filling of the non-serious adverse event report in the specific 
section of the case report form will be verified. It must be assured that before base closure of the study 
the non-serious adverse events are completed with a final resolution of adverse events and the totality 
of the information requested in the form of case report. 
17.4 Characteristics of the report of serious adverse events  
The researcher in charge and/ or person delegated for such task must report every adverse event, 
serious or non-serious that are presented during the development of the study, providing a diagnosis 
(name) to the condition(s) the subject presents. 
It must be assured that the adverse events are correctly reported, grouping the signs and symptoms of 
the subject in clinical diagnosis.  
In those cases in which the presence of several adverse events at once, and in which there is evidence 
that none of them correspond to the same pathological entity, each of the adverse events must be 
separately reported. For those surgical interventions programmed, the clinical diagnosis that caused the 
surgery must be reported instead of only the surgical event as such. For example: cholecystectomy 
(surgical event -NOT reported as adverse event); acute cholecystitis (Clinical diagnosis -reported as 
adverse event). 
 


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The reports of adverse events must indicate the date/ time of start, date/ time of conclusion, evolution 
and measures taken, as per the following: 
❖ Solved  
❖ Solved with aftereffects  
❖ Being solved  
❖ Unresolved 
❖ Unknown 
The information on the adverse events must be updated indicating the date of the kind of final solution of 
the adverse event or indicate as “being solved” for those cases in which the adverse event is still active. 
17.5 Causality  
The main researcher based on physical exploration, signs and symptoms referred by the study subject 
must indicate, based on a clinical judgement, if there is or not causal relation between the study drugs 
and the adverse events presented by the subject.  
The way to classify the causal relation to the study drug will be the following: 
17.5.1 Definitely related:  
There is certainty that the adverse event is related with the product being researched. 
17.5.2 Probably related:  
There is a high probability that the adverse event is related to the product being researched. 
 


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17.5.3 Possibly related:  
There is a probability that the product being researched is the cause of the adverse event, but other 
causes cannot be discarded. 
17.5.4 Not related:  
There is evidence that the adverse event is related to another cause different from the product being 
researched. 
17.5.5 Unknown:  
Adverse event for which causal evaluations were not possible. 
The relation between the study drug product with the adverse events is stablished as per the following 
criteria: 
❖ Previous experience with the drug. 
❖ Knowledge of the adverse reactions with its use. 
❖ Explanations for the adverse reactions. 
❖ Use of other drug products, concomitant diseases, non-pharmacological therapies, diagnostic 
tests or other procedures or, in its case, confusion patterns.  
❖ Time passed between the administration of the drug and the adverse event. 
❖ Concentrations of the drug. 
❖ Effects with re-exposition to the drug. 
 
17.5.6 Reporte de los Eventos Adversos Serios 
An active search of EAs must be performed using the spontaneous reports of the subject and physical 
explorations and interviews performed by the researcher during the visits. 
If the EA ends up interrupting the study, the researcher must complete the FCR, in the section 
corresponding to Termination of the study, and specify if the event is serious or not. 
 


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A form of serious adverse events must be completed by the main researcher or the physician in charge 
and sent to the sponsor within the 24 hours following the notification; even if not all the required 
information is yet available at the moment. All the information gathered afterwards must be sent 
immediately once it is available. The researcher must provide an adequate and complete follow-up of the 
EAs. At any time they must provide an updated report of the EAs and report in writing when there is a 
final result for it. 
In the same manner, all the EAs must be reported to the Committees of Ethics in Research, as well as 
the Regulatory authorities. 
All the EAs as per the previous definitions and independently of the treatment or relationship with the 
study drug must be notified as soon as the event is known. 
The researcher must notify the sponsor of the event sending the form “Serious Adverse Event Report” 
(“first notice”) within the 24 hours after knowing about it via email with all the available information on the 
serious adverse event to the department of Pharmacovigilance of Laboratorios Sophia, S.A. de C.V as 
well as attaching a copy by email to the monitor in charge of the center. 
17.5.7 Pharmacovigilance responsible: 
Dr. Alicia Paulina Melgarejo Martin Amaya. 
Email: farmacovigilancia@sophia.com.mx 
Laboratorios Sophia, S.A. de C.V. 
Av. Paseo del Norte, 5255 
Col. Guadalajara Technology Park.  
C.P. 45010 Zapopan, Jalisco. Mexico.  
Tel. 01 33 30 01 42 83 (Direct)  
01 33 3001 4200 Ext. 1029 
Mobile. 044 33 1043 1474 
Direct assistance line, toll-free number: 01 800 7102 254 
 


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Non-serious adverse events (mild and moderate) are reported to the regulatory authority by the end of 
the study (after the report or in the report) and the serious adverse events immediately. 
18. MONITORING AND AUDITING PROCEDURES. 
Each research center as well as each researcher will have a clinical monitor assigned and authorized to 
revise, monitor and procure the information obtained from the study subjects. 
Each research center will be submitted to an evaluation previous to its inclusion to grade its human, 
technological and logistic resources and determine their capacity to perform the study. 
Periodic monitoring visits will be performed for the revision of the files and the emptying of the information 
required in the case report forms (CRF), this will be done physically in paper within the clinical file and in 
electronic format in the forms located in the online electronic information portal, to which the researchers 
and coordinators will have access to perform such procedure within the following 72 hours to the date of 
the visit by the subject, so as to maintain the fidelity of the data obtained and implement more timely 
actions. 
The audits will be performed with an external supplier, by which the visit will be previously notified to the 
research center. The result of the audit will be evaluated by the Department of Clinical Operations of 
Laboratorios Sophia S.A. de C.V., together with the auditors and the main researcher. The findings will 
be described in a report of Corrective and preventive actions (CAPA) that will be filed in the general folder 
of the clinical study of the Department. All the findings detected in the audit will have a proper follow-up 
until their conclusion. 
 


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Audit - Inspection - Verification 
The researcher must be informed that the competent authorities can also perform an inspection or 
verification of the facilities of the sponsor and/or the center or research centers. 
The sponsor will inform the pertinent researchers immediately after receiving the notification of an 
inspection to the study centers. In the same manner, the researcher will inform the sponsor of any 
pending inspection.  
The researcher will allow the representatives of the competent authorities and the people responsible of 
the audit: 
o Inspect the site, the facilities and the material used for the study, 
o Meet with all the members of their team that partake in the study, 
o Have direct access to the study data and the source documents, 
o Consult all the documents related with the study. 
If there are computer medical files, the researcher commits to provide all the source documents and 
printings of the medical files of the participants, and if the computer system allows it, the registration of 
the changes performed during the study. 
19. BIOSAFETY CONSIDERATIONS 
NO BIOSAFETY IMPLICATIONS 
This protocol, titled: “Efficacy and safety of Zebesten® (bromfenac 0.09 %) on the inflammation of the 
conjunctival surface on subjects with pterygium grade I- III vs placebo” with number: SOPH155-0415/I 
HAS NO BIOSAFETY IMPLICATIONS, since NO infectious - contagious biological material, pathogen  
 


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strains of bacteria or parasites, any kind of virus, radioactive material of any kind, animals or cells or 
vegetables modified genetically, toxic, dangerous o explosive substances, any other kind of material that 
may risk the health of physical integrity of the personnel of the center of research or the subjects of the 
study or the environment will be used. As well, we declare that in this project no cell, tissue or organs 
transplant procedures nor cellular therapy will be performed, no laboratory, farm or wild animals will be 
used. 
20. ATTACHMENTS 
Classification of pterygium 
Grade 0 
Posterior to the limbus, pinguecula 
Grade I 
The tissue involves the limbus 
Grade II 
The tissue is only above the limbus 
Grade III 
The tissue is between the limbus and the pupil’s margin 
Grade IV 
The tissue overtakes the pupil’s margin 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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21. REFERENCES 
 
 


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22. APPENDICES 
 
Appedix 1: Declaration of Helsinki of the World Medical Association 
DECLARATION OF HELSINKI OF THE WORLD MEDICAL ASSOCIATION 
Ethical Principles for Medical Research in Humans 
 
Adopted by the 18th General Assembly of the World Medical Association, Helsinki, Finland, June 1964, 
and modified by the: 
 
29th General Assembly of the World Medical Association, Tokyo, Japan, October 1975 
35th General Assembly of the World Medical Association, Venice, Italy, October 1983 
41st General Assembly of the World Medical Association, Hong Kong, September 1989 
48th General Assembly of the World Medical Association, Somerset West, South Africa, October 1996 
52nd General Assembly of the World Medical Association, Edinburgh, Scotland, October 2000 
53rd General Assembly of the World Medical Association, Washington, 2002 (added clarifying note in 
paragraph 29) 
55th General Assembly of the World Medical Association, Tokyo, 2004 (added clarifying note in 
paragraph 30) 
59th General Assembly of the World Medical Association, Seoul, October 2008 
64th General Assembly of the World Medical Association, Fortaleza, Brazil, October 2013 
 
Introduction 
1. The World Medical Association (AMM) has promulgated the Declaration of Helsinki as a proposal of 
ethical principles for medical research in humans, including research on human material and of 
identifiable information.  
 
The Declaration must be considered in its entirety and a paragraph must be applied taking into account 
all other pertinent paragraphs.  
 
2. As per the mandate of the AMM, the Declaration is mainly intended for physicians. The AMM urges 
others involved in medical research in humans to adopt these principles. 
 
 


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General principles 
 
3. The Declaration of Geneva of the World Medical Association binds physicians to “attentively preserve 
above all the health of their subject” and the International Code of Medical Ethics states that “physicians 
must consider what is best for the subject when providing healthcare”. 
 
4. The physician’s duty is to promote and preserve the health, well-being, and rights of the subjects, 
including those who participate in medical research. The knowledge and awareness of the physician 
must be dedicated to complying with said duty.  
 
5. The progress of medicine is based on research that, ultimately, must include studies in humans.  
6. The main objective of medical research in humans is to understand the causes, evolution, and effects 
of illnesses and improve the preventive, diagnostic, and therapeutic interventions (methods, procedures, 
and treatments). Also, the best tested medical interventions must be continuously evaluated through 
research to ensure their safety, efficacy, efficiency, accessibility and quality.  
7. Medical research is subject to ethical standards that promote and ensure respect to all human beings 
and to protect their health and personal rights.  
8. Although the main objective of medical research is to generate new knowledge, this objective must 
never be prioritized over the rights and interests of persons participating in the research.  
 
9. In medical research, the physician’s duty is to protect the life, health, dignity, right to self-determination, 
intimacy, and confidentiality of personal information of the persons participating in the research. The 
responsibility to protect the persons taking part in the research must always be in the hands of a physician 
or another healthcare professional and never in the hands of the research participants, even after having 
granted their consent.  
 
10. Physicians must consider ethical, legal, and judicial norms and standards for research in humans in 
their own countries, as well as the current international norms and standards. It must be ensured that a 
national or international ethical, legal, or judicial requirement never reduces or eliminates means of 
protection of the persons participating in the research established in this Declaration.  
 
11. Medical research must be carried out in a way that reduces the possible damage to the environment 
to the minimum level.  
 


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12. Medical research in humans must be carried out solely by persons who have the appropriate 
education, knowledge, and scientific and ethical qualifications. Research in healthy subjects or volunteers 
requires the supervision of a competent and appropriately qualified physician or other healthcare 
professional. 
 
13. Groups that are underrepresented in medical research must have an appropriate access to participate 
in the research.  
 
14. Physicians who combine medical research with medical attention must involve their subjects in the 
research only as far as this is justified by a preventive, diagnostic, or therapeutic potential value and if 
the physician has adequate justification for believing that their participation in the study will not adversely 
affect the health of the subjects participating in the research.  
15. Appropriate compensation and treatment must be ensured for persons harmed during their 
participation in the research.  
  
Risks, Costs and Benefits 
16. In the medical practice and in medical research, most medical interventions entail some costs and 
risks.  
Medical research in humans should only be carried out when the importance of its objective is higher 
than the risks and costs for the person participating in the research.  
 
17. All medical research in humans must follow a careful comparison of the risks and costs for persons 
and groups participating in the research, compared to the foreseeable benefits to them and other persons 
or groups affected by the disease under investigation.  
 
Measures must be implemented to reduce the risks to the minimum level. Risks must be monitored, 
assessed, and documented continuously by the researcher.  
 
18. Physicians must not involve themselves in research studies in humans unless they are sure that the 
risks have been adequately assessed and that it is possible to confront them in a satisfactory manner.  
 
When the entailed risks are more significant than the expected benefits, or if there are conclusive tests 
of definitive results, physicians must assess whether to continue, modify, or immediately suspend the 
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Vulnerable Groups and Persons 
19. Some groups and persons subjected to the research are particularly vulnerable and may have a 
higher possibility to suffer abuse or additional harm. 
All vulnerable groups and persons must receive dedicated protection. 
20. Medical research in a vulnerable group is only justified if the research responds to the health needs 
or priorities of this group and the research cannot be carried out in a non-vulnerable group. Additionally, 
this group may benefit from the knowledge, practices, or medical interventions derived from the 
investigation.  
Scientific requirements and research protocols 
21. Medical research in humans must be made up of generally accepted scientific principles and must 
be supported in a profound knowledge of scientific literature, other pertinent sources of information, as 
well as correctly performed laboratory experiments and animals, as the case may be. Care must also be 
given to the well-being of the animals used in the experiments.  
 
22. The project and method of all studies in humans must be clearly described and justified in a research 
protocol.  
 
The protocol must always make reference to the ethical considerations that may apply and must indicate 
the manner in which the principles indicated in this Declaration have been taken into account. The 
protocol must include information regarding financing, sponsors, institutional affiliations, possible conflicts 
of interest, and incentives for the persons in the study and information on provisions for treating or 
compensating persons who suffer harm as a consequence of their participation in the research.  
 
In clinical trials, the protocol must also describe the appropriate arrangements for the post-trial provisions.  
 
Research Ethics Committee 
23. The research protocol must be sent, for consideration, comment, advice and approval to the pertinent 
ethics committee before the start of the study. This committee must be transparent in their workings, 
must be independent from the researcher or of any other type of undue influence and must be properly 
qualified. The committee must consider the current laws and guidelines of the country where the research 
study is taking place, as well as the current international standards, but it must be ensured that the 
protection of the participants of the study as described in this Declaration is not reduced or eliminated.  


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The committee has the right to control the ongoing trials. The researcher is obligated to provide control 
information to the committee, especially any serious adverse event. No modifications to the protocol may 
be done without the consideration and approval of the committee. After the study is complete, the 
researcher must present a final report to the committee with a summary of the results and conclusions of 
the study.  
 
Privacy and Confidentiality  
24. All possible precautions must be taken in order to protect the privacy of the individuals that participate 
in the research as well as the confidentiality of their personal information.  
 
Informed Consent 
25. The participation of individuals capable of giving their informed consent in the medical research must 
be voluntary. Although it may be appropriate to consult with the families or community leaders, no person 
able to give their informed consent may be included in the study without having accepted personally and 
freely.  
 
26. In medical research involving humans able to give their informed consent, each potential individual 
must receive adequate information about the objectives, methods, financial sources, possible conflict of 
interests, institutional affiliations of the researcher, expected benefits, foreseeable risks and discomforts 
derived from the experiment, post-study provisions and any other aspect pertinent to the research. The 
candidate must be informed of the right to participate or not in the research and of withdrawing their 
consent at any moment without punishment. Special attention must be paid to the specific needs of 
information of each potential individual, as well as the methods employed to deliver the information.  
After ensuring that the individual has understood the information, the physician or another properly 
qualified person must then request, preferably through writing, the informed and voluntary consent of the 
person. If the consent cannot be granted via granting, the process to achieve it must be formally 
documented and witnessed. 
All the participant in the medical research must have the option of being informed about the general 
results of the study.  
27. When asking for the informed consent for participating in the research, the physician must pay special 
attention when the potential individual is linked with him by a dependent relationship or if they consent 
under pressure. In a situation such as this, the informed consent must be lost by an adequately qualified 
person that has nothing no relation to that situation.  


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28. When the candidate is unable to give informed consent, the physician must ask for the informed 
consent of their legal representative. These individuals must not be included in the research study if there 
is no possible benefit to them, unless that the study has as an objective to promote the health of the 
represented group for the potential individual and this investigation cannot be performed in individuals 
able to give their informed consent and the research entails just a minimal risk and cost.  
29. If a candidate that takes part in the research study who is deemed unable to grant their informed 
consent is able to grant their consent about participating in the research, the physician must be the one 
to ask for it, in addition to the consent of their legal representative. The refusal of the potential individual 
must be respected.  
30. Research on individuals without the physical or mental capacity to grant their consent, for example 
unconscious subjects, may be done only if the physical/mental condition that prevents the individual from 
granting their informed consent is a necessary characteristic of the group being research. In these 
circumstances, the physician must ask the informed consent of the legal representative. If the  
aforementioned representative is not available and if they research cannot be delayed, the study can 
take place without informed consent, as long as the specific reasons for including the individuals with a 
disease that does not allow them to grant informed consent have been stipulated in the research protocol 
and the study has been approved by a research ethics committee. The consent to remain in the research 
study must be obtained as soon as possible from the individual or from a legal representative.  
31. The physician must fully inform the subject of the aspects of the care that are related to the research. 
The refusal of the subject to participate in a research study or their decision of withdrawing must not 
negatively affect the physician-patient relationship.  
 
32. For medical research where identifiable human material or human data is used, such as research 
about the material or data contained in biobanks and similar repositories, the physician must request the 
informed consent for the collection, storage, and reuse. There might be an exceptional situation where it 
is impossible or impractical to obtain the consent for such research. In this situation, the research can 
only be done after being considered and approved by an investigational ethics committee.  
 
Placebo Use  
33. The possible benefits, risks, costs and effectiveness of any new intervention must be evaluated via 
their comparison with the best proven interventions, except for the following circumstances: 
When there is no proven intervention, the use of placebo, or any intervention, is acceptable; or  


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Where for compelling and scientifically sound methodological reasons it is necessary to determine the 
efficacy or safety of an intervention the use of any intervention less effective that the best proven one, 
the use of placebo, or no intervention.  
Subjects that receive any sort of medical intervention less effective that the best proven one, the placebo 
or no intervention, will not run additional risks of serious injury or irreversible damage as a consequence 
of not receiving the best proven intervention.  
Extreme care must be taken to avoid abusing this option.  
Post-trial Provisions  
34. In advance of a clinical trial, sponsors, researchers and host country governments should make  
available provisions for post-trial access for all participants who still need an intervention identified as 
beneficial in the trial. This information must also be disclosed to participants during the informed consent 
process 
Research Registration and Publication and Dissemination of Results 
35. Every research study involving human subjects must be registered in a publicly accessible database 
before recruitment of the first subject. 
36. Researchers, authors, sponsors, editors and publishers all have ethical obligations with regard to the 
publication and dissemination of the results of research. Researchers have a duty to make the results of 
their research on human subjects publicly available and are accountable for the completeness and 
accuracy of their reports. All parties should adhere to accepted guidelines for ethical reporting. Negative 
and inconclusive as well as positive results must be published or otherwise made publicly available. 
Sources of funding, institutional affiliations and conflicts of interest must be declared in the publication. 
Research reports that do not comply with the principles of this Declaration should not be accepted for 
publication. 
 
Unproven interventions in the clinical practice 
 
37. In the treatment of a patient, when proven interventions do not exist or have been ineffective, the 
physician, after seeking expert advice, with informed consent from the patient or a legally authorized 
representative, may use an unproven intervention if in the physician's judgement it offers hope of 
saving life, re-establishing health or alleviating suffering. Afterwards, these interventions should be 
made the object of research to evaluate its safety and efficacy. In all cases, new information should be 
recorded and, where appropriate, made publicly available. 


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Appendix 2. Good Clinical Practices 
 
Good Clinical Practices directives of the International Conference on Harmonization include 13 basic 
principles, which are based on the Declaration of Helsinki. These principles are as follows: 
 
1. The first principle indicates that clinical trials should be conducted in accordance with ethical 
principles that have their origin in the Declaration of Helsinki, and that are consistent with Good Clinical 
Practices and the applicable regulatory requirement(s). 
 
2. The second principle states that before a trial is initiated, foreseeable risks and inconveniences 
should be weighed against anticipated benefit for the individual trial subject and society. A trial should 
be initiated and continued only if the anticipated benefits justify the risks. 
 
3. The third principle of Good Clinical Practices indicate that the rights, safety and well-being of the trial 
subjects are the most important considerations and should prevail over interest of science and society. 
 
4. The fourth principle states that the information available before the trial about an investigational 
product should be adequate to support the proposed clinical trial. 
 
5. The fifth principle establishes that clinical trials should be scientifically sound, and described in clear, 
detailed protocol. The requirements of this clinical trial protocol are also described in the directive 
guidelines of Good Clinical Practices of ICH. 
 
6. The sixth principle indicates that the trial should be conducted in compliance with the protocol that 
has received prior Institutional Review Board or Independent Ethics Committee approval. This implies 
that a study can not be started until it has been approved by these institutions. 
 
7. The seventh principle states that the medical care given to, and medical decisions made on behalf of 
subjects should always be the responsibility of a qualified physician or, when appropriate, of a qualified 
dentist. The medical care responsible should always be qualified physicians. 
 
8. The eighth principle indicates that each individual involved in conducting a trial should be qualified by 
education, training, and experience to perform his or her respective task(s). Usually the sponsor is the 
responsible of ensuring that all the people involved in the performance of the trial are sufficiently trained 


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to carry it out, regarding their education and work experience, as well as their training. This evaluation 
is performed based on a previous trial, in which the sponsor meets and interviews the staff to ensure 
that they are adequately prepared to perform the trial. As part of this evaluation, the sponsor reviews 
the curriculums vitae (CV) of the staff involved in the trial. 
 
9. The ninth principle specified that freely given informed consent should be obtained from every 
research subject prior to the clinical trial and the participation of the subject. It is worth mentioning that 
the freely given informed consent must be ready before the trial and that the subjects that might 
participate should not start any exploration with selection purposes to participate in the trial before they 
have given their freely given informed consent. 
 
10. The tenth principle establishes that all clinical trial information should be recorded, handled, and 
stored in a way that allows its reporting, interpretation and verification. In other words, this principle 
states that the information provided to the sponsor must be able to be accurately reported, interpreted 
and verified. 
 
11. The eleventh principle indicates that the confidentiality of records that could identify subjects should 
be protected, respecting the privacy and confidentiality rules in accordance with the applicable 
regulatory requirement(s).  
 
12. The twelfth principle of Good Clinical Practices indicates that Investigational products should be 
manufactured, handled and stored in accordance with applicable Good Manufacturing Practice for 
industrial manufacturing. Good Manufacturing Practices have existed long before than Good Clinical 
Practices and many countries of the world have followed the Good Manufacturing Principles to 
manufacture and storage the investigational products. The investigational products used in a clinical 
trial should be used in accordance to the approved protocol. The protocol includes a section that 
contains the detailed instructions to manufacture, handle and store the investigational product in a 
clinical trial. 
 
13. The thirteenth principle indicates that systems with procedures that assure the quality of every 
aspect of the trial should be implemented. Generally, this is the sponsors' responsibility. 


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In summary, we have addressed the directives of Good Clinical Practices established by the 
International Conference on Harmonization, and described their historical development, as well as the 
current content. We have addressed the different sections of these rules and we have established that 
the glossary is useful as a common language for the clinical global research. We have also described 
the current version of the directives of Good Clinical Practices dated on January 17th, 1997, which 
include an addendum titled Guidelines notes from September 8th, 1997. 
 
Document consulted in the international normative instrument of the Bioethical National Commission at: 
http://www.conbioeticamexico.salud.gob.mx/interior/normatividad/normainter.html on March 12th, 2015. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


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Appendix 3. Ocular Surface Disease Index 
 
 
The OSDI (ocular surface disease index) test is a simple test created to establish the severity and 
classification of dry eye according to its symptomology. 
 
Answer the following questions by checking the box that best represents your answer: 
1. 
Have you experienced any of the following during the last week? 
 
 
FREQUENCY 
 
All of the 
time 
Most of the 
time  
Half of the 
time 
Some of the 
time 
None of the 
time 
Eyes that are sensitive to 
light? 
4 
3 
2 
1 
0 
Eyes that feel gritty? 
4 
3 
2 
1 
0 
Painful or sore eyes? 
4 
3 
2 
1 
0 
Blurred vision? 
4 
3 
2 
1 
0 
Poor vision? 
4 
3 
2 
1 
0 
Subtotal: 
 
 


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2. 
Have problems with your eyes limited you in performing any of the following during the last 
week? 
 
 
FREQUENCY 
 
All of the 
time 
Most of the 
time  
Half of the 
time 
Some of the 
time 
None of the 
time 
Reading? 
4 
3 
2 
1 
0 
Driving at night? 
4 
3 
2 
1 
0 
Working with a computer 
or bank machine (ATM)? 
4 
3 
2 
1 
0 
Watching TV? 
4 
3 
2 
1 
0 
Subtotal: 
 
 
3. 
Have your eyes felt uncomfortable in any of the following situations during the last week? 
 
 
FREQUENCY 
 
All of the 
time 
Most of the 
time  
Half of the 
time 
Some of the 
time 
None of the 
time 
Windy conditions? 
4 
3 
2 
1 
0 
Places or areas with low 
humidity (very dry)? 
4 
3 
2 
1 
0 
Areas that are air 
conditioned? 
4 
3 
2 
1 
0 
Subtotal: 
 
 
 
 
 
OSDI score: total points × 25/Nº of answered questions.