Compositions and methods for treating neural degeneration in glaucoma and related conditions

Abstract

Provided herein are compositions and formulations for alleviating problems associated with glaucomatous neural degeneration and related conditions in an eye comprising the administration of Trabodenoson (eye drops or SR) or MMP based therapeutic modalities. Administration of Trabodenoson results in removing the disease rate limiting root causes associated with neural lineage cell loss in glaucoma and related conditions.

Description

[0001] COMPOSITIONS AND METHODS FOR TREATING NEURAL DEGENERATION IN GLAUCOMA AND RELATED CONDITIONS

[0002] CROSS-REFERENCE TO RELATED APPLICATIONS

[0003] The present application is related to and claims priority under 35 U.S.C. § 119(e) to U.S. provisional patent application No. 63 / 592,471, entitled “The Methods and Compositions For Treating Rate Limit Root Causes for Glaucoma Neural Degeneration and Related Conditions,” filed October 24, 2023, and to U.S. provisional patent application No. 63 / 613,610, entitled " The Methods and Compositions For Treating Rate Limit Root Causes for Glaucoma Neural Degeneration and Related Conditions," filed December 21, 2023. The entire content of the aforementioned patent applications is incorporated herein by this reference.

[0004] FIELD OF THE INVENTION

[0005] The invention relates generally to pharmaceutical compositions, formulations, dosing regimens, and to methods for making and using the same for treating glaucoma and related conditions.

[0006] BACKGROUND OF THE INVENTION

[0007] Glaucoma is a multifactorial progressive neurodegenerative disease affecting both the front and the back of the eye. It is the leading cause of irreversible blindness worldwide, projected to affect 120 million people in 2040, among which about 30% will become legally blind, and there is currently no cure. Optic disc cupping and progressive retinal ganglion cell (RGC) loss are hallmarks of glaucoma. Vision loss starts from the periphery, with visual field (VF) defects and scotoma often observed. While early-stage glaucoma can be asymptomatic, when the disease advances toward end stage, patients can become legally blind with tunnel vision; however, such patients can still possess 20 / 20 best corrected visual acuity (BCVA). Intraocular pressure (IOP) has been identified as the only disease modifiable risk factor in glaucoma. The standard of care glaucoma treatment accordingly includes IOP management, e. ., via administration of IOP lowering medications, laser treatments and / or surgeries. The most potent IOP lowering drugs described to date are Latanoprost Bunod (administered at 0.024%) and netarsudil / latanoprost, each of which can reduce IOP by up to 9.1 mmHg (>30%), but only slow down disease progression at a certain degree. Minimally invasive glaucoma surgery (MIGS) can address poor glaucoma patient compliance (>60% non-compliance), while suppressing the magnitude of TOP fluctuations to some degree. MIGS can therefore be a slightly better treatment than previously described eye drop formulations, for certain glaucoma patients. However, a need exists for significantly improved compositions and methods for treating glaucoma.

[0008] BRIEF SUMMARY OF THE INVENTION

[0009] The current disclosure relates, at least in part, to the discovery of trabodenoson as a therapy capable, on its own, when properly formulated / dosed, of halting retinal ganglion cell (RGC) death and glaucoma disease progression. Trabodenoson-derived MMP / A1 AR therapeutics are identified herein as a curative solution and the most effective glaucoma neural protection drug, acting via IOP normalization (the rate limit disease control), which has the potential to stop or halt glaucoma disease progression (measured by visual field (VF) test and / or optic coherent tomography (OCT) on RGC neural fiber layer thickness) with the superiority advantage of treating and preventing the progressive vision deterioration or visual impairment observed in early and moderate glaucoma. Hence, early intervention can stop patients advancing toward the end stage of becoming legally blind. The discovery herein of MMP therapy more generally as a new therapeutic modality capable of removing the rate limiting root causes of RGC loss in glaucoma expands the scope of this discovery from single drug treatment (Trabodenoson) to a platform therapy based on MMP acting on TM rejuvenation in glaucoma. MMP treatment can be delivered in eye drops or via an intracam eral route using an adenosine Al receptor agonist, such as trabodenoson, Cyclohexyladenosine (CHA), Cyclopentyladensine (CPA), 2-chlorocyclopentyladenosine (CCPA), a trabodenoson biosimilar, a MMP protein, or a MMP -based genetic biofactory such as AAV-MMP3 gene delivery or AAV-MMP-14 / MMP2 gene delivery, optionally with a dosing on / off switch, or MMP -based RNA therapy with dosing control.

[0010] Importantly, the discovery of effective single agent treatments for this rate-limiting root cause of glaucoma solves the century-old dogma of neural protection in glaucoma - the holy grail is the MMP therapy through removing the ECM debris, restoring the tissue elasticity of an aged or diseased trabecular meshwork, and improving the pressure sensor functionality, which differs from all previous and ongoing efforts targeting on the back of the eye with no success thus far. The rate limiting root causes of the RGC loss in glaucoma starts from the pressure sensing cell loss or metabolic deficiency (like RPE loss in AMD) resulting in the pressure sensor (chief IOP regulator) functional irregularities, which is the direct cause of the TOP diurnal irregularities or IOP stresss, and / or elevation. By removing the upstream fundamental disease root cause (rate limits), it stops or blocks all the downstream, intertwined signaling pathways, pertinent to the RGC apoptotic or necrotic cell death. Clinical evidence (synthetic data) has demonstrated that MMP treatment is sufficient to block all the downstream cascades and stop the visual field deterioration in early to moderate glaucoma, once patients achieve a disease-free drug holiday or their lOPs have been normalized.

[0011] In certain aspects, the present disclosure relates to compositions and formulations comprising trabodenoson as the first cure for glaucoma capable of achieving neural protection through its MMP upregulation, which allows for normalization of the IOP irregularities in patients with glaucoma, to an extent not yet observed for any other glaucoma treatments previously examined. Unlike other neural protection approaches that have attempted to address causative risk factors directly at the (relatively inaccessible) back of the eyes via the intravitreal delivery route, robustly effective therapeutic doses of trabodenoson can be delivered by standard eye drops (e.g., 1.5% trabodenoson eye drops) and / or administered as a sustained release (SR) formulation and / or implanted, for dosing via the intracameral delivery route, while acting upon the trabecular meshwork (TM) and protecting / stabilizing retinal ganglion cells (RGCs), thereby halting glaucoma disease progression to greater extent and in a less invasive therapeutic mode of administration than any prior treatments that ultimately target the back of the eye.

[0012] Administration of trabodenoson has been herein identified to solve the three major problems confronted in identifying an effective glaucoma treatment that is capable of fully managing the disease: 1) trabodenoson (and potentially other, similarly acting matrix metalloproteinase (MMP) / adenosine Al receptor (Al AR) pathway activating therapeutics) can be used for successful treatment of subjects identified as poor responders and / or non-responders to other glaucoma therapies, particularly including any subjects having uncontrolled IOP; 2) trabodenoson is a MMP pathway therapeutic capable of dramatic protection / stabilization of RGCs, thereby acting as a drug which completely halts glaucoma neural degeneration and therefore disease progression (which is effectively the holy grail of glaucoma therapy research); and 3) use of trabodenoson as described herein can solve glaucoma patient poor compliance, as trabodenoson eye drop dosing can be flexible (BID or QD or once every another day) and missing a few doses or a few days of eye drops does not do any harm. In one aspect, the instant disclosure provides a method for reducing or preventing retinal ganglion cell (RGC) loss in an eye of a subject having or at risk of developing glaucoma, the method involving administering trabodenoson formulated as eye drops to the front of the eye of the subject, where the trabodenoson is administered at a dose of about 1.0% to about 3.0%, thereby reducing or preventing RGC loss in the eye of the subject. In another aspect, the instant disclosure provides a method for reducing or preventing retinal ganglion cell (RGC) loss in an eye of a subject having or at risk of developing glaucoma, the method involving administering trabodenoson formulated as eye drops to the front of the eye of the subject, where the trabodenoson is administered at a dose of about 1.0% to about 3.0% or about 3.0% to about 6%, or 1 ,2%-l .5%, optionally 1.5% (BID or QD), thereby reducing or preventing RGC loss in the eye of the subject

[0013] In one embodiment, the trabodenoson is administered to the front of the eye of the subject twice per day, once per day (e g., morning or evening), or by a flexible dosing regimen. Optionally, administration occurs without requiring compliance with a fixed regimen. Optionally, the subject has achieved a drug holiday treatment status.

[0014] Another aspect of the disclosure provides a method for reducing or preventing retinal ganglion cell (RGC) loss in an eye of a subject having or at risk of developing glaucoma, the method involving administering trabodenoson within a sustained release (SR) intraocular delivery system (e.g. biodegradable intracameral rod) to the front of the eye of the subject, where the trabodenoson is administered as a SR formulation that releases an equivalent concentration of trabodenoson into the aqueous humor as corresponding eye drops formulated at 1.0% to 3.0% trabodenoson, thereby reducing or preventing RGC loss in the eye of the subject.

[0015] In one embodiment, reducing or preventing RGC loss in the eye of the subject is measured by determining VF stability in the eye of the subject, as compared to an appropriate control. Optionally, the VF of the eye of the subject is stable at a six- to twelve-month endpoint and / or at a twelve- to 24-month endpoint (optionally at a twelve- to eighteen-month endpoint) of administering (or after administering) the trabodenoson to the front of the eye of the subject.

[0016] In another embodiment, reducing or preventing RGC loss in the eye of the subject is measured by detection of apoptotic retinal cells (DARC) and / or optical coherence tomography (OCT) detection of retinal nerve fiber layer (RNFL) thickness and / or other visual functional biomarkers and / or biomarkers of RGC numbers and / or biomarkers of RGC neuroprotection / stability status. In an additional embodiment, intraocular pressure (TOP) irregularity is normalized in the eye of the subject administered trabodenoson to sufficient extent (optionally for a period of time (e.g., 3-6 months by SR or 9-15 months by trabodenoson eye drops)) that the subject is removed from one or more other drugs. Optionally, the other drugs are one or more of: topical P-adrenergic antagonists (e.g., timolol, betaxolol), carbonic anhydrase inhibitors (e.g., dorzolamide, brinzolamide), cholinergics (e.g., pilocarpine), a-adrenergic agonists (e.g., brimonidine), prostaglandins (e.g., latanoprost, travoprost, lantanoprost bunod), Rho kinase inhibitors (e.g. Rhopressa, ROCKLATAN), omidenepag isopropyl, and / or prostamides (e.g., bimatoprost). Optionally, the response of the subject to the one or more other drugs is improved in the eye of the subject by administration of trabodenoson, as compared to an appropriate control.

[0017] In one embodiment, pressure sensor functionality is improved or recovered fully or partially in the eye of the subject administered trabodenoson to sufficient extent (optionally for a for a period of time that allows the subject to achieve MMP treatment steady-state) that the subject avoids an invasive surgical procedure to reduce IOP. Optionally, the invasive surgical procedure is an insertion of a tube shunt or a trabeculectomy. In a related embodiment, the subject is administered a trabodenoson SR single loading dose with treatment duration for 1-3 months or 3- 6 months; or trabodenoson eye drops for a period of time (e.g. 3-6 months or 6-12 months or 12- 24 months) sufficient to allow the subject to avoid surgery.

[0018] In another embodiment, the trabodenoson administration normalizes IOP diurnal irregularities in the eye of the subject. Optionally, the normalizing of IOP diurnal irregularities in the eye of the subject results in RGC rescue and glaucomatous neural protection in the eye of the subject.

[0019] In an additional embodiment, the trabodenoson administration reduces optic neuropathy in the subject. Optionally, the trabodenoson administration stops deterioration of the optic nerves in the subject and / or stops retinal nerve fiber layer (RNFL) loss in the subject.

[0020] In one embodiment, the trabodenoson administration treats the subject for one or more of the following conditions: primary angle closure glaucoma (PACG), primary open angle glaucoma (POAG), ocular hypertension (OH), normal tension glaucoma (NTG), secondary glaucoma, poor or non-responsiveness to lOP-reducing therapy, uncontrolled IOP, and / or previously unbeatable ECM pathologies associated with glaucoma. Optionally, the secondary glaucoma is uvetic glaucoma, pseudo exfoliation glaucoma, or refractory glaucoma. In another embodiment, the subject is a poor or non-responder to one or more symptom relief IOP lowering drugs and / or other non-trabodenoson glaucoma therapy. Optionally, the subject has uncontrolled IOP or IOP failure before the trabodenoson administration.

[0021] In an additional embodiment, the trabodenoson administration results in an IOP drug holiday in the subject. Optionally, the trabodenoson administration provides an extended duration of RGC protection without undesirable side effects to the subject. Optionally, the extended duration of RGC protection or VF stability is one or more of the following: 6 months or longer, 12 months or longer, 18 months or longer, two years or longer, three years or longer, four years or longer, five years or longer, six years or longer, seven years or longer, eight years or longer, nine years or longer, and / or ten years or longer.

[0022] In another embodiment, the trabodenoson administration improves or restores pressure sensor functionality or pressure sensing cell homeostasis or pressure sensing cell intricate metabolic competence in the eye of the subject.

[0023] In one embodiment, the subject has early-stage or mid-stage glaucoma.

[0024] In another embodiment, the subject has late-stage glaucoma and / or refractory glaucoma.

[0025] In an additional embodiment, the trabodenoson is administered within a SR intraocular delivery system or implant for one of the following time periods: 1-3 months, 3-6 months, 6-9 months, or 9-12 months. Optionally, the trabodenoson is administered for a time period of about 3-4 months of treatment duration. Optionally, the trabodenoson is administered in a biodegradable AC rod. Optionally, the trabodenoson is administered in a repeated dose of once a year or once every 2-3 years or longer, optionally depending on disease staging in the subject. Optionally, the repeated dosing interval is longer for an early-stage disease subject than for a subject having advanced stage glaucoma.

[0026] In a related embodiment, the trabodenoson is administered in an amount sufficient to induce an IOP drug holiday in the subject. Optionally, the subject is administered a further course of trabodenoson as an eye drop formulation. Optionally, administration of the trabodenoson formulation prolongs the IOP drug holiday duration or SR loading dose interval in the subject, as compared to an appropriate control.

[0027] In another embodiment, the trabodenoson administration reduces or eliminates vision loss in the eye of the subject. Optionally, the subject has hypertensive glaucoma and / or OH. In one embodiment, the trabodenoson administration halts glaucoma disease progression in the eye of the subject. Optionally, the disease progression is halted at an early or moderate stage of glaucoma. Optionally, the glaucoma is one or more of the following: hypertensive glaucoma, OH, and / or PACG.

[0028] In certain embodiments, the disease progression is halted at an advanced stage of glaucoma or refractory glaucoma. Optionally, the glaucoma is hypertensive glaucoma or OH.

[0029] In another embodiment, the trabodenoson administration reduces visual field loss in normal tension glaucoma (NTG) in the eye of the subject. Optionally, the reduction in VF loss is more effective than the current standard of care. Optionally, the current standard of care is one or more of the following: an implant of bimatoprost SR intracameral delivery, selective laser trabeculoplasty (SLT), and / or administration of a prostaglandin analog (PGA). Optionally, the PGA is in a sustained release format (e g., Durysta®, iDose). Optionally, the PGA is one or more of the following: a latanoprost microdose delivery with Optejet (Microprost, Eyenovia), a latanoprost delivery via an intracameral implant (OTX-TIC, Ocular Therapeutix), a latanoprost or travoprost delivery via a punctal plug (L-evolute and T-evolute, Mati Therapeutics), travoprost in an ENV515 delivery vehicle (Envisia Therapeutics) and / or travoprost in an iDose (Glaukos) delivery format.

[0030] In one embodiment, the trabodenoson administration reduces or eliminates visual field loss in the eye of the subject better than current standard of care, where the current standard of care is one or more of the following: micro invasive glaucoma surgery (MIGS), tube shunt, trabeculectomy, and IOP lowering eye drops. Optionally, the current standard of care IOP lowering eye drops are one or more of the following: latanoprostene bunod ophthalmic solution (0.024%, Vyzulta, Bausch + Lomb) and netarsudil ophthalmic solution (0.02%, Rhopressa, Alcon), and / or prostaglandin analog (PGA) eye drops.

[0031] In another embodiment, the trabodenoson administration increases matrix metalloproteinase (MMP) levels and / or activates Ai adenosine receptor (A1AR) in the eye of the subject in an amount sufficient to maintain extracellular matrix (ECM) equilibrium at the trabecular meshwork (TM) of the eye of the subject. Optionally, MMP secretion is deficient and the MMP-to-tissue inhibitor of metalloproteinase ratio (MMP / TIMP ratio) in the eye of the subject is in imbalance (low, due to reduced MMP levels) as compared to an appropriate control. Optionally, MMP-14 and MMP-2 are increased by the trabodenoson administration in the eye of the subject.

[0032] In one embodiment, the trabodenoson is administered to the subject at a dose of 1 ,0%-3.0% in an eye drop formulation. Optionally, the trabodenoson is administered to the subject at a dose of about 1.0% to about 2.5%. Optionally, the trabodenoson is administered to the subject at a dose of about 1.2%-1.5%. Optionally, the trabodenoson is administered to the subject at one of the following doses: about 1.2% and about 1.5%. Optionally, the trabodenoson is administered BID. Optionally, the trabodenoson is administered for a duration of about 14-28 days.

[0033] Another aspect of the disclosure provides a method for stabilizing the visual field of an eye of a subject having glaucoma in the eye, the method involving administering trabodenoson formulated as eye drops to the front of the eye of the subject, where the trabodenoson is administered at a dose of 1.0% to 3.0%, thereby stabilizing the visual field of the eye of the subject.

[0034] In one embodiment, the trabodenoson is administered to the front of the eye of the subject twice per day, once per day, or by a flexible dosing regimen. Optionally, administration occurs without requiring compliance with a fixed regimen. Optionally, the subject has achieved a drug holiday treatment status.

[0035] A further aspect of the disclosure provides a method for stabilizing the visual field of an eye of a subject having glaucoma in the eye, the method involving administering trabodenoson within a sustained release (SR) intracam eral delivery system to the front of the eye of the subject, where the trabodenoson is administered as a SR formulation that releases an equivalent concentration of trabodenoson into the aqueous humor as eye drops formulated at 1.0% to 3.0% trabodenoson, thereby stabilizing the visual field of the eye of the subject.

[0036] In one embodiment, visual field stability is determined in the eye of the subject, as compared to an appropriate control. Optionally, the visual field of the eye of the subject is stable at a six- to twelve-month endpoint and / or at a twelve- to 24-month endpoint (e.g., at a twelve- to eighteen-month endpoint) of administering the trabodenoson to the front of the eye of the subject.

[0037] In another embodiment, intraocular pressure (IOP) is normalized in the eye of the subject administered trabodenoson to sufficient extent that the subject is removed from one or more other drugs. Optionally, the other drugs are one or more of: topical P-adrenergic antagonists (e.g., timolol, betaxolol), carbonic anhydrase inhibitors (e.g., dorzolamide, brinzolamide), cholinergics (e.g., pilocarpine), a-adrenergic agonists (e g., brimonidine), prostaglandins (e.g., latanoprost, travoprost, lantanoprost bunod), Rho kinase inhibitors (e g., Rhopressa®, ROCKLATAN®), omidenepag isopropyl, and / or prostamides (e.g., bimatoprost). Optionally, the response of the subject to the one or more other drugs is improved in the eye of the subject by administration of trabodenoson, as compared to an appropriate control.

[0038] In one embodiment, intraocular pressure (IOP) irregularity is normalized in the eye of the subject administered trabodenoson (e.g., as an SR formulation or as an eye drop formulation) for a period of time selected from the group consisting of from 2-3 months, 3-6 months, 6-12 months or 12-18 months or longer.

[0039] In an additional embodiment, pressure sensor functionality is improved in the eye of the subject administered trabodenoson to sufficient extent that the subject avoids an invasive surgical procedure to reduce IOP. Optionally, the invasive surgical procedure is an insertion of a tube shunt or a trabeculectomy.

[0040] In one embodiment, the trabodenoson administration normalizes diurnal irregularities in IOP in the eye of the subject. Optionally, the normalizing of diurnal irregularities in IOP in the eye of the subject results in RGC rescue (preventing or stopping the RGCs from undergoing irreversible apoptosis or necrotic cell death or cell loss) and glaucomatous neural protection in the eye of the subject.

[0041] In an additional embodiment, the trabodenoson administration reduces optic neuropathy in the subject. Optionally, the trabodenoson administration stops deterioration of the optic nerves in the subject.

[0042] In another embodiment, the trabodenoson administration treats the subject for one or more of the following conditions: primary angle closure glaucoma (PACG), primary open angle glaucoma (POAG), ocular hypertension (OH), normal tension glaucoma (NTG), and / or secondary glaucoma. Optionally, the secondary glaucoma is uvetic glaucoma, pseudo exfoliation glaucoma, or refractory glaucoma.

[0043] In one embodiment, the subject is a poor or non-responder to one or more symptom relief lOP-lowering drugs and / or other non-trabodenoson glaucoma therapy. Optionally, the subject has uncontrolled IOP or IOP failure before the trabodenoson administration.

[0044] In another embodiment, the trabodenoson administration stabilizes IOP in the subject and allows for an IOP drug holiday in the subject. Optionally, the trabodenoson administration provides an extended duration of visual field stability without undesirable side effects to the eye of the subject. Optionally, the extended duration is 6 months or longer, 12 months or longer, 18 months or longer, two years or longer, three years or longer, four years or longer, five years or longer, six years or longer, seven years or longer, eight years or longer, nine years or longer, and / or ten years or longer.

[0045] In one embodiment, the trabodenoson administration improves or restores pressure sensor functionality or pressure sensing cell intricate metabolic competence in the eye of the subject.

[0046] In another embodiment, the trabodenoson is administered within a sustained release (SR) intraocular delivery system or implant (optionally a biodegradable AC rod) for a time period of 1- 3 months, 3-6 months, 6-9 months and / or 9-12 months. Optionally, trabodenoson is administered for a time period of 3-4 months of treatment duration.

[0047] In one embodiment, the trabodenoson is administered within a sustained release (SR) intracameral delivery system (optionally a biodegradable AC rod) that administers trabodenoson at a consistent daily release rate under a zero-order kinetic. Optionally, trabodenoson administration achieves a trabodenoson concentration in the aqueous humor at a level that is approximately equivalent to the trabodenoson concentration achieved in the aqueous humor of an eye delivered trabodenoson eye drops at 1.0%-3.0% BID for 1-7 days, for 7-14 days, or for 4-12 weeks. Optionally, trabodenoson is administered for 14-28 days. Optionally, a drug holiday is induced in the subject. Optionally, the subject is administered a further course of trabodenoson as an eye drop formulation. Optionally, administration of the trabodenoson eye drop formulation stabilizes or prolongs the drug holiday in the subject, as compared to an appropriate control.

[0048] In another embodiment, the trabodenoson eye drops are administered to the subject at about 1.5% BID.

[0049] In one embodiment, the trabodenoson administration cures blindness caused by primary hypertensive glaucoma and / or OH in the eye of the subject.

[0050] In another embodiment, the trabodenoson administration halts glaucoma disease progression in the eye of the subject. Optionally, the disease progression is halted at an early or moderate stage of glaucoma. Optionally, the glaucoma is hypertensive glaucoma or OH.

[0051] In an additional embodiment, the disease progression is halted at an advanced to end stage of glaucoma. Optionally, the glaucoma is hypertensive glaucoma or OH.

[0052] In one embodiment, the trabodenoson administration improves upon the current standard of care for reducing or stopping the visual field loss or deterioration. Optionally, the current standard of care is one or more of: an implant of bimatoprost sustained release intracameral delivery, selective laser trabeculoplasty (SLT), and a prostaglandin analog (PGA). Optionally, the PGA is in a sustained release format. Optionally, the PGA is an atanoprost microdose delivery with Optejet (Microprost, Ey enovia), a latanoprost delivery via an intracameral implant (OTX- TIC, Ocular Therapeutix), a latanoprost or travoprost delivery via a punctal plug (L-evolute and T-evolute, Mati Therapeutics), travoprost in an ENV515 delivery vehicle (Envisia Therapeutics), and / or travoprost in an iDose (Glaukos) delivery format.

[0053] In another embodiment, the trabodenoson administration reduces or stops the visual field loss or deterioration in the eye of the subject better than a current standard of care treatment, where the current standard of care treatment is bimatoprost sustained release intracameral implant (Durysta) or iDose, MIGS, invasive drainage surgeries (tube shunt and trabeculectomy), and / or IOP lowering eye drops. Optionally, the current standard of care IOP lowering eye drops are latanoprostene bunod ophthalmic solution (0.024%, Vyzulta, Bausch + Lomb), netarsudil ophthalmic solution (0.02%, Rhopressa, Alcon), and / or prostaglandin analog (PGA) eye drops.

[0054] In one embodiment, the trabodenoson administration as eye drops increases matrix metalloproteinase (MMP) and / or Ai adenosine receptor (Al AR) levels in the eye of the subject in an amount sufficient to maintain extracellular matrix (ECM) equilibrium at the trabecular meshwork (TM) of the eye of the subject. Optionally, MMP- 14 and MMP-2 are increased in the eye of the subject.

[0055] In another embodiment, the trabodenoson is administered to the subject at a dose of 1.0%- 2.5%. Optionally, the trabodenoson is administered to the subject at a dose of about 1.2% or about 1.5%.

[0056] In an additional embodiment, the trabodenoson administration induces consistent IOP improvement (optionally time, dose and / or disease stage-dependent) in the subject.

[0057] In one embodiment, the subject has early-stage or mid-stage glaucoma.

[0058] In another embodiment, the subject has late-stage glaucoma.

[0059] In one embodiment, the trabodenoson administration provides neural protection benefit to RGCs in the eye of the subject for a duration of time of about 3-6 months, about 6-9 months, about 9-12 months, about 12-18 months, or about 18-24 months or longer.

[0060] In another embodiment, trabodenoson is administered to a population of subjects and the trabodenoson administration achieves a drug holiday state in a majority of the subjects in the trabodenoson-administered population. Optionally, a drug holiday state is achieved in about 80% or more of the subjects in the trabodenoson-administered population.

[0061] In one embodiment, the trabodenoson administration achieves a disease-free drug holiday in the subject within about 3-4 months of initiating the trabodenoson administration. Optionally, the trabodenoson administration is SR trabodenoson.

[0062] Another aspect of the disclosure provides a method for treating or preventing corneal endothelium loss in an eye of a subject, the method involving administering trabodenoson formulated as eye drops or within a sustained release (SR) intraocular delivery system to the front of the eye of the subject, where the trabodenoson is administered at a dose of 1.0% to 3.0% to the front of the eye of the subject, thereby treating or preventing corneal endothelium loss in the eye of the subject.

[0063] In one embodiment, the trabodenoson is administered to the subject at a dose of 1.0%- 2.5%. Optionally, the trabodenoson is administered to the subject at a dose selected of about 1.2% or about 1.5%.

[0064] In another embodiment, the subject has or is at risk of developing Fuchs endothelial dystrophy, bullous keratopathy or cornea endothelium decompensation in conditions of cornea graft failure.

[0065] An additional aspect of the disclosure provides a method for reducing or preventing retinal ganglion cell (RGC) loss in an eye of a subject having or at risk of developing glaucoma, the method involving administering one or more matrix metalloproteinases (MMPs), an Ai adenosine receptor (Al AR), and / or an Al AR biosimilar to the eye of the subject in an amount sufficient to maintain extracellular matrix (ECM) equilibrium at the trabecular meshwork (TM) of the eye of the subject, thereby reducing or preventing RGC loss in the eye of the subject.

[0066] In one embodiment, MMP-1, MMP-2, MMP-3 and / or MMP-14 is administered to the front of the eye of the subject.

[0067] In another embodiment, the one or more MMPs, A1AR and / or A1AR biosimilar is administered as a polypeptide or as a polynucleotide. Optionally, the one or more MMPs, A1AR and / or A1AR biosimilar is administered to the subject via viral vector- (optionally AAV) or nanoparticle-mediated delivery. Optionally, the polynucleotide is RNA.

[0068] In one embodiment, the one or more MMPs, A1AR and / or A1AR biosimilar is / are delivered to the eye of the subject via an adeno-associated virus (AAV), nanoparticle eye drops, a sustained release (SR) implant (optionally to the anterior chamber of the eye) and / or a genetic biofactory. Optionally, the delivery system includes a dosing switch on / off mechanism. Optionally, delivery is for a period of 1-6 months. Optionally, for a period of 2-3 months.

[0069] Another aspect of the disclosure provides a method for reducing or preventing retinal ganglion cell (RGC) loss in an eye of a subject having or at risk of developing glaucoma, the method involving administering an Ai adenosine receptor (Al AR) agonist to the eye of the subject, thereby reducing or preventing RGC loss in the eye of the subject.

[0070] In one embodiment, the A1AR agonist is a small molecule. Optionally, the A1AR agonist includes the structure:

[0071] Ri is an optionally substituted (C5-C6) cycloalkyl (optionally substituted with one or more OH, or

[0072] R2 is H or a halogen atom (F, Cl, Br, or I); and

[0073] Ra is H or NO2. Optionally, the A1AR agonist is trabodenoson, cyclopentyladenosine (CPA), 2- chlorocyclopentyladenosine (CCPA) or cyclohexyladenosine (CHA).

[0074] In one embodiment, the A1AR agonist is administered as an eye drop formulation to the eye of the subject.

[0075] In another embodiment, the A1AR agonist is administered as a SR formulation via intracam eral delivery route to the eye of the subject.

[0076] In one embodiment, the A1AR agonist is administered to the subject in an amount sufficient to upregulate MMP secretion in the eye of the subject. Optionally, the administration of the Al AR agonist induces and maintains extracellular matrix (ECM) equilibrium at the trabecular meshwork (TM) of the eye of the subject.

[0077] In an additional embodiment, the Al AR agonist is administered to the subject in an amount sufficient to stabilize IOP in the eye of the subject.

[0078] Another aspect of the disclosure provides a biodegradable intracameral implant for dosing to the aqueous humor of the eye of a subject, the implant including SR trabodenoson at a dose level equivalent to that observed in a subject administered trabodenoson eye drops at about 1.0%- 2.0% concentration for a period of 1-16 weeks.

[0079] An additonal aspect of the disclosure provides a method for treating a subject having or at risk of developing glaucoma, the method involving: (a) identifying the presence of two or more of the following in an eye of the subject: (i) diurnal irregularities in IOP in the eye of the subject (optionally in a longitudinal assessment); (ii) non-responsiveness of the eye of the subject to IOP- lowering drugs; and (iii) identification of surgery as a next therapeutic step for the eye of the subject, and / or the eye of the subject has already been subjected to surgical intervention for glaucoma treatment (optionally without significant benefit); and (b) administering an A1AR agonist to the eye of the subject, thereby treating the subject having or at risk of developing glaucoma.

[0080] In one embodiment, the A1AR agonist is trabodenoson.

[0081] In another embodiment, the A1AR agonist is administered to the subject as an eye drop formulation. Optionally, the Al AR agonist is administered at a concentration of about 1 0%-3.0%. Optionally, the Al AR agonist is administered at a concentration of about 1.5%.

[0082] In an additional embodiment, the A1AR agonist is administered to the subject via an implant. Optionally, the A1AR agonist is administered to the subject via an intracameral implant. Optionally, the A1AR agonist is administered to the aqueous humor of the eye of the subject.

[0083] In one embodiment, the A1AR agonist administration prevents blindness in the eye of the subject at a timepoint of six months or more post-administration. Optionally, the A1AR agonist administration prevents blindness in the eye of the subject at a timepoint of nine months or more. Optionally, the A1AR agonist administration prevents blindness in the eye of the subject at a timepoint of twelve months or more. Optionally, the A1AR agonist administration prevents blindness in the eye of the subject at a timepoint of 18 months or more. Optionally, the A1AR agonist administration prevents blindness in the eye of the subject at a timepoint of 24 months or more.

[0084] In another embodiment, A1AR agonist administration reduces or eliminates visual field loss in the eye of the subject better than a current standard of care therapy, where the current standard of care therapy is MIGS, invasive drainage surgeries (tube shunt and trabeculectomy), and / or IOP lowering eye drops. Optionally, the current standard of care IOP lowering eye drops are latanoprostene bunod ophthalmic solution (0.024%, Vyzulta, Bausch + Lomb), netarsudil ophthalmic solution (0.02%, Rhopressa, Alcon), and / or prostaglandin analog (PGA) eye drops.

[0085] Definitions

[0086] That the present disclosure may be more readily understood, certain terms are first defined. In addition, it should be noted that whenever a value or range of values of a parameter are recited, it is intended that values and ranges intermediate to the recited values are also intended to be part of this disclosure.

[0087] The articles “a” and “an” are used herein to refer to one or to more than one (i.e., to at least one) of the grammatical object of the article. By way of example, “an element” means one element or more than one element, e.g., a plurality of elements.

[0088] The term "including" is used herein to mean, and is used interchangeably with, the phrase "including but not limited to".

[0089] The term "or" is used herein to mean, and is used interchangeably with, the term "and / or," unless context clearly indicates otherwise.

[0090] The term “about” is used herein to mean within the typical ranges of tolerances in the art. For example, “about” can be understood as about 2 standard deviations from the mean. In certain embodiments, about means ±10%. In certain embodiments, about means ±5%. When about is present before a series of numbers or a range, it is understood that “about” can modify each of the numbers in the series or range.

[0091] As used herein, "trabodenoson" refers to an adenosine mimetic optimized to target selectively the adenosine Al receptor (A1AR; trabodenoson binds A1AR with a Ki of 0.97 nM, while trabodenoson binds the A2a receptor with a Ki of 4690 nM and trabodenoson binds the A3 a receptor with a Ki of 704 nM). The chemical structure of trabodenoson (Formula: CisEboNeOe; MW: 380.36, also known as "INO-8875"; from US 2014 / 0271876, Me Vicar el al is:

[0092]

[0093] The trabodenoson molecule has also been depicted (e g., in WO 2012 / 028585; Kalar et al ) as having an electrostatic interaction between the NO2 moiety and the remainder of the molecule:

[0094] Successful “treatment” of an eye disease according to this invention may have any effect that is beneficial to the subject being treated. This includes decreasing severity, duration, or progression of a condition, or of any adverse signs or symptoms resulting therefrom. In some circumstances, MMP agents can also be used to prevent or inhibit presentation of a condition for which a subject is susceptible, for example, loss of visual field.

[0095] A “therapeutically effective amount” is an amount of a compound or agent of the present disclosure that (i) treats the particular disease, condition, or disorder, (ii) attenuates, ameliorates, or eliminates one or more symptoms of the particular disease, condition, or disorder, (iii) prevents or delays the onset of one or more symptoms of the particular disease, condition, or disorder described herein, (iv) prevents or delays progression of the particular disease, condition or disorder, or (v) at least partially reverses damage caused by the condition prior to treatment.

[0096] As used herein, a “subject” is an animal, such as a mammal, including a primate (such as a human, a non-human primate, e.g. , a monkey, and a chimpanzee), or a non-primate (such as a rat, or a mouse). In a preferred embodiment, the subject is a human, such as a human being treated or assessed for a disease, disorder, or condition; a human at risk for a disease, disorder, or condition; a human having a disease, disorder, or condition; or human being treated for a disease, disorder, or condition as described herein.

[0097] BRIEF DESCRIPTION OF THE DRAWINGS

[0098] The following detailed description, given by way of example, but not intended to limit the disclosure solely to the specific embodiments described, may best be understood in conjunction with the accompanying drawings, in which:

[0099] FIG. 1 shows a molecular model rendering of trabodenoson’s chemical structure.

[0100] FIG. 2 shows that trabodenoson normalized IOP diurnal irregularities in glaucoma via matrix metalloproteinase (MMP) / AlAR-mediated trabecular meshwork (TM) repair and restoration of pressure sensor functionality, and that this analysis demonstrated that a 1.5% BID dosage was more effective for glaucoma patients than the 0.6% BID dosage previously identified in the art as optimal (this recent analysis involved a more complete consideration of the (MMP) / AlAR-mediated effects). At top, graphs showing dual mechanistic modes and recently identified updated clinical dosing principles for trabodenoson are shown. The left-hand graph at top shows the timing of progression to a steady-state IOP reduction level across various tested doses of trabodenoson, when MMP / A1AR therapeutics (such as trabodenoson) were considered ("slow mode" MMP / A1AR therapeutic effects with steady state - the MMP / A1AR steady state represents the maximal clinical therapeutic benefits, seen when the extracellular matrix (ECM) degradation and synthesis achieved equilibrium). The middle graph at top shows that consideration of vascular effects of trabodenoson revealed a bell-shaped dose-response curve for IOP reduction (these vascular effects were "fast mode" effects), which had resulted in the prior art's identification of 0.6% trabodenoson as the "sweet spot" for achieving IOP reduction in subjects, with only the vascular effect considered. The right-hand graph at top then shows the result of an updated analysis that included consideration of both the MMP / A1AR route effects and vascular effects (as a sum of IOP reduction by trabodenoson acting via dual mechanisms of action). At bottom, phase 2 clinical trial results for trabodenoson IOP pattern behaviors in patients (POAG / OH dual) having both primary open angle glaucoma (POAG) and ocular hypertension (OH) were evaluated using these updated criteria, and it was recently revealed that 1.5% BID dosing would actually be the optimal dosing in such patients (when both vascular effects that produced the bell-shaped curve and MMP / A1AR route effects were considered together). The IOP profiles demonstrated a dose dependent IOP improvement (left bars) and a bell-shaped IOP reduction result (right bars), which peaked at 0.6% BID. The same molecule (trabodenoson) was therefore effectively two different drugs (the first drug acting via the "fast mode" vascular effects, and the second acting via "slow mode" MMP / A1AR effects). FIG. 2 was adapted from U.S. Serial No. 18 / 356,874.

[0101] FIG. 3 shows a graphical illustration of the relationship between the pressure sensing cells (also called Schlemm’s canal endothelium, or SC endothelium) of the eye and the trabecular meshwork (TM) lamellae beams in pulsatile IOP regulation. SC endothelium loss is modeled as the result of oxidative stress and insults driven by the metabolic deficiency, possibly (and without wishing to be bound by theory) related to the SC chamber compression abnormalities observed in glaucomatous eyes. The pulsatile flow into aqueous veins involves three specific structural outflow systems: 1) compressible chamber - shown here as Schlemm’s canal (SC), 2) valves - corresponding to episcleral venous pressure (EVP); and 3) the energy source (cardiac driven force). Abnormal compression of the SC results in a shear force damage to the pressure sensing cells; this likely creates a prolonged physical contact stretch between the cells at the SC inner wall and the SC outer wall under an irregular IOP driven force. In response to cardiac-dependent changes in choroidal volume, the anterior chamber experiences continuous pulsatile alteration in pressure oscillation force, the TM outward in systole, followed by recoil in diastole, and SC volume oscillates as a result. Image from Johnstone et al. J. Clin. Med. 12: 6599, described as an aqueous pump model incorporating valves and compressible chambers. From the resting state in diastole, systole induces an intraocular pressure (IOP) rise, causing an ocular pulse wave in the anterior chamber (AC). The trabecular meshwork (TM) distends as IOP rises. TM distention causes Schlemm’s canal (SC) to narrow, reducing its volume while forcing fluid through the collector channel (CC) outlet valve entrances which are initially in an open configuration, followed by septa movement outward, forcing aqueous out of the circumferentially oriented deep scleral plexus (CDSP). TM recoil during the following diastole causing CC entrances to open into the CDSP. Aqueous flows into the intertrabecular spaces, into SC through the conduits of the SC inlet valves, and into CDSP. The cycle then repeats.

[0102] FIG. 4 shows a schematic alongside clinical trial results, that demonstrate the neural protection benefit to retinal ganglion cells of achieving a drug holiday state (essentially a disease- free state) in patients with glaucoma, via use of MMP-targeting therapeutics (e.g., trabodenoson) to normalize IOP diurnal irregularities. As identified herein, the rate limiting root cause of visual field loss in patients (POAG / OH) having both primary open angle glaucoma (POAG) and ocular hypertension (OH) was the intraocular pressure diurnal irregularities and IOP stress. The left panel (adapted from Qiu. EC Ophthalmology (2015)) provides a comprehensive map of various risk factors attributing to glaucomatous neural degeneration, resulting from RGC apoptosis and optic neuropathy. lOP-dependent (lOP-driven) downstream risk factors were newly identified herein - these were previously believed to be lOP-independent risk factors (Qiu. EC Ophthalmology. 2.2 (2015): 81-91), e.g., neuroinflammation driven by microglia astrocyte activation releasing a cluster of cytokines and neurotoxins (e.g., glutamate). The right panel shows 20-month Phase 3 clinical trial results for a bimatoprost (a structural analog of prostaglandin F2«) sustained release (SR) intracameral implant in patients with POAG / OH, which indicated that patients treated with the SR implant for 12 months had their vision or visual field (VF) better preserved, with stability, as compared to a control group treated with timolol (beta-blocker) eye drops BID for 20 months, in which patients’ VF deteriorated over time, with clinical significance observed at 12 months (*p<0.037 vs. timolol based on a mixed-effect model for repeated measures including treatment, visit, treatment-by-visit interaction, baseline MD, and visit-by-baseline interaction). The right panel specifically shows the plotted results of measuring mean change in the visual field mean deviation (MD) from baseline by Humphrey perimetry in study eyes. Test results from eyes that had received rescue lOP-lowering treatment were excluded from the original analysis. The number of eyes included in the analysis of change in MD from baseline at visits from week 28 to month 20 ranged from 101 to 143 in the 10 pg bimatoprost implant group, 102 to 143 in the 15 pg bimatoprost implant group, and 123 to 144 in the timolol BID group (BID indicates twice daily; BL indicates baseline; SEM indicates standard error of the mean). During an eight-month drug holiday period without MMP therapeutic in the absence of active pharmaceutical ingredient (API), patients sustained a strong positive trend with mild VF decline. It was identified herein that the visual field stability seen in patients treated with bimatoprost intracameral implant appeared to have been produced by an MMP therapeutic effect on IOP normalization, which produced neural protection benefits, which is an effect that had not been previously recognized - indeed, the authors of Bacharach et al. (Drugs 81 : 2017-2033), from which the right panel is copied, believed that the observed bimatoprost intracameral implant effect was the result of a slow release effect (similar to MIGS procedure), which was not correct. The extended IOP stability seen in bimatoprost intracameral implant-treated patients was initially attributed to the bimatoprost free acid inducing lymphangiogenesis in the human ciliary body, as set forth in L Charters (Ophthalmology Times. 47(5), citing Dr. Douglas Rhee's original assessment of clinical results). It has been newly identified herein that such VF stability benefit more likely resulted from the MMP therapeutic aspect of the bimatoprost sustained release (SR) intracameral implant when delivered at a high dose API (not via eye drops). By the current analysis, the slight decline of the VF stability at twelve months has been attributed to the following three reasons: 1) the high dose API triggered clinically significant inflammation that killed the RGCs at the back of the eye (main reason); 2) some of the patients may not have been in a “true” drug holiday state, as the current limits of IOP monitoring have been based on selective 2-3 timepoints, not at 24-hour monitoring, which meant that the IOP diurnal irregularities might still have been present in some individuals included in the original analysis; 3) during the first 2-3 months, treated patients were still losing vision, before their lOPs were being normalized or before reaching the drug holiday state. In principle, once a patient reaches the drug holiday or their IOP has been normalized, that patient should not continue to lose their vision, and their RGCs should be protected under a true drug holiday status (as effectively a disease-free state). Based upon the current reassessment of the panel at right, if bimatoprost were to have been replaced by trabodenoson in the SR system, the VF stability results would likely have been much better, because of the paired trabodenoson advantages of excellent clinical safety and higher therapeutic potency (as a MMP / A1 AR therapeutic), as compared to bimatoprost SR. It was thereby identified herein that by normalizing IOP irregularities and inducing patients into an extended drug holiday state, trabodenoson administration would likely eliminate glaucoma- induced visual field loss and effectively halt disease progression entirely, in trabodenoson-treated glaucoma patients. FIG. 5 shows that proteins in the aqueous humor and in the vitreous cavity showed significant overlaps. The plot (from Wilson et al. Transl Vis Sci Technol. 12: 9) is a principal component score plot for principal components PCI with 87.5% explained variance and PC2 with 12.5% explained variance, which specifically reflects quantification of proteins in aqueous humor (AH), vitreous humor (VH), and serum (SE). Each point of the plot represents a sample in this space with the matrix color-coded. The plot provides a visual representation of the relationship between samples based on their protein expression profiles, with PCI separating SE from AH / VH and PC2 showing a lesser shift between the AH and SE samples.

[0103] FIG. 6 shows clinical data of a single arm GEMINI study (derived from Pyfer et al. Clin Ophthalmol. 15: 3931-3938) that employed one type of the modern micro invasive glaucoma surgery (MIGS), an OMNI® device that accesses, catheterizes, and viscodilates the Schlemm's canal, and also the distal outflow system, beginning with the collector channels, which was used to perform a sequential ab interno canaloplasty followed by a trabeculotomy. This MIGS process demonstrated its impact upon glaucoma patients’ IOP diurnal profile. The plot at top demonstrates that individual diurnal IOP irregularities in patients with POAG persisted after canaloplasty / trabeculotomy surgeries, at 12-month follow-up vs baseline (shown is the variability observed in the three diurnal IOP measurements - at 9 am, noon, and 4 pm - for each patient at preoperative (squares) and month 12 (circles)). This is a post adhoc multi-center analysis for 128 patients of the GEMINI study. Canaloplasty / trabeculotomy was performed between 90-120 degrees on open angle glaucoma (OAG) patients. The graphs at bottom further demonstrated that canaloplasty / trabeculotomy could only reduce the magnitude (by half) of IOP diurnal fluctuations at 12-month follow up, as compared to baseline.

[0104] FIG. 7 shows that Hydrus® (microstent) glaucoma surgery also slowed down (but could not stop) the visual field loss observed in early-stage glaucoma (POAG / OH) patients. Data were based on 5-year clinical study of VF stability from Hydrus® Horizon trials (Montesano et al. Am J Ophthalmol 251 : 143-155), with the rate of VF decline slowed from an average 0.5dB / year (slope analysis) in the control group with cataract removal alone (similar to glaucoma standard of care by eye drops) to 0.35dB per year in patients with cataract removal plus Hydrus® implant, averaging from 5-years of data. Participants were early-stage POAG / OH, who were randomized between Hydrus®+cataract removal and cataract removal alone. It was a very early-stage glaucoma population. FIG. 8 displays a schematic diagram illustrating the effect of trabodenoson treatment (which exerts MMP and Al AR effects) to promote glaucoma neural protection and trabodenoson's related therapeutic potency, in comparison with a bimatoprost SR implant (bimatoprost intracameral implant), with trabodenoson acting as a MMP therapeutic, which imparted symptom relief for IOP irregularities when administered as eye drops, also as compared with patients that received MIGS surgeries.

[0105] FIG. 9 displays graphs that compare drug holiday induction results for bimatoprost SR implants and trabodenoson eye drops. The graph at top left shows that a durable drug holiday was achieved with a single dose implant of bimatoprost SR (involving 4.2 month loading of respective 10 pg and 15 pg amounts of bimatoprost as the API), as an estimated 68%, 47%, 40%, and 28% of patients, respectively, were observed to be on drug holiday at respective 6M, 9M, 12M, and 20M timepoints post-implantation. The graph at lower left shows results observed for the timing of bimatoprost SR induction of drug holiday in treated subjects. While a single bimatoprost SR implant that dosed for 4.2 months and was loaded with 10 pg or 15 pg led to achievement of drug holiday at six months in approximately 68% of treated subjects, longer treatments (e.g.., with two consecutive implants, which extended dosing to approximately eight months, or with three consecutive implants, which extended dosing to approximately twelve months) induced drug holiday in an increasing proportion of treated subjects - e.g., treatment with three consecutive implants over the span of twelve months resulted in approximately 80% of treated subjects achieving drug holiday, while two consecutive implants achieved approximately 70% of treated patients on drug holiday. The graph at top right shows that trabodenoson administered as low dose eye drops (1.5% BID) was so effective that it allowed for a unique dosing switch from BID to QD in treated subjects, as early as day 29 of treatment in subjects having mild-to-moderate POAG / OH, and at eight weeks in subjects who had previously responded poorly to a commonly prescribed PGA treatment, latanoprost. This dosing switch was a clinical biomarker of improved TM durability for treated subjects, a precursor of drug holiday. The graph at lower right shows that administration of trabodenoson eye drops to patients that have already received a single implant of bimatoprost SR can significantly improve both the proportion of treated patients that achieve drug holiday and the duration of drug holiday in drug-responsive subjects. Thus, it is estimated that trabodenoson eye drops can promote drug holiday induction and durability, the latter of which is achieved by stabilizing the condition of patients with glaucoma, when combined with a SR MMP therapeutic as a loading dose (e.g., bimatoprost SR). With sequential dosing, at least 80% of treated patients_in total (including patients treated with trabodenoson eye drops during the drug holiday period) are identified to achieve a stable, durable drug holiday at 12 months, and even maintained until 24 months or more, e.g., for three to five years or more. Graphs at top left and lower left are noted as derived from bimatoprost SR implant phase 2 and phase 3 clinical trial results, while the graph at top right was created using trabodenoson eye drop phase 2 clinical trial results.

[0106] In principle, a trabo-SR (sustained release trabodenoson) format can induce a drug holiday in a subject at a faster speed, across a higher percentage of patients - including those patients having a more advanced stage of glaucoma (e.g., patients with 3-4 medications or glaucomatous eyes currently having received trabeculectomy or IDose implants, which have often failed) - and with a longer duration, as compared to bimatoprost SR implant. Also in trabodenoson SR's favor, longer SR induction should induce a higher percentage of patients to a more durable drug holiday, as compared to a shorter term SR format (e.g., 6M of treatment is better than 3M of treatment for severe glaucoma). However, bimatoprost SR's MMP therapeutic benefit is proportionally tempered given the sight-threatening side effects to the cornea and TM health observed for current bimatoprost SR implants, hence, the bimatoprost SR MMP benefit is compromised.

[0107] The graph at top left shows that a durable drug holiday was achieved with a single dose implant of bimatoprost SR (involving 4.2 month loading of respective 10 pg and 15 pg amounts of bimatoprost as the API), as an estimated 68%, 47%, 40%, and 28% of patients, respectively, were observed to be on drug holiday at respective 6M, 9M, 12M, and 20M timepoints postimplantation. The graph at lower left shows results observed for the timing of bimatoprost SR induction of drug holiday in treated subjects. While a single bimatoprost SR implant that dosed for 4.2 months and was loaded with 10 pg or 15 pg led to achievement of drug holiday at six months in approximately 68% of treated subjects, longer treatments (e g.., with two consecutive implants, which extended dosing to approximately eight months, or with three consecutive implants, which extended dosing to approximately twelve months) induced drug holiday in an increasing proportion of treated subjects - e.g., treatment with three consecutive implants over the span of twelve months resulted in approximately 80% of treated subjects achieving drug holiday, while two consecutive implants achieved approximately 70% of treated patients on drug holiday. The graph at top right shows that trabodenoson administered as low dose eye drops (1.5% BID) was so effective that it allowed for a unique dosing switch from BID to QD in treated subjects, as early as day 29 of treatment in subjects having mild-to-moderate POAG / OH, and at eight weeks in subjects who had previously responded poorly to a commonly prescribed PGA treatment, latanoprost. This dosing switch was a clinical biomarker of improved TM durability for treated subjects, a precursor of drug holiday. The graph at lower right shows that administration of trabodenoson eye drops to patients that have already received a single implant of bimatoprost SR can significantly improve both the proportion of treated patients that achieve drug holiday and the duration of drug holiday in drug-responsive subjects. Thus, it is estimated that trabodenoson eye drops can promote drug holiday induction and durability, the latter of which is achieved by stabilizing the condition of patients with glaucoma, when combined with a SR MMP therapeutic as a loading dose (e.g., bimatoprost SR). With sequential dosing, at least 80% of treated patients in total (including patients treated with trabodenoson eye drops during the drug holiday period) are identified to achieve a stable, durable drug holiday at 12 months, and even maintained until 24 months or more, e.g., for three to five years or more. Graphs at top left and lower left are noted as derived from bimatoprost SR implant phase 2 and phase 3 clinical trial results, while the graph at top right was created using trabodenoson eye drop phase 2 clinical trial results.

[0108] FIG. 10 illustrates that AlAR-mediated neuromodulation is inhibitory by nature. Al AR pathway activation coupled to G protein Gi / Gs inhibits adenylyl cyclase, drives cell membrane hyperpolarization (producing a resting stage), with membrane homeostasis subsequently restored by inhibiting calcium influx and reducing glutamate neural transmitter release, thereby increasing K+-ATP pump conductance. Therefore, A1AR activation has strategic importance for protecting neuronal cells from ischemia reperfusion damage and oxidative stress, which distinguishes the A1AR activation effects observed for trabodenoson from those drugs that activate the MMP therapeutic pathway (alone, without activating A1AR), such as SR bimatoprost and other PGA drugs.

[0109] FIG. 11 illustrates that neurotrophic receptors are distributed at the brain (visual cortex), via retrograde mode and propagation mechanism, the neurotrophins exert its biological activities towards the RGC in the retina. Tyrosine kinase A, B, and C receptors, and p75 are the primary receptors for nerve growth factor (NGF), brain derived neurotrophic factor (BDNF), neurotrophin 3 (NT3), and neurotrophin 4 / 5 (NT4 / 5), respectively. These receptors are distributed at the axon terminals in the brain. Neurotrophins have been described to work via a retrograde mode and a propagation mechanism. CNTF (ciliary neurotrophic factor) does not express in the neurons but via RPE, muller glia and astrocyte regulation on photoreceptors. More than 50% of the neurotrophins and cytokines or proteins are via retrograde mode from the brain to the retina to nourish the RGC health. If retrobulbar ophthalmic artery and vein suffer compression (ischemiareperfusion), it bocks the neurotrophins pathway to the RGC bodies. IOP elevation, spikes and diurnal irregularities can cause vascular perfusion defect at the optic nerve head, along with the aging rigidity of the lamina cribrosa, which blocks the nutrients flow through the optic disc to the retina, subsequently triggers the RGC apoptosis. The retrobulbar vascular perfusion problem is often seen in normal tension glaucoma. In glaucomatous eyes, the rate of visual field loss was approximately 5.5 times faster in optic disc hemorrhagic (ODH) eyes than non-ODH eyes. From this diagram, it also suggests that intravitreal delivery of BDNF proteins or gene therapy for treating glaucoma will be difficult to achieve pharmacological or therapeutic concentration at the targeted receptor sites in human brain, which explain prior efforts of various neurotrophins failed in clinical trials for glaucoma. Data source: Gitty DD, Segal RA. Curr Opin Neurobiol. 2002 Jun;12(3):268-74.

[0110] FIG. 12 illustrates how cardiac-induced pulsatile aqueous outflow in the eye serves as a water pump system, which causes choroidal vascular volume changes during diastole and systole phases. At left, pulsatile aqueous outflow is diagrammed, while at right, resultant pulsatile flow into the aqueous veins is illustrated. The cardiac cycle results in pulsatile blood flow into the choroid, causing a rise in IOP. The IOP increase causes the TM to move outward, compressing Schlemm's canal (SC). The oscillatory SC compression causes a pulsatile wave of aqueous to enter the episcleral veins. At right, steps 1-5 represent different manifestations of pulsatile flow observed in diastole and systole. EVP refers to episcleral vein pressure, while AVP indicates aqueous vein pressure. In glaucoma patients, TM elasticity decreases and the pressure sensor of the eye becomes dysfunctional with irregularities, which causes abnormal vascular perfusion (defects), clinically referred to as ischemia-reperfusion damage at the optic nerve head, which subsequently blocks the retrograde transportation of neurotrophins such as BNDF through the RGC exons in the optic nerve bundles from the brain to the retina. The age-related TM rigidity and loss of tissue elastic compliance in response to normal cardiac pulses has direct links to optic nerve damage as a result of the vascular volume changes at the retrobulbar and choroidal space in patients having glaucoma, especially those patients having normal tension glaucoma. In addition to the abnormal vascular perfusion around optic nerve head, the deformation and rigidity of the lamina cribrosa also affects retrograde nutrient transport, which is the main mechanism responsible for neuronal cell survival in the retina (see FIG. 11 above). Illustration from Johnstone et al. J. Clin. Med. 12: 6599.

[0111] FIGs. 13A and 13B show that the preferred target for IOP levels is the one that allows a glaucoma patient to achieve a drug holiday status. FIG. 13A shows an image (at right) of glaucomatous optic neuropathy (disc / cupping ratio), as compared with a normal optic disc. Fig 13B shows an image (at left) of early-stage glaucoma with a target IOP range at 15-17mmHg, moderate glaucoma (middle) with a target IOP at 12- 15mmHg, and severe glaucoma (at right) with a target IOP at 10-12mmHg. This provides a reference guide, along with Humphrey VF testing and / or OCT to help physician to set the IOP management strategy: one bottle or two bottles of eye drops, or surgeries, etc. Target IOP varies from eye to eye, individual to individual. In clinical practice, the target IOP is defined based upon the damage of optic disc and nerve fibers, as assessed using the Humphrey visual field test, which is retrospective, as readings are delayed by 6-12 months. The best guideline for a therapeutic is therefore that of determining when a patient has achieved drug holiday status, at which point the IOP is the most accurate target IOP Images from Sihota et al. Indian J Ophthalmol . 66: 495-505.

[0112] FIGs. 14A and 14B provides evidence that challenges the currently most prevalent principle of clinical IOP management: “the lower, the better”. Current clinical best practice is to compete and identify which drug or treatment lowers the IOP more than the other in a subject as a guide of good IOP control. Rather, the current figure tells an opposite story, by showing that the ideal target IOP may be higher than that obtained by treatment with a potent IOP lowering drug such as bimatoprost, FIG. 14A shows that patients’ IOP under bimatoprost SR treatment at week 2 and at week 6 with the API present (7-8mmHg reduction compared to baseline) was about 1.0 mmHg lower than patients that achieved a drug holiday state at week 12 (when the API was not present: 6-7mmHg reduction compared to baseline). FIG. 14B shows a comparison of indicated levels of bimatoprost SR treatment and timolol BID treatments. The drug holiday was therefore the result of bimatoprost SR-derived MMP therapeutic benefits. It seems that few in the art realized or appreciated this fact before Applicant. The ideal target IOP for an individual patient should be identified as the level when the individual patient or eye achieves a disease-free state, with this state also referred to herein as a “drug holiday” state. Trabodenoson therapy as described herein sets a principle or rule with a new standard of glaucoma disease management by introducing IOP drug holiday and its resulting TOP target, which is the ideal target TOP, under which the RGC neurons feel most comfortable and are being protected.

[0113] FIG. 15 presents a schematic diagram that demonstrates the transformative impact of trabodenoson on glaucoma, in the IOP management drug landscape. The current standard of care for IOP management in glaucoma is of symptom relief to lower the IOP, which cannot stop disease progression and therefore does not provide a curative solution for patients with glaucoma. About 30-40% patients will become legally blind at the advanced or end stage of glaucoma. As identified herein, trabodenoson can reverse the aging of TM degeneration, stop the neuronal cell death, and thus offers the first cure and most effective glaucoma neural protection available, via its exerting a combined MMP / A1 AR therapeutic effect upon IOP normalization. Trabodenoson can therefore solve two major problems in glaucoma specialty care: 1) poor or non-responders to IOP lowering medications or glaucoma drainage surgeries; 2) the holy grail of actually robustly protecting against neural degeneration and RGC loss in patients with glaucoma.

[0114] FIG. 16 displays a schematic diagram that shows how MMP therapeutics (e.g., trabodenoson) have been herein discovered to protect against the rate limiting root cause of glaucoma, which is RGC loss. The diagram summarizes three major pathways of the RGC cell death rooted by or started from the IOP stress. IOP diurnal irregularities are the rate limiting root cause of RGC loss at the back of the eyes, and the IOP problem is caused by the pressure sensing cell loss and the sensor dysfunction as the result of the TM aging. The three pathways to trigger the RGC cell loss are intertwining and connected to each other, providing a global picture of the IOP problem - specifically IOP diurnal irregularities as the rate limiting root cause of glaucomatous vision loss. In clinics, ocular hypertension does not lead to the optic necrophagy at early stage, whereas normal tension glaucoma kills the RGC at the very start. It is the diurnal irregularities that pose the biggest threat to RGC health at the back of the eye. First, IOP stress triggers microglia and astrocyte activation and proliferation that produces a cluster of harmful neurotoxin and cytokines such as glutamate, TNF-a, ILs and NF-KappaB. These proinflammatory molecules trigger RGC cell apoptosis, also accelerating the ECM deformation at the lamina cribrosa. The ECM thickening and deformation at the optic nerve head constitute the 2ndpathway of RGC death triggered by the IOP irregularities. Thirdly, IOP irregularities induced ischemiareperfusion damages to the optic nerve head, subsequently affecting the retrograde transport of neurotrophins (>50%) from the brain to the retina, which triggers the deprivation of nutrient supplies to the RGC, impacting RGC health and contributing to the RGC cell body metabolic inflammation and dendritic inflammation (synapse pathologies). If IOP stress and diurnal irregularities can be removed, the RGC will be protected from these damages by all above three domains of the downstream signaling pathways. The trabodenoson therapies disclosed herein (e.g., eye drops or SR intracameral implant (or AC rod)) offer the most effective or curative solution to prevent and stop RGC loss in patients with glaucoma.

[0115] The present invention is further illustrated by the following detailed description.

[0116] DETAILED DESCRIPTION OF THE INVENTION

[0117] The disclosure provides, at least in part, to identification of trabodenoson as a curative solution and the most effective glaucoma neural protection drug, acting via IOP normalization (the rate limit disease control), which has the potential to stop or halt glaucoma disease progression (measured by VF test and / or OCT on RGC neural fiber layer thickness) with the superiority advantage of treating and preventing the progressive vision deterioration or visual impairment observed in early and moderate glaucoma. In phase 2 and phase 3 clinical trials, Trabodenoson has demonstrated its excellent clinical safety and MMP-14 / MMP-2 therapeutic potency with A1AR induced sensing cell neural protection and anti-inflammatory benefits; it offers a superiority advantage over currently available MMP treatments delivered by Durysta® or IDose as one-time treatment only, because of the PGA drug triggered intraocular inflammatuion that kills the cornea endothelium and RGCs at the back of the eyes, observed in clinical trials (which were not previously recognized). Trabodenoson is the only drug that has the potential to deliver continuously, repeatedly a life-time neural protection treatment to all stages of glaucoma and all types of glaucoma, via eye drops and / or sustained release formulation such as a biodgradable anterior chamber rod (AC rod).

[0118] Trabodenson in sustained release formula, such as in an AC rod, can be used as the loading dose, or drug holiday inducer, and offers a quick onset of RGC cell rescue or neural protection, estimated at 3-4 months to achievement of MMP treatment steady state, at which point the maximal neural protection benefit is anticipated. Early-to-moderate glaucoma patients may enjoy a disease- free IOP drug holiday without other medications or surgeries. Trabodenoson eye drops at optimal dosing (e.g. 1.5% BID) take a longer time (e.g., 6-12 months) for patients to achieve the maximal RGC neural protection benefit. Thus, it is envisioned herein that trabodenoson eye drops might be best used as a drug holiday stabilizer. Trabodenoson eye drops are the only current eye drops at a low dose that can deliver MMP therapeutics (other IOP -reducing drops do not have the right mechanism of action (via both MMP and Al AR routes) to remove ECM debris).

[0119] None of the current standard-of-care treatments for glaucoma possesses the correct mechanism of action (MOA) to reduce or eliminate the rate limiting pathophysiological processes that contribute to disease progression, which has limited the efficacy of such treatments. Identifying the rate-limiting root causes of multifactorial diseases, such as glaucoma and age- related macular degeneration (AMD), has proven challenging, and many drugs initially believed to address such root causes of glaucoma and AMD have failed in clinical trials. Among glaucoma drugs originally believed to impart neural protection, memantine, NGF, BDNF, NT3, NT4, CNTF, and Brimonidine have all failed in clinical trials or preclinical development. During clinical trials of certain such compounds, complaints were also made regarding a lack of sensitive and surrogate clinical biomarkers.

[0120] Trabodenoson was previously described to alter extracellular matrix (ECM) turnover by trabecular meshwork (TM) cells and to increase conventional outflow facility, thereby lowering IOP in young and aged mice (Li et al. Invest. Ophthalmol. Vis. Sci. 59: 383-392). In particular, trabodenoson treatment was observed to have significantly increased MMP-2 activity and MMP- 14 abundance, while decreasing fibronectin and collagen IV expression (Ibid). The prior art mistakenly ascribed slow mode MMP biological effects to fast mode vascular effects responsible for reducing the IOP (representing a universal blind spot in the art). Indeed, MMP treatment does not “reduce” the IOP itself, instead it treats the aging TM pathologies and improves a damaged pressure sensor functionality, thereby improving patient responsiveness to an IOP lowering drug. Applicant recently discovered (e.g., in PCT / US23 / 70729) that pressure sensor dysfunction or failure is the rate-limiting root cause of IOP elevation in patients with glaucoma; and Applicant further demonstrated that administration of low-dose trabodenoson (e.g., 1.5%) to patients, by upregulating MMP-14 and MMP-2, exerted a therapeutic effect sufficient to produce a drug holiday in treated patients. Low-dose trabodenoson therefore provided a curative solution for preventing and treating the IOP diurnal irregularities and uncontrolled IOP (or IOP failure) commonly observed across all types of glaucoma. While a bimatoprost intracameral implant (Durysta® trade name) was recently identified to activate MMP to therapeutic benefit for treatment of RGCs via a neural protection mechanism (as evidenced by significant reduction of VF loss at 12 months), PGA (prostaglandin analogue) also triggered intraocular inflammation, which compromised its neural protection benefits with limitation to one time treatment only (PCT / US23 / 70729). To a progressive neural degenerative disease over one’s lifetime like glaucoma, one time treatment is certainly far from sufficient, neither to stop the disease progression nor offer a curative solution to glaucoma-induced blindness.

[0121] Once a patient achieves the IOP drug holiday, their IOP level is considered an ideal target IOP, under which the retina and optic nerve head are in a stress free environment and their RGC cells are in a safe harbor being protected. Therefore, it makes no difference between a 9 mmHg IOP drug or a 6-7mmHg IOP drug. The current practice is misled by the rule of “the lower the better” which may do more harm than good, because of the ischemia-reperfusion damage especially the low vascular perfusion to the optic nerve head that may block the retrograde transport of neurotrophins (>50%) from the brain to the retina. The discovery of the MMP therapeutic towards a disease-free drug holiday is contemplated to set a new standard of IOP management, with the goal being to induce every glaucoma patient into a sustained IOP drug holiday (as early as possible) for the purpose of RGC neural protection for a lifetime.

[0122] The discovery of the rate limiting root causes pertinent to the vision loss observed in glaucoma is based on assessment of MMP therapeutics, delivered as bimatoprost SR and trabodenoson, respectively. The first rate limiting root cause is the sensing cell loss (similar to RPE loss in AMD), the culprit of the retinal ganglion cell loss in patients with glaucoma. The second rate limiting root cause is the IOP diurnal irregularities, which triggers three downstream signaling pathways, collectively causing the RGC cells undergoing apoptotic or necrotic cell death (prior arts each only grabs an ear of a giant elephant). Trabodenoson on glaucoma neural protection is through IOP normalization and removing the diurnal irregularities in glaucoma, such acts maybe through three neurovascular mechanisms: 1) normalize retinal / choroidal vascular perfusion around the ONH and improving neurotrophin retrograde transports and propagation, and 2) remove the neuroinflammation around the RGCs as a result of the microglia and astrocyte activations; 3) reduce lamina cribrosa rigidity and abnormal ECM deposition as a result of the oxidative stress and neuroinflammation.

[0123] Aqueous outflow is a part of the cardiovascular system, like any other tissue organ in the body, the ocular circulation is a nearly closed loop with the ophthalmic artery, as an entry pumping the high oxygen blood into the ocular tissues, and the ophthalmic vein and the cortex vein collecting the low oxygen blood and carrying the wastes as an exit from the globe. Outflow resistance at the TM is the rate limit or stumbling block of the entire circulation in the eye, if the outflow slows down or stops, it affects the entire globe circulation, specifically the vascular perfusion to the optic nerve head, which is the rate limit to the retrograde neurotrophin transports towards the RGC bodies and dendrites (e.g. metabolic inflammation at RGC dendritic synapsis).

[0124] Aging is the key risk factor of AMD and Glaucoma. MMP-2 treatment can turn a 60-year- old Bruch’s membrane into what is effectively a 40-y ear-old Bruch’s membrane (one possessing increased hydraulic conductance and elastic youth) as the basis of 2RT / MMP treatment for dry AMD and DME (ref: Prof. John Marshall), which provides a powerful scientific and clinical evidence (connecting the dots) of the MMP therapeutic on TM rejuvenation as the rate limit disease control for aged related glaucoma (POAG, PACG, NTG). In patients with glaucoma, the pressure sensor dysfunction or wearing out is the result of TM aging and oxidative damage as well as parainflammation or metabolic inflammation to the sensing cells and ECM pathologies (thickening or atrophy), collectively causing IOP elevation and diurnal irregularities, which is the direct cause or the secondary rate limiting root cause of vision loss in glaucoma. The rate limiting root cause is the dominant driving force in multifactorial slow progressive neural degenerative diseases such as glaucoma and AMD, the lead actor of a show. Trabodenoson or MMP treatment is the bottleneck control of glaucoma disease progression, not simply a disease modifying agent, and therefore is significantly preferred to the myriad other glaucoma therapies that are only disease-modifying (with no potential of being curative).

[0125] That trabodenoson derived MMP / A1AR therapeutic repairs and restores the metabolic hemeostasis of the pressure sensing cells whilst removing the ECM debris at the TM, collectively improves the pressure sensor functionality is the fundamental basis of the RGC neural protection in patients with glaucoma, which differs from the symptom relief IOP lowering drugs via the vascular effect (fast mode). Of important note, the MMP treatment is of neural protective in nature through the IOP normalization (slow mode) that may take from weeks to months depending upon the disease staging of a subject, MMP therapeutic potency and treatment regimen (e.g., SR vs eye drops), it does not reduce the IOP itself as indicated in all prior arts (the universal blind spot), instead it improves patient response to current IOP lowering medications. Therefore, Trabodenoson is very effective in treating the poor or non-responders in refractory glaucoma at an advanced disease stage, and rescuing the remaining pressure sensing cells and RGC cells from reaching to the tipping point of becoming non-recoverable, metabolically.

[0126] In contrast to the vascular effect, MMP treatment has a steady state where the ECM degradation and synthesis (turnover) reaches equilibrium and TIMP and MMP are in a balance that allows for maintaining the TM functional and anatomic integrity in glaucomatous eyes. As the rate limiting control, the MMP treatment, when reaching steady state, has the ability to reverse the pathological damage at the TM, resulting in clinically meaningful outcomes, such as dosing switch, drug holiday, or reduction of the need for medication. In comparison, Rhopressa® or Latanoprost Bunod both have mild therapeutic benefit - when these treatments reach steady state, only mild or transit IOP improvement was discerned by Applicant, and such small alterations were not appreciated by previous drug developers. Unlike current IOP lowering eye drops, trabodenoson eye drops, given at optimal dose, preferably 1.5% BID or 1.5% QD (flexible dosing / regimen) offer the most effective neural protection treatment, either as a standalone therapy, or in combination with MIGS surgeries (i Stent, Hydrus) or Ellios Laser (in development) or bimatoprost SR (in relay). In early and moderate stage glaucoma, it can fully cease glaucoma disease from advancing toward a late-stage vision loss (legally blind). Early intervention can eradicate glaucoma-induced blindness, in particular to hypertensive glaucoma (POAG, OH and PACG). To advanced stage glaucoma (POAG / OH, PACG, NTG) or refractory glaucoma, trabodenoson in SR or eye drops dosing at optimal concentration can be used in combination with Tube Shunt and Trabeculectomy or other late-stage drainage surgeries. Trabodenoson is an adenosine Al receptor agonist (Al AR), and its activation drives cell membrane hyperpolarization towards a resting stage, which is essential to restore neuronal cell homeostasis and improve cell metabolic competence. Trabodenoson at an optimal low dose eye drop (or sustained release, SR) provides a therapeutic neural protection towards the pressure sensing cells and cornea endothelium cell (CEC), both share similar neural lineage origin, therefore, it may offer effective treatment to Fuch’s cornea dystrophy and other cornea endothelium edema or decompensation caused by surgical, trauma or graft failure in corneal transplant conditions. The sensing cell loss at the SC inner wall is the trigger and the culprit of vision loss in glaucoma; similar to RPE loss in AMD, Bruch’s membrane is the rate limit, ECM pathologies are perhaps the rate limit to the sensing cell loss in glaucoma. Trabodenoson derived MMP / A1 AR therapeutic removes the two rate limit causes of vision loss in glaucoma, thus provides the most effective neural protection for a lifetime treatment without undesirable side effects.

[0127] TM outflow drainage system is a part of the cardiovascular circulation, aging related TM rigidity or atrophy slows down and stops the aqueous outflow in patients with glaucoma. MMP treatment repairs, rejuvenates and reverses the TM aging with increased hydraulic conductance and tissue elastance, hence restores the aqueous outflow homeostasis towards normalization. IOP diurnal irregularities result in abnormal vascular perfusion at the optic nerve head in patients with glaucoma. The ischemia-reperfusion damage causes deficiency of the retrograde neurotrophin transports within the axonal fibers from the brain to the retina through the lamina cribrosa and causing the RGC apoptosis. Trabodenoson MMP / A1AR therapeutic steady state represents the ECM equilibrium in the aging TM, at which the protein synthesis and degradation reaches to equilibrium and drug holiday becomes possible. Glaucoma remains the IOP problem as a result of the TM aging lost tissue elastance. Early prevention of the IOP failure or non-responders has the potential to eradicate glaucoma related blindless (30-40% patients become legally blind). In normal tension glaucoma, a subset of POAG, IOP irregularities or IOP stress remains a driven force that triggers the downstream signal pathways attacking the RGC complex (soma, dentritic synapsis, and axons) in the retina, including neurovascular inflammation, ischemia-reperfusion and oxidative damage to the RGC).

[0128] Set a new clinical standard: The discovery of trabodenoson derived MMP / A1R therapeutic or MMP treatment alone can induce glaucoma patients to a disease free IOP drug holiday, which was surprisingly found to be able to fully stop the VF loss, a neural protective to the RGC in the retina via the IOP normalization (a new mechanistic mode) through repairing or restoring the aged or damaged pressure sensor functionality by MMP treatment. The self-regulated IOP level during patient on drug holiday has been clinically validated (synthetic data analysis, Fig 4 and Fig 14) as the ideal target IOP, under which the retina and the optic nerve head is in a stress free environment and the RGC neurons are being protected. This new finding is challenging the current standard care that is based on the golden rule of “the lower the better”, which may do more harm than good. Trabodenoson sets a new standard of a clinical target IOP for glaucoma disease management by inducing patients on an extended drug holiday, a disease-free state during which patients can self-regulate their IOP as a result of the pressure sensor functional recovery. Glaucoma disease stage and clinical disease monitoring (caveats): glaucoma is an age-related, multifactorial, chronic and slow progressive neural degenerative disease and featured as optic neuropathy and optic nerve fiber layer thinning as the result of RGC cell loss that is irreversible. IOP is the only disease modifying risk factor and glaucoma neural protection has been the holy grail. Clinically glaucoma can be characterized as early stage, moderate stage and advanced stage of glaucoma (or servere or refractoy glaucoma), based on the severity of the VF loss or damage (as showed on Figure 13). Glaucoma disease monitoring is based on the current clinical standard of care using humphery VF tests and / or OCT on optic nerve fiber layer thickness assessments on every 6 to 12 months or more frequent (e.g. 3-6 months), by which a target IOP for individual eye is set forth to guide the IOP management for this subject, e.g. most patients (if diagnosed early) usually start with one medication at early stage, as the disease processes to the moderate and advanced glaucoma, two or three or four medications combined, and / or surgical or laser intervention may be required. The goal has been to lower the IOP at a target level set forth by above mentioned parameters (as showed on Figure 13). The principle of the IOP reduction has been “the lower, the better”, which is though based on well-established glaucoma interventional study results, suggesting that every l.OmmHg IOP reduction could slow down or reduce the disease progression by 20%. Such principle may have done more harm than good to some individuals, e.g. a single digit target IOP, often recommended to a severe glaucoma, which may excerbate the ischemia-reperfusion damage to the optic nerve head. This golden rule also may do more harm than good to early and moderate stage glaucoma. Figure 14 provides a clinical evidence of an ideal target IOP for early-to-mid stage glaucoma, which seems about l.OmmHg higher at week 12 when majority of patients (>2 / 3) are on drug holiday than that being driven forcibly by Bimatoprost when the API is still present at the week 2 and week 6 IOP timepoints. Current glaucoma clinical practice and drug development have been using the IOP reduction to assess which drug or treatment lowers the IOP more than the other to define the treatment effectiveness, which could be misleading or may not be applicable or relevant.

[0129] To reduce the IOP has been the mainstay therapeutic approach for glaucoma disease control and prevention. Despite the fact that there are over a dozen of FDA approved IOP lowering medications, various new MIGS surgical devices, trabeculectomy, laser and tube shunts available, about 30-40% glaucoma patients become legally blind, for decades physician surgeons have been troubled by the non-responders or uncontrolled IOP or IOP failure, few had understood why. New Standard of Glaucoma Disease Management & Drug Holiday Induction: The discovery of the pressure sensor (and the pressure sensing cell loss) as the first rate limiting root cause of IOP diurnal irregularities that directlyleads to the RGC loss as the 2ndrate limit of RGC loss in patients with glaucoma is changing the mindset and setting a new standard for glaucoma disease management in decades to come. Early disease intervention is no longer to lower the IOP at a target level that was set based upon the optic nerve damage (with 6-12 months in delay). To early and moderate stage glaucoma, inducing patient to an extended drug holiday will be the new standard of care for glaucoma. FIG. 4 (right) provides a clear evidence suggesting that patients on IOP drug holiday without a treatment better preserve their vision or visual field stability compared to patients treated with current standard of care, timolol eye drops (BID).

[0130] 'TOP diurnal irregularities" refer to an irregular or abnormal diurnal IOP flucturation (e g. average of 3-5mmHg daily flucturation in non-glaucoma eye, whereas a glaucomateous eye or patient may suffer 2-8 mmHg daily flucturation at more frequent basis (ups and downs), randomly, unpredictable, which presents the key metabolic stress to the RGC cell health at the back of the eye. Early stage glaucoma patient has better tolerance to such IOP stress compared to advanced stage glaucoma. Such irregularities are caused by the pressure sensor functional irregularities as the result of the pressure sensing cell loss accompanied by the TM rigidity and the loss of the tissue elastance (which has not been recoganized before). To protect and preserve the pressure sensor and sensing cell health (like RPE in AMD) is of strategic importance, it is the only way to prevent patient becoming non-responders or IOP failure or uncontrolled IOP at an advanced stage glaucoma or refractory glaucoma, thus, prevent glaucoma related blindness.

[0131] IOP Irregularities & Ischemia-reperfusion Damage: IOP is synchronized with the cardiovascular heart beat, dancing around the circadiam ryhtmn. Acqueous outflow is a part of the cardiovascular system, aging TM rigidity (loss of the elastic contracibility) slows down or stops the acqueous flow exit, which presents the key resistance and the bottleneck of the entire ocular blood flow circulation through the choroid / retina and optic nerve head, this is the basis of the ischemia-reperfusion damage in glaucoma. The IOP random spikes or irregularities in glaucoma directly translate into the ischemia-reperfusion injuries to the optic nerve head, which negatively affects the neurotrophin transport via retrograde mode (50%) from the brain to the retina. This explains why normal tension glaucoma patients lose their vision at very start, whereas ocular hypertension does not kill the RGC at the start. The RGCs seem to have better tolerance to a stable and relatively high pressure than the pressure random spikes.

[0132] IOP normalization & downstream risk factors: the current disclosure is related to Trabodenson MMP / A1AR therapeutic leading to drug holiday through IOP normalization in patients with glaucoma, which differs from all prior and ongoing efforts of glaucoma neural protection drug discoveries targeting on the downstream risk factors at the back of the eye. By removing the rate limiting root cause of the IOP stress or irregularities at the upstream is the most effective treatment as it blocks the damages caused by all downstream risk factors such as glutamate toxicity, neuronflammation (complement attack, TNF-alpha, NF-Kappa B), ischemiareperfusion injury, currently known or unknown.

[0133] Targeted population and disease segment: as the first neural protection drug, trabodenoson can be used for treating all stages of glaucoma, and all types of glaucoma. To address the most pressing unmet needs, trabodenoson therapeutic has unique superiority advantage of treating the poor or non-responders or refractoy glaucoma, and provides a lifetime neural protection with repeated dosing, trabodenoson can solve patient poor compliance of eye drops by inducing patients to a long-term extended drug holiday, during which there is no need for strict compliance as current IOP drops require, trabodenson eye drop can be given at twice daily or once daily at morning or evening, anytime, missing a few days may not do a harm. Trabodenoson is the only known eye drops that delivers the MMP therapy effectively and safety (Phase 2 and Phase 3 evidences). In addition to primary glaucoma such as POAG, PACG, NTG or OH, trabodenoson eye drops can also be used for treating the previously untreatable ECM pathologies involving with congenital glaucoma (seen in childen and young population), secondary glaucoma such as uveitic glaucoma or steroid induced glaucoma or pseudo exfoliation glaucoma etc.

[0134] Trabodenoson in SR vs Eye Drops: The holy grail of MMP treatment as a platform therapy is preferably delivered by Trabodenoson, an adenosine Al receptor agonist in an eye drop formula, and / or a sustained release (SR) formulated by biodegradable polymer, through the intracameral delivery route to target on the TM (site of action), preferably via a minimally invasive office based procedure. Trabodenoson SR product offers intensive 24 / 7 MMP treatment with a quick onset to achieve a drug holiday in about 80% patients at early and moderate glaucoma (used as a drug holiday loading dose). To advanced or severe glaucoma, trabodensoon therapeutic in SR formula can quickly reach to the MMP treatment steady state within 3-4 months with the maximal therapeutic or neural protection benefit for rescuing the RGC cell death and preventing patients at the tipping point, from becoming legally blind, usually in 3-6 months (legally blind: VF is equal or less than 20 degree (tunnel vision) in better seeing eye, or BCVA is equal or less than 20 / 200 in better seeing eye). Trabodenoson eye drops dosing optimal (e.g. 1.5%) alone can induce patient toward a drug holiday state but may take more than 3 months (e.g. 6-12 months or 12-24 months), it will be preferably used as drug holiday stabilizer, it offers a convenient dosing flexibility that does not require a strict dosing compliance. To a certain glaucomateos condition or IOP elevation involving severe intraocular inflammation such as uveitic glaucoma, steroid induced IOP spikes or pseudo exfoliation glaucoma, trabodenoson eye drops presents a unique advantage to this therapeutic niche market compared to trabodenoson in a SR biodegradable polymer system.

[0135] Trabodenoson SR Product Design: regardless of the size, shape, dimension, location, or materials used to carry or release the API, the guiding principle of Trabodenoson SR product design parameters: API loading dose, daily release speed and API duration are strictly determined by the patented dosing optimal of Trabodenoson eye drop: 1.5% or at a range between 1.2%-3% dosed at twice daily for preferably 14-28 days that allows to achieve a target API concentration in the acqueous humor in human eyes. Once the SR formula achieves the zero order pharmacokinetic, the target API concentration released from the SR system with daily concistency should be the same range as to the API concentration delivered by trabodenoson eye drops dosing optimal. Accordingly, the selection of clinical or preclinical SR dosing optimal (API loading dose, API release speed, API duration) is governed by or valiated by its signature IOP pattern behavior that is the incremental improvement of IOP performance in patients with glaucoma (Trabodenoson Phase 2 and Phase 3 trials). In a biodegradable SR formulation made by PLGA, PGE, hydrogel or other biodegradable materials, the API release (speed / duration) and the degradation (speed / duration) of biodegradable materials (or called API carrier or the carrier) should be in a similar pace to avoid residual API precipitations or remaining empty SR system without the API, preferably the API is released ahead of the carrier (visible in the AC) for 5-7 days or maximal 7- 14 daysThe following detailed description is exemplary and explanatory and is intended to provide further explanation of the present disclosure described herein. Other advantages, and novel features will be readily apparent to those skilled in the art from the following detailed description of the present disclosure. References of INO-8875 or trabodenoson Patent Nos. 7,423,144; 8,501 ,708; 9,522,160; 9,370530 and US patent application Serial No. US2016 / 0158268. WO 2012 / 028585 Al.

[0136] Trabodenoson (formerly known as INO-8875) is a potent (Ki=0.97nm) and selective adenosine Al receptor agonist (Al AR), the structure of which is shown in FIG. 1 according to the publication in Patent PCT / EP2011 / 064829 (Kalar J. et al. PCT Int Appl WO 2012 / 028585 Al. Page 31 2012 March 8), and PCT / WO2014 / 152723A1 (WK McVicar et al. Ophthalmic Formulations). At a low dose eye drop (0.6% BID, or 1.5%BID), Trabodenoson simultaneously activates three independent pathways at the trabecular meshwork ™ resulting in the signature IOP pattern behaviors, governed by its unique dual MO As. One molecule contains two different drugs, one arm represents an IOP drug with a fast mode vascular effect that requires optimal dose to achieve the maximal IOP reduction (6-7mmHg at day 28 in Phase 2 clinical trials); the other arm represents the MMP / A1 AR drug, with a slow and accumulative mode of MMP cleavage biological effects, along with its A1AR induced cell hyperpolarization of the sensing cells (resting state), it upregulates and delivers MMP-14 and MMP -2 with anti-inflammatory property at therapeutic level in a time, dose and disease staging dependent manner, with a steady state. The synergy of MMP / A1AR biological effects is of therapeutics to repair the TM, does not reduce the IOP but improves the pressure sensor functionality, fully or partially. Full recovery represents a healthy state of the pressure sensor, where patient regain its intricate cell biological competence of the sensing cells and can self-regulate the IOP without the need for treatments, called IOP drug holiday, a disease-free state. Partial recovery includes two scenarios, to early and moderate stage glaucoma, MMP / A1AR therapeutic may have not reached to the steady state but on the recovery road, about 80% or more patients at early to moderate stage with one or two medications can potentially achieve the IOP drug holiday. To severe or refractory glaucoma, when MMP / A1AR reaches to the steady state with maximal treatment effects, the remaining sensing cells (the threshold of the minimal percentage of pressure sensing cells that can compensate for its full functionality and self-regulating the IOP is unknown) may not be able to compensate for the significant cell loss to fully recover the pressure sensor’s functionality that allows to achieve the IOP drug holiday, and patient may still need extra treatment such as adding one medication or MIGS. This is the biology underpinning a combination therapy of trabodenoson (eye drops or SR) with current standard of care of IOP lowering medications, such as Rhopressa® or MIGS such as i Stent. With trabodenoson improving the pressure sensor functionality and potentiating the remained sensing cell metabolic competence, patients at an advanced glaucoma or severe refractory condition could become medication responders again without the need for an aggressive risky drainage surgery such as tube shunt, otherwise. In a similar vein, cornea endothelium loss in Fuch’s cornea dystrophy, when the cell loss reaches to a threashold (less than 15%), patients will need a cornea transplant. Massive RPE loss leads to large geographic atrophy in AMD, at which point the RPE transplant may be required. Luckily, trabodenoson on MMP rejuvenation may spare glaucoma patients from the need for TM sensing cell transplant at the end stage, and early intervention is key to achieving a cure.

[0137] The MMP therapeutic steady state refers to the ECM degradation and synthesis achieving an equilibrium, during which MMP and TIMP secretions are in balance. Such equilibrium is important for maintaining the structure and anatomic integrity of Trabecular meshwork ™ tissue health (elastic youth) in normal or healthy condition. In patients with glaucoma, such equilibrium is disturbed or becomes imbalance with the ECM degradation being slower than its synthesis (the turnover runs down), possibly for two reasons: one is the MMP down regulated at the TM endothelium as a result of aging and oxidative stress or damage; Secondly, the normal level of MMP secretion can no longer meet an increased demand for a speedy clearance of the daily increased deposition of physiological or pathological proteins, such as laminin, fibronectin, type IV collagen and glaucomatous pathological proteins, under an increased oxidative stress, and / or intraocular inflammation, etc. Such accumulative protein depositions ultimately lead to ECM thickening, rigidity, clotting of the mesh pores in the aging TM. The aqueous outflow is pulsatile, synchronizes with the cardiovascular heartbeat, driven by the healthy contractible and elastic ECM tissue complex, similar to a water pump system. When TM tissue becomes rigid and loses its elastic youth, the pulsatile aqueous outflow could slow down or stop moving through the contractible pump system towards the Schlemm’s canal and exit to the episcleral vein (ref: Murray Johnstone 2023), thus, IOP becomes irregularities with unpredictable spikes and / or elevated during the diurnal circle. The pressure sensing cell or sensor is the chief regulator of the aqueous outflow pump system. The sensing cell loss is the first rate limiting root cause of IOP diurnal irregularities in patients with glaucoma (like RPE loss in patients with AMD).

[0138] Trabodenoson specifically activates the Al receptor at the pressure sensing cells, leading to G protein couple cell membrane hyperpolarization, similar to its action mode in the retinal ganglion cells, both are neural lineage cells which has abundant distribution of A1AR on the cell membrane surface. This neuronal cell membrane hyperpolarization represents a resting stage of cell metabolic status, which is of strategic importance to restoring cell homeostasis and boosting metabolic competence under a constant oxidative stress. Similar action mode applies to the cornea endothelium cells that shares a similar embryonic lineage with the pressure sensing cells.

[0139] In prior phase 2 studies that assessed monotherapy of trabodensoon eye drops and combination add-on to Latanoprost poor responders, a dosing switch from BID to QD was seen within 3 months, which is an example of partial recovery before MMP / A1AR reaching to the steady state of a drug holiday, this may take longer than 3 months. To advanced or end stage glaucoma, if the sensing cell loss reaches to a threshold where the remaining cells can not compensate for its full functional duty, patient may still need additional treatment (e.g. IOP lowering drops or surgeries), this small group of patients may or may not be able to achieve the disease free and drug holiday status when MMP / A1 AR therapeutic reaches to the steady state (to be investigated). Based on bimatoprost SR induced MMP treatment in early-moderate glaucoma, about 2 / 3 to 80% patients with one or two medications prior can achieve drug holiday status with 1 to 3 consecutive implants over 4 to 12-month MMP treatment, to the same group patient, Trabodenoson can induce more than 80% of patients on drug holiday at a given time (eye drops and SR differ) because of its added Al AR benefits towards the sensing cell health, and its high potency of MMP-14 with anti-inflammatory benefit is of a plus. To advanced glaucoma, trabodenonson derived MMP / A1AR dual therapeutic may shift the disease spectrum from early- mid stage glaucoma to an advanced stage glaucoma, of which a patient may achieve the IOP drug holiday than Durysta, iDose or other MMP treatment alone.

[0140] High dose API of bimatoprost (4400x higher than its eye drops dosing) triggered significant intraocular inflammation that killed the cornea endothelium at an alarming rate (20% CEL in 20 months), also likely exerts similar inflammatory attack to the pressure sensing cells and RGCs at the back of the eyes. On one hand, bimatoprost SR derived MMP can repair a damage sensor and rejuvenate the TM, on the other hand, the high-level inflammation also accelerates the disease progression by killing the pressure sensing cells which defines glaucoma disease staging, the rate limiting root cause of RGC cell loss.

[0141] The recoverability of pressure sensor functionality is dependent upon the disease staging (totality of sensing cell number and its metabolic state). And the drug therapeutic potency also plays an important role. Discovery of Rate limiting root causes in Glaucoma from Patients (Proof)

[0142] There is a fundamental difference between a drug that can remove the rate limiting root causes and drugs or treatments that cannot do so. Current IOP lowering drugs are largely of symptom relief, can only slow down the disease progression at very limited level (S=l-3 on eye drops, S=5 on MIGS, S=6 on bimatoprost SR, S=10 on Trabodenoson shown in FIG. 8). The visual field (VF) results of FIG. 4 clearly showed that patients treated with timolol in the positive control continued to lose vision despite the fact that these patients' lOPs were under good control (VF decline >1 OdB sharply at 12M, and at the 20M), whereas patients in the bimatoprost SR group maintained their VF stability at 12M, with very small decline (<0.3dB). The small VF decline in patients on drug holiday was caused by high dose API, which triggered massive intraocular inflammation, which killed the RGCs, causing sensing cell loss and cornea endothelium cell loss (CEL) with clinical significance. Bimatoprost SR-caused CEL (20% loss in 20 months) was faster and more severe than Cypass (30% CEL in 5 years), which was pulled from the market in 2019. Such magnitude of intraocular inflammation poses significant metabolic stress and oxidative damage to both of the sensing cell stability and the RGCs, which are already under oxidative stress in response to high metabolic demands in glaucomatous eyes.

[0143] A prior study team likely did not fully comprehend the biological implication associated with the VF benefits in this context. From existing publications of the bimatoprost SR study team and other experts in this field, most people attributed the cornea problem to a mechanical damage (swelling rod), which was incorrect. The inflammatory attack is of an accumulative and slow mode towards pan-cornea, whereas mechanic injuries happen fast (in weeks) in cornea clinic, it starts at the local point of contact. From the VF stability results at 12M and 20M, it clearly showed that lOug is better than 15ug (loading dose), which is in concert with our prior findings that the PGA triggered intraocular inflammation is API dose dependent, proportionally increased over time. After the API is gone (around 12 months), the inflammation cascade did not stop completely. Visual field loss was primarily caused by PGA triggered inflammation (FIG. 4), which happened during and after the API was gone. When patients reached drug holiday, a disease-free state, they should not have continued losing vision.

[0144] ECM equilibrium: In glaucomatous eye, oxidative damage and para inflammation caused excessive pathological ECM protein to build up at the BM, and MMP secretion in the TM cells does not meet the high demand in such pathological condition, which caused BM thickening and TM mesh pore cloting. There is a deficiency of MMP (MMP < TIMP, tissue inhibitor of metalloproteinase) in glaucomatous eyes. Trabodenoson and high dose PGA such as bimatoprost SR can upregulate MMP secretions to supplement MMP deficiency, which restores the balance between MMP and TIMP, further repairs and restores the ECM equilibrium by accelerating ECM protein degradation. In bimatoprost SR treated patients, when the API is presence during the first 12 months, MMP upregulation is controlled by the negative roop feedback from the ECM substrates (collagen, fibronectin, lamina or pathological ECM in glaucoma) at the TM, it prevents over digestion and degradation by the excessive enzyme (MMP). Once MMP therapeutics reach to a steady state, MMP and TIMP achieve the equilibrium to maintain the ECM integrity and health. Without the presence of API (bimatoprost), MMP upregulations will stop, however the inflammatory molecules could stay inside the globe especially in the vitreous cavity for a long time. This explains why patients on drug holiday continued to lose their VF at 12M and 20M. The VF difference between 12M and 20M in bimatoprost SR treated groups (lOug and 15ug) suggests that the MMP treatment is important to stabilize the sensing cell functionality. There is a possibility that some patients might not be on “true” drug holiday which was included in the analysis because patient rescue (with medication) was solely based on handful IOP timepoints, not a 24-hour IOP monitoring. During the first 3-month drug holiday induction period, patients continued losing vision (RGC cell loss) before their lOPs being fully normalized, at which point the RGCs are in safe harbor being protected. Hence, above three collective factors explain the VF decline at 12 months and 20 months compared to the baseline VF in patients treated with bimatoprost SR. If trabodenoson SR (3-month API duration) is used as a loading dose followed by Trabodenoson eye drops (between 1.0%-3.0%, preferably 1.5%) as MMP maintainence therapy, within 3 months, a majority of the patients could achieve the MMP therapeutic steady state with a potential to eliminate the RGC loss, completely. This is the future of glaucoma specialty care.

[0145] IOP Diurnal Irregularities, the 2ndRate Limit

[0146] Like blood pressure, IOP synchronizes with the cardiovascular heartbeat with diurnal variances. In a normal healthy eye, individual IOP diurnal variance is regular, consistent, reproducible, or predictable. In glaucoma patient, the diurnal IOP fluctuation centering around the circadian rhythm becomes irregular with spikes and dancing round the clock, such diurnal irregularities are unpredictable, and inconsistent day by day or week by week. Glaucoma is bilateral disease, the diurnal irregularities in the two affected eyes for the same patient also can be different depending upon the disease staging. Such irregularities signify the pressure sensor functional irregularities, caused by ECM clotting, basement membrane thickening, and rigidity that prevents the outflow exist smoothly. It also can be related to the pressure sensing cell metabolic abnormalities (e.g., cell edema) or functional irregularities alone or combined with ECM problem. As glaucoma disease advances to a late stage, these neural lineage derived sensing cells, similar to cornea endothelium and RPE, lack of self-renew in adulthood in mammalian eyes, undergo apoptosis as the results of oxidative damage, aging, and inflammation etc. When the sensing cell loss reaches to a threshold which is unknown at this point (e.g. 50% loss), the remaining sensing cells can no longer compensate to provide the full functional support, at which point patients become poor or non-responders to medication, hence tube shunt or trabeculectomy becomes inevitable. Most glaucoma patients become legally blind during this stage due to high rate of surgical complications (>50% failed in 3-5 years). Similar to cornea endothelium loss in Fuchs cornea dystrophy, and RPE loss in GA / AMD patients, cell tissue transplant surgeries are the final rescue strategy.

[0147] Trabodenoson Impact Upon the Rate Limiting Root Cause of RGC Cell Loss in Glaucoma

[0148] One of the most important features of trabodenoson derived from its being a MMP / A1AR therapeutic lies in its ability to normalize the IOP diurnal irregularities observed in patients with glaucoma (FIG. 2). Trabodenoson rejuvenates, repairs and restores the functional performance of the pressure sensor, and boosts the sensing cells' metabolic competence. Ultimately this is the rate limit to RGC health. In hypertensive glaucoma (POAG, PACG) and OH, IOP stress and diurnal irregularities are the rate limiting root cause of RGC cell apoptosis or loss. Trabodenoson is disclosed herein as the first cure for hypertensive glaucoma, and its impact should be greater than Lucentis for wAMD, because of the high prevalence of glaucoma (which is the leading cause of irreversible blindness worldwide, affecting 120M patients worldwide by 2040).

[0149] Glaucoma Optic Neuropathy & Lamina Cribrosa: RGC axons exit the orbit through a mesh-like lamina cribrosa (LC) at the optic disc; the optic nerve fiber bundles project toward the optic chasm (crossover) to the visual cortex in the brain. The LC deformation and displacement is associated with its ECM thickening and rigidity, which affects the anterograde and retrograde transports of growth factors and neurotrophins from the brain visual cortex to the retina and vice versa (Ref: Gitty DD, Segal RA. Curr Opin Neurobiol. 2002 Jun;12(3):268-74 ). About 50% of the nutrient supplies to the RGC cell bodies come from the brain; IOP irregularities especially the unpredictable spikes cause ischemia-reperfusion damage to the optic nerve head, further causes RGC metabolic deficiency. IOP stress also triggers the neurovascular inflammation via microglial and astrocyte activations, which releases a cluster of harmful excitatory neural transmitters / proteins, such as glutamate and dopamine, and inflammatory cytokines, such as the master inflammatory regulator, NF-Kappa B, TNFa and ILs, collectively, these neurotoxin and inflammatory cytokines trigger the RGC apoptotic pathway or even necrotic cell death. At the same time, these harmful risk factors also disturb the MMP / TIMP balance and causing ECM building up around the LC, which is a key root cause of pathophysiologic mechanism of glaucomatous optic neuropathy.

[0150] Neurotrophins & Neuronal Tyrosine Kinase (Trk) Signaling Pathway . Neurotrophins bind to tropomyosin related kinases (Trk) receptors mainly at axonal endings. RGC exonal terminals are located at the visual cortext on the brain. Each member of the neurotrophin family, such as nerve growth factor (NGF), brain-derived neurotrophic factor (BDNF), neurotrophin-3 (NT-3) and neurotrophin-4 (NT-4) interacts with specific tropomyosin regulated kinase (Trk) receptors which regulate growth and survival via activation of PI3K-Akt, extracellular signal-regulated kinase (Erk) and phospholipase C-y (PLCy) pathways. For example, NGF has a specific high binding affinity with Trk A, BNDF binds to Trk B receptors, NT3 interacts with p75, and etc. The paracrine neurotrophins released from the brain, through the retrograde mode and propagation mechanism, the vesicular transports of the neurotrophin-TrK complexes transmits a survival signal that involves PI3K and Erk5. Other, non-vesicular modes of retrograde signaling are likely to function in parallel (Ginty DD, Segal RA. Retrograde neurotrophin signaling: Trk-ing along the axon. Curr Opin Neurobiol. 2002 Jun;12(3):268-74).

[0151] Recent studies highlight the importance of the location of stimulation as a determinant of Trk signaling. Decades of efforts spending on neural protection drug discovery failed, the most extensive studied neurotrophic factors perhaps are BDNF, NGF, followed by neurotrophins (3 / 4) and CNTF. Of important note, their respective binding receptors are tyrosine kinase A, B, C, located at the brain visual cortex, not in the RGC bodies at the retina as most people may have thought. In human clinical trials, these growth factors including recent BDNF gene therapy (preclinical) are delivered to the vitreous cavity, which is off-target (on site of action). Perhaps it explains one reason why none of these factors had worked in prior clinical trials. Most of the preclinical experiments are done in a small rodent model, which usually work well, because the pharmacological distribution of the proteins from the IVT route to the brain likely achieves a therapeutic concentration a in small rodent model, but unlikely it can reach to a therapeutic level in the brain via IVT route.

[0152] Ophthalmic Vascular Perfusion and Glaucoma: Cardiac-induced pulsatile aqueous outflow and choroidal blood volume changes, which determines the vascular perfusion to the entire globe via the ophthalmic blood vessel distribution such as ciliary long and ciliary short vascular branches and central / branch retinal arteries and central / branch retinal veins to nourish the optic nerve head and the neural sensory retina. Outer layer of the retina (mainly made of photoreceptors and RPE) draw metabolic nutrients from its underneath choroidal vascular circulation, through metabolic exchanges crossing the blood-retinal barrier, which is made of RPE and its underlying Bruch’s membrane. The fenestrated microvascular capillary network in the choroidal space holds the key blood volume affecting the pulsatile IOP regulations, along with the ciliary body, the middle layer of the choroid tissue serves as the “heart” of the eyeball. The vascular perfusion defect, specifically, the ischemic-reperfusion damage has been associated with glaucoma neural degeneration by various clinical and preclinical studies (Prof. Alan Harris at Indiana University). However, the state of art research has not recognized that the TM aging rigidity and pressure sensor dysfunction could directly affect the back of the eye on the vascular perfusion via pulsatile IOP irregularities. Prior arts also did not recognize that the TM health affects the pressure sensing cell metabolic competence and the RGC cell health at the back of the eye, both. Trabodensoon derived MMP upregulation leading to the TM rejuvenation solves the fundamental IOP problem (irregularities). The clinical trial evidence of MMP therapeutics lead to dosing switch, IOP improvement, and a disease-free drug holiday, during which patient preserves their vision (visual field stability) also indicate that the IOP diurnal irregularities (spikes) is the rate limiting root cause of the abnormal vascular perfusion at the optic nerve head in patients with glaucoma.

[0153] Neural Protection in Normal Tension Glaucoma (NTG)

[0154] Normal tension glaucoma (NTG)is a small subset of the POAG population. POAG accounts for 74% of the cases, PACG (primary angle closure glaucoma) is about one quarter of POAG cases however it is responsible for 50% of glaucoma blindness. All PACG are hypertensive. Among the subset of POAG is NTG, its prevalence varies greatly by different studies and different ethnic groups (Asia > Europe), e.g. about 40% Japanese with POAG are NTG (Van Eijgen J, et al. Front Med (Lausanne). 2023). For NTG, lowering the TOP is still the most effective treatment to reduce the vision loss in glaucoma clinic. The target IOP is based on the VF stability, which does not provide real time guide for IOP management. The IOP diurnal irregularities remain the key causative factor, the rate limit control of IOP dependent risk damage to the neurons in NTG. Additionally, there are IOP independent risk factors attributing to the RGC cell apoptosis, which is also rooted to the IOP stress or irregularities, these causative factors are previously thought as IOP independent risks are indeed of IOP driven downstream risk factors leading to the RGC death, including but not limited to neurovascular inflammation (choroidal perfusion, optic disc perfusion, cerebrospinal fluid pressure), choroidal-retinal vascular perfusion, aging related oxidative damage and para inflammation, along with IOP stress, collectively, activate and trigger various bad actors (microglial, astrocyte and oligodendrocyte) releasing harmful cytokines and proteins such as NF- kappaB, TNF-a, glutamates, complement factor (Cql), crystalline, heat shock proteins and others, which triggers RGC cell apoptosis. Intracellularly, mitochondrial stress and damage, autophagy are under metabolic stress. In NTG, IOP irregularities intertwine with neurovascular inflammation underpinning by microglia, astrocytes, and oligodendrocyte, and choroid ischemia-reperfusion damage attributing to the RGC apoptosis and optic nerve fiber loss. A summary of such complex biological and pathological processes involved in the RGC cell apoptosis and vision loss in glaucoma was also prepared herein (FIG. 4, left).

[0155] The prior art suggests that vascular perfusion defect is a key risk factor associated with NTG. For example, obstructive sleep apnea syndrome (OSAS) may compromise optic nerve head perfusion and cause glaucomatous optic neuropathy by creating transient hypoxemia and increasing vascular resistance. These vascular abnormalities are associated with the abnormal regulation and imbalanced activities between parasympathetic and sympathetic never systems, which is intertwined with the pulsatile aqueous outflow driven by the cardiovascular pump system. Although aqueous outflow drainage system through the TM (accounts for >85% outflow exit ) is avascular system without nerve terminal innervation (like in the cornea), the ciliary bodies that secrets the aqueous humor and episcleral veinous system that serves as a valve have rich parasympathetic nerve innervations.

[0156] Trabodenoson and bimatoprost SR have not been tested for its neural protection in NTG population. The collaborative normal tension glaucoma study over 5-year period, comparing 30% IOP reduction in NTG vs control (no treatment) showed that the pressure lowering of 30% is beneficial to some patients, but did not stop the disease progression to all patients (AJO 1998, 1998;126:498-505). Based on the evidence discussed herein, lowering the magnitude of the IOP fluctuation (spike) does not solve the problem of the diurnal irregularities, the unpredicted IOP spikes and high frequency of the turbulation pose significant stress (risks) to the metabolic health of the optic nerve head and RGCs at the back of the eye. Also, forcibly lower the IOP by 30% may do more harm than good to some patients, depending on their target IOP level at a given stage of the disease, e.g., from baseline IOP at 18mmHg to 12.6mmHg (too low) may cause an optic disc perfusion deficiency. In a clinical study of Rescula and Latanoprost on patients with NTG showed that Rescula IOP lowering effect is less effective than latanoprost, but their visual field stability at 12-month endpoint is similar or has no statistical difference.

[0157] In glaucoma clinics, ocular hypertension (OH) patient does not have the optic neuropathy at the beginning or early stage, but NTG causes RGC death at the very start, which provides further evidence suggesting that high IOP is not the key threat, it is the unpredictable IOP spikes, diurnal irregularities that presents the key stress triggering the downstream signaling pathways and cascade neurovascular inflammatory attacks towards the back of the eye that causes the RGC death in glaucoma. In Trabodenoson Ph 1 / 2 dose escalation, trabodenoson MMP treatment is less effective in patients with ocular hypertension (OH) compared to POAG patients, which adds another clinical evidence of the IOP irregularities as the rate limiting root cause.

[0158] Trabodenoson MOA and Therapeutics

[0159] Trabodenoson is an adenosine small molecule drug, specifically activates adenosine Al receptor (Al AR), and simultaneously triggers three independent signaling pathways at the TM cells, which led to M2 receptor activation that reduces IOP as symptom relief (fast mode), and MMP upregulations along with its A1AR driven neural protection to the sensing cells, both synergistically improve the IOP performance as a therapeutic drug (slow mode). Trabodenoson improves IOP performance through repairing and restoring the pressure sensor functionality partially or fully, the later indicates a drug holiday, a healthy state where pressure sensor can selfregulate the IOP without the need for extra medication. Such healthy state represents the steady state of MMP treatment where extracellular matrix (ECM) synthesis and degradation reach to the equilibrium (MMP / TIMP level in balance). The steady state of MMP therapeutic enables a full recovery of the pressure sensor, suggesting that MMP is able to remove the rate limit disease root cause at the TM. Rho-kinase inhibitor and Prostaglandin Bunod with nitric oxide donation both have mild clinical benefit via relaxing the actin dynamic in cytoskeleton contractability at the JCT, or exerting the cytoprotection to the sensing cell via NO donation, respectively, however, when they reach to the steady state, the IOP improvement is not clinically significant. Whereas MMP therapeutic leads to the TM rejuvenation which allows to dosing switch (from BID to QD), reduction of the medication or drug holiday, which is the holy grail, an indicator of the full functional recovery of the pressure sensor.

[0160] Once the MMP treatment reaches to its steady state, it is important to maintain the ECM equilibrium in patients with glaucoma by supplementing a small stream of MMP at daily base or less frequent dosing regimen to keep the TM clean and preventing the meshpore clotting again, resulting in IOP irregularities that kills the RGCs at the back of the eye. There is a time window (which varies patient by patient) allowing for a disbalanced MMP and TIMP level at the TM whilst the newly repaired pressure sensors can compensate for their functionality before the IOP irregularities re-occur, therefore, trabodenoson eye drop (e g., 1.5% QD) is a preferable option for delivering such a maintenance therapy to stop and prevent the RGC loss in glaucoma. Trabodenoson eye drops in this setting does not require a strict dosing compliance, missing a few drops or a few days won’t do any harm as current IOP drops do. This is the new standard of care for glaucoma disease management, by maintaining or delivering a sufficient MMP level at the TM in glaucomateous eyes could potentially achieve a lifetime neural protection to prevent the sensing cell loss at the TM and RGCs cell apoptosis at the same time, offers a “dual” neural protection to the front and back of the eye in glaucoma.

[0161] MOA-Disease Match

[0162] In drug discovery, the principle of drug MOA and disease root cause match is the key for developing a curative solution for treating any disease involving with multifactorial risk factors. In patients with glaucoma, the MMP production is deficient or down regulated in aged TM endothelium, oxidative stress and para inflammation accelerates ECM deposit at TM beams, accumulatively causing the TM basement membrane thickening, rigidity and clotting the mesh pores, which causes pressure sensor functional irregularities or dysfunction that is the rate limiting root cause of IOP elevation or IOP failure (clinically defined as uncontrolled IOP to a target level), bimatoprost SR derived MMP therapeutic leading to drug holiday suggests that MMP treatment is sufficient to remove such rate limiting root cause, fully restore pressure sensor functionality in mild and moderate glaucoma in about 80% treated patients. Trabodenoson not only upregulates potent MMP-14 / MMP2 but also provides additional neural protection to the sensing cell, which allows to shift therapeutic spectrum toward advanced or late-stage glaucoma, and also allow to achieve higher IOP drug holiday induction rate (>80%).

[0163] Applicant first discovered the pressure sensor as the rate limiting root cause of IOP diurnal irregularities in glaucoma (G Qiu, PCT / US23 / 70729). Bimatoprost SR induced MMP treatment alone can fully restore the damaged pressure sensor with a full functional recovery (for a short period time) toward a disease-free drug holiday status. Currently, trabodenoson and PGA in SR (such as bimatoprost SR and iDose) are the only drug or products releasing the MMP at therapeutic level with a proof of Ph3 clinical evidence. ROCK inhibitor such as Rhopressa® works via juxtacanalicular tissue (JCT) relaxation but does not have the right MOA to upregulate MMP thus, cannot remove ECM debris. Vyzulta delivers nitric oxidate (NO) to protect the sensing cell health but does not upregulate MMP at low dose eye drops (so do all the marketed PGA eye drops). MIGS solves patient compliance, reduces the magnitude of IOP spikes, but cannot eliminate or normalize the IOP diurnal irregularities in patients with glaucoma. Travoprost SR intracameral implant (OTX-TIC @Phase 2, Ocular Therapeutics) may face similar problem as bimatoprost SR. iDose is another PGA drug (Travoprost) in a SR format via medical coating (Glaukos), which also has caused significant corneal endothelium loss. PGA induced intraocular inflammation could damage both the pressure sensing cells and RGCs at the back of the eye. Strictly, PGA should not be made in SR delivering via intraocular routes (either intracameral or intravitreal) because of the visual threatening side effects, PGA is a very potent pro inflammatory agent that releases bradykins, causing prolonged cystoid macular edema clinically.

[0164] To normalize the IOP diurnal irregularities via MMP therapeutic is the most effective approach to glaucoma neural protection.

[0165] Because current IOP lowering drugs (eye drops) can offer only symptom relief, even while requiring strict dosing compliance, they can only slow down disease progression to some extent and were assigned herein an efficacy score level of 1-3, even including the most potent IOP drug, Vyzulta, which achieves up to 9mmHg IOP reduction (FIG. 3). MIGS devices solve the poor compliance issues, and they therefore tend to be better than non-trabodenoson eye drops, having been assigned a score of around 5. Another glaucoma drug with therapeutic benefit is Rescula, a B-K channel activator that removes the intracameral inflammation leading to IOP improvement in refractory glaucoma with active inflammation (small subset), but to majority of POAG / OH patients, rescula does not show “a therapeutic TOP profile” with a 3-4mmHg reduction (a weak IOP lowering drug). Rescula does not have the right MOA to remove the existing damage to the ECM (thickening, rigidity), it needs MMP, the holy grail therapy for glaucoma. In a similar vein, complement therapy (Syfovre) can only slow down the geographic atrophy progress by 20% after 2-year treatment, because parainflammation (subthreshold) is not the rate limit to dry AMD or glaucoma (G Qiu, book chapter, 2023). In drug discovery, it is vital to identify the rate limiting root cause before desiging a therapeutic target, otherwise, the clinical trials failure rate will be very high (>90%). The discovery of Trabodenoson MMP therapeutic on RGC protection is from patient data to drug MoAs, its MOA-disease match has been validated by phase 3 clinical trials with positive results, hence, the clinical trial success will be warrant. This is the new frontier of big data for medicine innovation.

[0166] The Holy Grail: RGC Neural Protection via MMP on IOP Normalization

[0167] Glaucoma remains the IOP driven neural degenerative disease featuring of optic neurapthy underpinning by the RGC loss (apoptosis and / or necrosis). Decades of glaucoma neural protection research have been largely focusing on the following three pathways, which separated or disconnected the IOP risk factor from its downstream causative factors at the back of the eye: 1) neuroinflammatin pathway via activaton of microglia and astrocyte releasing a cluster of harmful neurotoxins (glutamate and dopamine) and cytokines (TNFa, IL and NF -Kappa, crystalline, heat shock protein etc), ultimately leading to the RGC cell death; 2) ischemia-reperfusion damage to the back of the eye, especially optic nerve head, the bottleneck of the retrograde neurotrophin transport from the brain to the retina causing the neutrient deprivation of the RGC complex; 3) lamina cribrosa deformation at the optic disc, underpinning by the ECM thickening and / or atrophy. These three pathways intertwined are at the downstream, which is driven by the upstream IOP problem: IOP stress or diurnal irregularities (abnormal or irregular IOP fluncturation) or IOP elevation. Prior arts each only grabs an ear of a giant “elephant”. IOP is not only a disease modifying risk factor, but also the domain driven force or bottle neck rate limit control of all currently known risk factors pertinent to the RGC loss in glaucoma.

[0168] IOP stress includes three scenarios: elevated IOP above 21mmHg, high magnitude diurnal IOP variance, and the diurnal irregularities caused by intricate pressure sensor damage or dysfunction, all contributes to the RGC death. Trabodenoson MMP / A1 AR therapeutic normalizes IOP diurnal irregularities in patients with glaucoma (phase 2 trial), which potentially reduces RGC cell death, evidenced by bimatoprost SR MMP therapeutic leading to drug holiday, during which period patients have their vision preserved (visual field stability (phase 3 trial results).

[0169] The current discovery of MMP as a form of therapy that can fully stop the visual field deterioration observed in patients with glaucoma is based on bimatoprost SR phase 3 clinical trials that were led by Jason Bacharach et al, which showed compromised VF results, as patients during the IOP drug holiday period should not lose vision or visual field because their IOP should have been normalized by the SR MMP treatment; however, there was a slight decline of the VF result at 12 months in patients treated with bimatoprost SR (P=0.037 between bimatoprost SR vs Timolol eye drop), because SR PGA treatment triggered intraocular inflammation, which increased proportionally to the API dose level, which caused RGC cell loss at a similar degree to what was see on the cornea endothelium, which was loss at an alarming rate (20% loss in 20 months, compared to 1% normal aging loss annually). It was identified herein that if a trabodenoson SR implant were to be used instead, the VF result at 12 months should be much better than p=0.037 at 12 months and 20 months.

[0170] Drug Holiday Stabilizer & ECM Turnover & Equilibrium. Once patients reach to the drug holiday state, where ECM synthesis and degradation reach to the equilibrium (MMP / TIMP level in balance), they only need a small stream of MMP to supplement the deficiency of MMP production in glaucomatous eyes. Clinical Evidence: In prior clinical trials (Ph2 and Ph3), Trabodenoson eye drop (BID / QD) has led to IOP improvement over treatment time consistently, suggesting that MMP production is at "surplus" (MMP»TIMP), ECM degradation is quicker than synthesis, exceeds the level that needs to maintain such equilibrium. In other words, trabodenoson eye drops at low dose (e.g., 0.6% or 1.5% twice daily) deliver surplus MMP effectively that can stabilize the IOP drug holiday in those who have been induced by bimatoprost SR or other products in the future. Bimatoprost SR Phase 2 clinical trials with single implant led to >68% patients on drug holiday at 4 months; this group of patients do not need intensive high dose MMP treatment at 24 / 7 by 2ndor 3rdimplant to maintain their drug holiday status. Instead, Trabodenoson eye drop provides a safer and effective thus a better alternative as MMP treatment, moreover, Trabodenoson could potentially heal the cornea endothelium and sensing cell damage, or stress caused by bimatoprost SR high dose triggered intraocular inflammation with clinical significance. Given the fact that Trabodenoson at low dose eye drop upregulates MMP with surplus, it can also be used as drug holiday inducer in combination settings with MIGS, where no drug and drug interaction, and no maximal IOP is required. The time to reaching to the steady state will be longer than that with bimatoprost SR within 4-6 months. Trabodenoson MMP therapeutic arm has been validated for its efficacy, its ability to restore the pressure sensor functionality leading to dosing switch from BID to QD in Latanoprost poor response suggests that trabodenoson can deliver MMP effectively at a therapeutic dose level to supplement the MMP deficit in patients with glaucoma, this is the reason for us to believe that trabodenoson eye drops given at the similar dose or dose range (e.g. 1-3%, or 3-6%, preferably 1.5% BID) can maintain the ECM equilibrium that has already been achieved once a patient reaches the IOP drug holiday.

[0171] Broader Impacts

[0172] Trabodenoson is a breakthrough therapy and will set a new standard of glaucoma disease management, solve patient poor compliance and treats non-responders or refractory glaucoma or previously unbeatable ECM pathologies associated with glaucoma. Trabodenoson is ushering into a new era of biology-based medicine, as trabodenoson induced IOP drug holiday could potentially cut Medicare costs by half or more. Some glaucoma surgical procedures and laser treatments damage the pressure sensor and should therefore be limited in clinical practice. The heretofore prevalent "golden rule" for IOP management has been "the lower the better", which actually may do more harm than good.

[0173] The Rate limiting root causes of Vision Loss in Glaucoma

[0174] The rate limiting root cause is the dominant driving force in multifactorial slow progressive diseases, the lead actor of a show. To remove the rate limiting root cause is the only path to find a cure for a given disease. Therefore, to identify the rate limiting root cause is most challenging in multifactorial chronic neural degenerative diseases such as glaucoma, AMD and Alzheimer’s disease, this is the very reason why drug discovery on this topic is considered the holy grail, which has failed many new drugs in clinical development, currently there is no cure for this category of the diseases.

[0175] In this disclosure, Applicant has specifically nailed down the 2ndrate limiting root cause of visual loss in glaucoma, which is the diurnal irregularities or IOP stress. The first rate limiting root cause is pertinent to the IOP failure or uncontrolled IOP, which lies at the pressure sensor failure, damage, worn out, or functional irregularities, or underperformed. The pressure sensor is made of the pressure sensing cell lining at the inner wall of SC (monolayer) and its underlying basement membrane (BM, perhaps also including the adjacent BM at the JCT area), similar to RPE and its underlying Bruch’s membrane relation (ref: U.S. Serial No. 18 / 356,874). The sensing cell functional irregularities or significant loss causes the IOP irregularities or uncontrolled IOP, or non-responders. The IOP diurnal irregularities occur at very early on before any clinical symptom becomes detectible, such as a decreased light sensitivity, transient IOP elevation or early stage peripheral scotoma on the VF testing. The IOP diurnal irregularities are associated with the sensing cell functional irregularities in the aging TM, underpinning by the ECM thickening, clotting, rigidity, atrophic thinning, and loss of tissue elastic youth or hydraulic conductance, as a result of the oxidative stress and para inflammation around the TM complex. In patients with glaucoma, the pulsatile outflow slows down or stops as disease advances to late stage, which also directly affects the ocular blood perfusion to the ONH, together with the lamina cribrosa ECM rigidity and stretch, it blocks the neurotrophins retrograde transports from the brain to the retina, and vice versa, ultimately leads to the RGC apoptosis or necrotic death in patients with glaucoma, including all types of glaucoma, POAG, NTG, OH, PACG and secondary glaucoma etc. The IOP diurnal irregularities or stress causes optic neuropathy at the lamina cribrosa through activation of microglia, astrocytes and other immune cells releasing harmful neurotoxin and cytokines, leading to RGC cell apoptosis, at the same time, the neuro-inflammation also accelerates the abnormal ECM protein deposition at the lamina cribrosa, further acerbating the ECM rigidity, the optic disc cupping perhaps is a result of the IOP problems and vascular perfusion (ischemia-reperfusion damage to the ONH).

[0176] Seeing the Elephant in Glaucoma Vision Loss

[0177] A Strategic Global View on The Rate limiting root cause of RGC Loss in Glaucoma Prior arts of research & drug discovery have been focusing on one or more causative risk factors pertinent to the vision loss in hypertensive and normal tensive glaucoma, but none of the prior approaches has captured the global spectrum to nail down the fundamental root cause, dominant driven force of RGC loss, one needs a holistic approach (360 degree) to see the elephant. TM aging resulted IOP problem lies at the diurnal irregularities underpinning pressure sensor functional irregularities, this is the dominant drive force of vision loss in glaucoma, everything else is the subsequent result of such. Eye is like any tissue organ, an integral part of the cardiovascular system, there is a central artery entering into the eye (to pump the blood), and a central vein out while collecting the metabolic waste, the ocular blood flow is directly connected to the aqueous outflow. There is a valve at the EVP (episcleral vein pressure, about 8-10mmHg in normal eyes), there is a chamber that is the Schlemm's canal. IOP level should not be lower than the EVP level. Under the old golden rule “the lower the better”, some tube shunt surgeries was forcibly driving the IOP level at single digit below the EVP, which may stop the aqueous flow exit and cause ischemia damage to the optic disc. Trabecular meshwork (TM) serves as the bottleneck of this circulation system within the eye, where aqueous outflow exits exteriorly. The TM also serves as a water pump system to drive the flow through the SC toward the EVP. The outflow resistance lies at the TM (mainly at the JCT area). When TM aging lost its elasticity, the outflow slows down and stops, which causes IOP problem (elevation or irregularities). The IOP problem directly translates into the blood perfusion problem at the back of the eye, affecting the blood circulation of the optic nerve head. Ischemia-reperfusion is a typical pathological process involving optic neuropathy in glaucoma, especially NTG or late-stage refractory glaucoma when patient IOP is being forced to lower down at single digit (target IOP) by current standard practice (e.g., tube shunt), sometimes below the EVP level which may exerbate the RGC death. To a severe and refractory glaucoma, repair and rejuvenate the pressure sensor and retore the sensing cell hemeostasis is the logic approach and the most effective treatment to prevent the RGC loss and stop the disease deterioration, and MMP treatment, preferably delivered by Trabodenoson (SR or eye drop) is the best choice thus far.

[0178] Eye is also a unique organ with optic nerve head, where all the nerve bundle and vessels have to squeeze through the lamina cribrosa, a mesh-like structure, the vascular perfusion is of important to maintain the health of the nerve fibers, which is the RGC axons. About 50% of the nutrient supplies to the RGC body in the retina come from the brain via a retrograde mode transport (of neurotrophins and proteins). When optic disc (head) suffers ischemia-reperfusion damage, it deprives the main neuritent supply and causes the metabolic inflammation of RGC leading to irreversible neuronal cell death and optic neuropathy in glaucoma.

[0179] At the front, the aqueous humor secreted by the ciliary body serving as a waste carrier, circulating within the globe from the anterior chamber to the vitreous cavity, and backwards, the aqueous fluids exit primarily via Trabecular Meshwork: TM (85% outflow via TM), the rest is via suprachoroidal space. Dr Murray Johnstone's review paper (Johnstone, M et al J. Clin. Med. 2023, 72, 6599) provides clear evidence of the physiological feature of the outflow circulation, pointing out the TM rigidity as a reason for which the outflow stops or slows down in patients with glaucoma. If this stumbling block can be removed, the outflow can move smoothly within the TM complex, and the IOP becomes normalized without the diurnal irregularities, then glaucoma is cured. His work did not connect things to the back of the eye (optic disc), and most prior art references are focused on one aspect either at the front or the back, but not seeing the entire elephant (the entire eye). Also, most research are focusing on physiological aspect, that's why all IOP drugs are symptom relief, none of them connects the physiological abnormities (abnormal outflow drainage) to the pathological features, such as MMP role in ECM pathologies and sensing cell (loss), the culprit of RGC loss, among all risk factors, the TM aging is the rate limit, fundamental problem in glaucoma. In clinic, the TM pathologies and IOP irregularities occur long before the optic disc cupping. TM aging is the driven force of optic neuropathy and vision loss in glaucoma.

[0180] IOP irregularities affect the blood flow at the optic nerve head, it also activates microglial, astrocyte to produce a cluster of neurotoxin and harmful cytokines such as NF-kappB, ILs, and TNFa etc, which triggers RGC cell apoptosis, the intraocular inflammation accelerates the abnormal ECM deposition at the laminal cribrosa, its deformation and stretch further blocks the axonal nutrient supplies and metabolic transports.

[0181] Trabodenoson MMP / A1AR removes the rate limit of ECM pathologies and sensing cell stress as a result of TM aging, and normalize the IOP diurnal irregularities, which blocks the downstream cascade neuroinflammation around the RGC and optic disc (lamina cribrosa) and vascular perfusion defect (ischemia reperfusion damage) around optic nerve head.

[0182] Setting a New Standard for Target IOP in Clinical Management of Glaucoma

[0183] Current glaucoma disease management has been directed at reducing IOP; however, patients at different disease stages have different target lOPs for each individual eye. The disease staging is roughly defined according to the severity of the optic neuropathy and the nerve fiber damage of retinal ganglion cells in the retina, Humphrey visual field test has been used as the standard for clinical diagnosis of glaucoma and monitoring the disease progression, every 6-12 months on average. Spectral Domain-OCT (SD-OCT) has also been introduced for clinical diagnosis and disease monitor of glaucoma in recent years. SD-OCT is more sensitive to early- moderate stage of glaucoma compared to VF test, whereas to advanced stage or late stage glaucoma, ONFL become very thin, and VF is more accurate and sensitive measure to this group, especially when patients reach to a tipping point or blink where the VF sharp decline could happen within 3-6 months. Despite of these diagnostic tools, the target IOP is based on the damage of the optic nerve fiber layer (ONFL), which is at least 6-12 months delay before the adjustment of the IOP lowering medication or surgeries are to be made. This is far from accurate. The ideal target IOP should be at when patient’s IOP irregularities have been normalized as a result of the pressure sensor functional recovery, at which point, there is no need for extra treatment. Current IOP lowering methods including the MIGS are to reduce the magnitude of the IOP spikes and slows down the vision loss in glaucoma. These data may also give a false impression that the lower the better. Trabodenoson MMP therapeutic will change the current standard of target IOP onset, based on instant and timely 24-hr diurnal variance normalization, not a delayed VF damage. The diurnal variance normalization assessment should be based on 24-hour IOP monitoring (taking 3 or more timepoints per day) for minimal 3-5 days, preferably 5-7 days with consistent clinical results (test and retest method should be used). This is a reason why 1.5%BID or QD is chosen as the optimal dosing for Trabodenoson as a drug holiday stabilizer, 1.5% not only delivers the MMP at therapeutic level but also generates the fast mode vascular effect leading to moderate IOP reduction (6-7mmHg@ Phase 2 results), hence this dose will be beneficial to patients who are not on “true” drug holiday (technical limits).

[0184] In current glaucoma IOP management, there is a misconception, which is “the lower the better”. This concept is based on the notion that l.OmmHg reduction translates into a delay of 20% of the visual loss. Many late stage or end stage glaucoma patients are being treated by invasive drainage surgeries, the IOP is at single digits, below the EVP level (average EVP is 8-10mmHg), which may do more harm than good. Below if the intraocular pressure is below the EVP level, it will negatively affect the vascular perfusion to the optic nerve head as showed on Figure 13; and abnormal blood vascular perfusion (e.g. too low) to the ONH could cause the deficiency of retrograde neurotrophins transports from the brain to the retina showed on Figure 12. When the pulsatile outflow stops in late-stage glaucoma, the metabolic exchange via aqueous humor with the blood circulation slows down, which accelerates the disease progression at the front of the eye and negatively affect the entire outflow drainage systems.

[0185] In early-to-moderate stage glaucoma, the concept for “the lower the better” is also being challenged by emerging clinical evidence from phase 3 randomized clinical trials of bimatoprost SR intracameral implants (Dursyta®), suggesting that once patients achieve a drug holiday, a disease-free status, their IOP levels seem to bounce up toward a trend of a higher IOP with a stability, compared to patients’ IOP level being forcefully reduced by Bimatoprost. ARTEMES 2 phase 3 clinical trial IOP profde under bimatoprost SR implant during the first 12 weeks were assessed. The mean IOP at week -12 seems higher (a suggestive trend) compared with the IOP at week 2 & 6. The SR API release peaks at 51 days, lasts till at least day 65, by the end of week 12 (84 days), perhaps the API is below the detection level. In another word, the mean IOP reduction at week 2 and 6 is driven by bimatoprost API, whereas the IOP level at week 12 perhaps is maintained by PGA-triggered MMP therapeutic leading to drug holiday, for which >2 / 3 of treated patients could have achieved a disease-free drug holiday status and can self-regulate the IOP without the need for extra treatment. At this point the IOP should be the ideal target IOP level for which patient RGC cells should be in safe harbor. Current clinical IOP management for Vyzulta and Rocklatan being the first line choice with 8-9mmHg reduction perhaps is over-treated to some patients. Target IOP for early-stage glaucoma set at 16-17mmHg may be too low. Overtreatment with lOP-lowering drugs could also accelerate the disease progression for early-stage glaucoma, as it may introduce risks of the vascular perfusion problem that compromises the RGC health at the back of the eye.

[0186] Trabodenoson derived MMP / A1AR therapeutic leading to drug holiday is therefore provided herein to set a new standard of a target IOP that is physiologically healthy, in concert with the vascular perfusion to the optic nerve head at the back of the eye.

[0187] Glaucoma Disease Staging and Progression

[0188] Determination of glaucoma disease stage is performed by art-recognized means and as described elsewhere herein.

[0189] Monitoring o f Glaucoma Disease Progression in Treated Patients

[0190] Glaucoma disease progression in treated patients can be performed via visual field assessment, OCT, RNFL thickness measurement, or via IOP measurements (e.g., for diurnal IOP irregularities and / or any normalization of same), or via other means known in the art.

[0191] Patient Selection

[0192] In certain aspects of the instant disclosure, specific class(es) of patients are pre-selected for administration of a MMP (e.g., trabodenoson) therapy. For example, and without limitation, a preferred type of patient to which trabodenoson therapy can be administered includes one for whom two or more of the following are present or true in the treated eye of the patient: (i) diurnal irregularities in IOP in the eye of the subject (optionally established in a longitudinal assessment); (ii) past poor or non-responsiveness of the eye of the subject to lOP-lowering drugs; and (iii) identification of surgery as the likely next therapeutic step for the eye of the subject, or the eye of the subject has already been subjected to surgical intervention for glaucoma treatment (optionally without significant benefit). Other forms of patient selection for MMP therapies as disclosed herein are also contemplated.

[0193] Trabodenoson and Related Agents

[0194] As defined above, trabodenoson is an adenosine mimetic optimized to target selectively the adenosine Al receptor (A1AR; trabodenoson binds A1AR with a Ki of 0.97 nM, while trabodenoson binds the A2a receptor with a Ki of 4690 nM and trabodenoson binds the A3 a receptor with a Ki of 704 nM). The chemical structure of trabodenoson (Formula: CisFhoNeOe; MW: 380.36, also known as "INO-8875"; from US 2014 / 0271876, Me Vicar etal is:

[0195] The trabodenoson molecule has also been depicted (e.g., in WO 2012 / 028585; Kalar el al. ) as having an electrostatic interaction between the NO2 moiety and the remainder of the molecule:

[0196]

[0197] Other molecules having close structural relation to trabodenoson include the cyclopentyladenosine ("CPA"), 2-chlorocyclopentyladenosine ("CCPA") and cyclohexyladenosine ("CHA") structures of U.S. Patent Publication No. 2016 / 0158267, shown below.

[0198] Cyclopentyladenosine (CPA)

[0199]

[0200] 2-Chlorocyclopentyladenosine (CCPA)

[0201] Cyclohexyladenosine (CHA)

[0202] Other related compounds include:

[0203]

[0204] In certain embodiments, it is expressly contemplated that compounds having a close structural relationship to trabodenoson might also display similar effects. Accordingly, certain embodiments of the instant disclosure contemplate use of a compound of the following genus, where trabodenoson is referenced.

[0205] wherein:

[0206] Ri is an optionally substituted (C5-C6) cycloalkyl (optionally substituted with one or more OH, or

[0207] R2 is H or a halogen atom (F, Cl, Br, or I); and

[0208] R.3 is H or NO2.

[0209] Eye Drop Formulations, Sustained Release Formulations, and Delivery

[0210] Eye drop formulations of agents described herein (e.g., trabodenoson, other MMP therapies) can be made by art-recognized methods, including, without limitation, those described elsewhere herein. SR formulations of agents described herein can also be made by art-recognized methods, including, without limitation, those described elsewhere herein, with delivery of such agents also performed via art-recognized methods (e.g., injection or surgery that implants a reservoir, stent, etc. at, e.g., the aqueous humor of the eye of a subject, optionally also involving removal of the reservoir or stent post-administration period), including, without limitation, those modes of delivery described elsewhere herein. Trabodenoson eye drop optimal dosing and / or optimal ranges have also been previously described in PCT / US23 / 70729 (G Qiu).

[0211] SR Dosing Equivalence

[0212] In certain embodiments, SR dosing of an agent of the disclosure is performed in a manner designed to achieve effectively equivalent dosing as a corresponding eye drop formulation of the agent. Establishing such dose equivalent levels can be performed by any means known in the art (as are routinely performed in the art), with the principles driving such dosing including API daily release (speed), total API drug loading, and the duration (e.g., 3 months), which can be determined by the optimal API concentration at the aqueous humor in reference by the optimal eye drop dosing (e.g., 1.5% trabodenoson or range of 1.2%-1.5%, 1.0-3.0%, or 3%-6%). Optionally, the reference dosing optimal for SR should be based upon, e.g., 1.5% eye drops , optionally delivered twice daily for 5-7 days, or for 7-14 days or for 14-28 days, optionally for 14-28 days when the API concentration achieves a level in aqueous humor at the anterior chamber, at which point the IOP reduction reaches to about 6-7mmHg. Under the optimal dosing, SR trabodenoson will generate the unique IOP pattern behaviors reflective of being at the maximal therapeutic dose for pressure sensor repair and functional restoration of the treated eye. In an exemplary embodiment, total API loading, API release speed and SR duration are determined by optimal API concentration rendered by trabodenoson eye drops delivered to the aqueous humor. Such optimal dosing yields a distinct or unique therapeutic IOP pattern behavior that is reproducible and repeatable. The API carriers (e g., biodegradabe polymer) and API release speed should be in concert to avoid any residual API precipitation or burst, or empty polymer system without API. Optionally, API release should occur ahead of the biodegradable system dissolving, e.g., 5-7 days, or 7-14 days ahead, but optionally no more than 28 days ahead.

[0213] Delivery of certain MMP macromolecule therapies (e.g., proteins, polynucleotides capable of expression MMPs) can be performed by art-recognized means, including via formulations suitable for delivery of macromolecules to targeted tissues / cells. For polynucleotides, packaging and delivery in nanoparticles, including lipid nanoparticles (LNPs), or in viral vector delivery systems (e.g., AAV), optionally together with appropriate molecular drivers of MMP expression, is also expressly contemplated.

[0214] Methods of Treatment

[0215] Treatment using MMP agents (e.g., trabodenoson, related compounds, and / or protein or polynucleotides as disclosed herein for delivery of MMP) is primarily described herein for eye drops and SR formulations that are administered directly to the eye (or optionally involving packaged macromolecules); however, it is expressly contemplated that any of a number of art- recognized delivery routes can be employed for the agents disclosed herein (whether small molecule, e.g., trabodenoson or related compound, or macromolecule, e.g., MMP biologies).

[0216] Routes of Administration

[0217] Typically, a MMP agent of this disclosure is administered directly to the exterior or interior of the eye of the subject, or to a surrounding tissue. Local administration includes topical administration, administration via syringe and / or administration via an implantable device. Featured is the treatment of anterior (front of the eye) ocular conditions and posterior (back of the eye) ocular conditions, primarily via administration of MMP agents to the front of the eye of a subject.

[0218] In some cases, an effective amount of a MMP agent (e.g., trabodenoson, etc.) is delivered to the anterior chamber of the eye via topical administration. The MMP agent may be instilled in the anterior of the eye using eye drops, ointment or gel (e.g., to the conjunctiva and / or cornea) as is needed to treat, ameliorate, and / or prevent the eye disease of interest. The MMP agent can be an ophthalmic preparation in the form of eye drops that contains an amount of the active agent sufficient to provide for a therapeutically effective concentration at the site of action inside the eye.

[0219] Local administration to the front of the eye (e.g., to the conjunctiva and / or cornea) may also be done using a contact lens that carries the MMP agent. This can improve the bioavailability and prolong the residence time of an active agent.

[0220] To increase the amount of drug load and to control drug release, a contact lens or hydrogel may include: (i) polymeric hydrogels with controlled hydrophilic / hydrophobic copolymer ratio; (ii) hydrogels for inclusion of drugs in a colloidal structure dispersed in the contact lenses; (iii) ligand-containing hydrogels; (iv) molecularly imprinted polymeric hydrogels; (v) hydrogel with the surface containing multilayer structure for drugs loading and releasing. Hydrogels are a preferred material of soft contact lenses because of their biocompatibility and transparent characteristic. A hydrogel contact lens can be used to release an active agent to the front of the eye in a controlled release upon contact with the thin fdm of tears coating the eye. The contact lens can be worn daily according to a dosing schedule to provides for local administration of an effective amount of the MMP agent for treatment of an eye disease (e.g., as described herein). Contact lens devices include those devices described in U.S. Pat. No. 6,827,996 and U.S. Publication Nos. 2010 / 0330146 and 2006 / 0251696.

[0221] Local administration to the front of the eye can also be done by subconjunctival injection. A subconjunctival injection can be used to inject a MMP agent to either the subconjunctival space or the sub-Tenon's space. Since the subconjunctival space is more anterior that the sub-Tenon's space, subconjunctival injections can have a more pronounced effect on drug delivery to the anterior segment, while sub-Tenon's injections can have more of an effect the posterior segment. Local administration to the anterior and posterior segments of the eye can also be achieved by intraocular injection, e.g., an intracameral or intravitreal injection. An intracameral injection is an injection that is generally delivered into a chamber in the anterior of the eye (e.g., in front of the lens). An intravitreal injection is an injection delivered into the vitreous chamber in the posterior of the eye (e g., behind the lens). Because of the risk of damage to the retina layers and optic nerve by raising intraocular pressure, a maximum volume of about 0.1 mL should be administered by either intracameral or intravitreal injection. In some cases, an intracameral injection can provide administration without an increase in intraocular pressure that is associated with an intravitreal injection. A sudden increase in intraocular pressure can cause discomfort to a patient and place the optic nerve at risk of damage. Administration via injection is generally performed in a manner that minimizes exposure of the eye to pathogens.

[0222] Local administration can also be done via an implantable ocular device, placed in the eye, for example, by corneal incision. Ocular devices include stents (e.g., trabecular stent), organo-gel implant, and those compositions and devices described in U.S. Pat. Nos. 5,501,856, 5,869,079, 5,824,072, 4,997,652, 5,164,188, 5,443,505 and 5,766,242.

[0223] U.S. Pat. No. 5,501,856 discloses controlled-release pharmaceutical preparations for intraocular implants to be applied to the interior of the eye after a surgical operation for disorders in retina / vitreous body or for glaucoma. U.S. Pat. No. 5,869,079 discloses combinations of hydrophilic and hydrophobic entities in a biodegradable sustained release implant, and describes a polylactic acid polyglycolic acid (PLGA) copolymer implant comprising dexamethasone. U.S. Pat. No. 5,824,072 discloses implants for introduction into a suprachoroidal space or an avascular region of the eye, and describes a methylcellulose implant comprising dexamethasone. U.S. Pat. Nos. 4,997,652 and 5,164,188 disclose biodegradable ocular implants comprising microencapsulated drugs, and describes implanting microcapsules comprising hydrocortisone succinate into the posterior segment of the eye. U.S. Pat. No. 5,164, 188 discloses encapsulated agents for introduction into the suprachoroid of the eye, and describes placing microcapsules and plaques comprising hydrocortisone into the pars plana. U.S. Pat. Nos. 5,443,505 and 5,766,242 discloses implants comprising active agents for introduction into a suprachoroidal space or an avascular region of the eye, and describes placing microcapsules and plaques comprising hydrocortisone into the pars plana. To provide a delayed release drug delivery implant or depot, an injectable formulation including the subject active agent can be injected into a subject, which results in the in situ formation of an organogel implant. Upon contact with bodily fluid, crosslinking agents begin to crosslink the organogel to form a more stable matrix that modulates the escape of the active agent to the eye of the subject. In some instances, this method of administration can provide a prolonged release period of the active agent. In some cases, an in vivo biodegradable cross-linked matrix is formed that includes a non-aqueous aprotic biocompatible solvent system that is non-miscible with water (Zhou, T, et al., Journal of Controlled Release 55: 281-295, 1998).

[0224] Formulation of Medicaments

[0225] An ophthalmic preparation can be prepared by mixing a MMP agent as disclosed herein with a pharmaceutically acceptable base or carrier and as needed one or more pharmaceutically acceptable excipients. Ingredients acceptable in an ophthalmic formulation are excipients or carriers that cause little to no ocular irritation, provide suitable preservation if needed, and deliver one or more agents in a suitable volume. Examples of a base or carrier include water; an aqueous solvent such as a polar solvent; a polyalcohol; a vegetable oil; and an oily base. Examples of the base or carrier for an intraocular injection include water for injection and physiological saline.

[0226] For ophthalmic delivery, a MMP agent may be combined with acceptable excipients for use in and around the eye, such as a surfactant, preservatives, co-solvents, a flavor or cooling agent, an antiseptic, a bactericide or antibacterial agent, a pH adjusting agent, a tonicity agent, a chelating agent, a buffering agent, a stabilizer, an antioxidant, viscosity enhancers, penetration enhancers, sodium chloride and a thickening agent. In some cases, a composition for intraocular injection may contain one or more of a solubilizing agent, a suspending agent, a tonicity agent, a buffering agent, a soothing agent, a stabilizer, and an antiseptic. The ophthalmic composition carrier and excipients can be combined to form an aqueous, sterile ophthalmic suspension, solution, or viscous or semi- viscous gels or other types of solid or semisolid composition such as an ointment.

[0227] Exemplary excipients and additives that can be used include the following. Surfactants: for example, nonionic surfactants such as polyoxyethylene (hereinafter sometimes referred to as “POE”)-polyoxypropylene (hereinafter sometimes referred to as “POP”) block copolymers (e.g., poloxamer 407, poloxamer 235, poloxamer 188), ethylenediamine POE-POP block copolymer adducts (e.g., poloxamine), POE sorbitan fatty acid esters (e.g., polysorbate 20, polysorbate 60, polysorbate 80 (TO- 10 etc.)), POE hydrogenated castor oils (e.g., POE (60) hydrogenated castor oil (HCO-60 etc.)), POE castor oils, POE alkyl ethers (e g., polyoxyethylene (9) lauryl ether, polyoxyethylene (20) polyoxypropylene (4) cetyl ether), and polyoxyl stearate; amphoteric surfactants such as glycine-type amphoteric surfactants (e.g., alkyl diaminoethyl glycine, alkyl polyaminoethyl glycine), betaine-type amphoteric surfactants (e.g., lauryldimethylaminoacetic betaine, imidazolinium betaine); cationic surfactants such as alkyl quaternary ammonium salts (e.g., benzalkonium chloride, benzethonium chloride); etc.

[0228] Flavors or cooling agents: for example, camphor, borneol, terpenes (these may be in the d- form, 1-form, or dl-form); essential oils such as mentha water, eucalyptus oil, bergamot oil, anethole, eugenol, geraniol, menthol, limonene, mentha oil, peppermint oil, rose oil, etc.

[0229] Antiseptics, bactericides, or antibacterial agents: for example, polidronium chloride, alkyldiaminoethylglycine hydrochloride, sodium benzoate, ethanol, benzalkonium chloride, benzethonium chloride, chlorhexidine gluconate, chlorobutanol, sorbic acid, potassium sorbate, sodium dehydroacetate, methyl paraoxybenzoate, ethyl paraoxybenzoate, propyl paraoxybenzoate, butyl paraoxybenzoate, oxyquinoline sulfate, phenethyl alcohol, benzyl alcohol, biguanide compounds (in particular, polyhexam ethylene biguanide or its hydrochloride etc.), Glokill (Rhodia Ltd.), etc. pH adjusting agents: for example, hydrochloric acid, sodium hydroxide, potassium hydroxide, calcium hydroxide, magnesium hydroxide, triethanolamine, monoethanolamine, diisopropanolamine, sulfuric acid, phosphoric acid.

[0230] Tonicity agents: for example, sodium bisulfite, sodium sulfite, potassium chloride, calcium chloride, sodium chloride, magnesium chloride, potassium acetate, sodium acetate, sodium bicarbonate, sodium carbonate, sodium thiosulfate, magnesium sulfate, disodium hydrogen phosphate, sodium dihydrogen phosphate, potassium dihydrogen phosphate, glycerin, propylene glycol.

[0231] Chelating agents: for example, ascorbic acid, edetic acid tetrasodium, sodium edetate, citric acid. Buffering agents: for example, phosphate buffering agents; citrate buffering agents such as citric acid and sodium citrate; acetate buffering agents such as acetic acid, potassium acetate, and sodium acetate; carbonate buffering agents such as sodium bicarbonate and sodium carbonate; borate buffering agents such as boric acid and borax; amino acid buffering agents such as taurine, aspartic acid and its salts (e g., potassium salts etc.), and e-aminocaproic acid. Ophthalmic solution formulations may be prepared by dissolving the agent in a physiologically acceptable isotonic aqueous buffer. Further, the ophthalmic solution may include an ophthalmologically acceptable surfactant to assist in dissolving the agent. Viscosity building compounds, such as hydroxymethyl cellulose, hydroxyethyl cellulose, methylcellulose, polyvinylpyrrolidone may be added to improve the retention of the compound.

[0232] Sterile ophthalmic gel formulations may be prepared by suspending the agent in a hydrophilic base prepared from the combination of, for example, CARBOPOL®-940. VISCOAT® (Alcon Laboratories, Inc., Fort Worth, Tex.) may be used for intraocular injection. Other compositions of the present disclosure may contain penetration enhancing materials such as CREMOPHOR® (Sigma Aldrich, St. Louis, Mo.) and TWEEN® 80 (polyoxyethylene sorbitan monolaureate, Sigma Aldrich), in the event the agents of the present disclosure are less penetrating in the eye.

[0233] This disclosure provides commercial products that are kits that enclose unit doses of one or more of the agents or compositions described in this disclosure. Such kits typically comprise a pharmaceutical preparation in one or more containers. The preparations may be provided as one or more unit doses (either combined or separate). The kit may contain a device such as a syringe for administration of the agent or composition in or around the eye of a subject in need thereof. The product may also contain or be accompanied by an informational package insert describing the use and attendant benefits of the drugs in treating the senescent cell associated eye disease, and optionally an appliance or device for delivery of the composition.

[0234] MMP and Laser Treatment in Glaucoma

[0235] Laser trabeculoplasty has been used in glaucoma clinical practice for decades; however, few may have appreciated that SLT induced long-term IOP reduction is mainly through the upregulation of MMP (moderate level) from the newly formed trabecular endothelium TM cells as the result of laser stimuli, replenishing pressure sensing cells lining at the inner wall of Schlemm’s canal (with limited self-renewal in adulthood). MMP treatment can restore pressure sensor functionality with neural protection benefits. CR Rolim-de-Moura et al (2022) conducted a large data basis analysis (Cochrane Center Register) on laser trabeculeculoplasty for POAG and OH patients, 5613 eyes of 4028 patients across 40 studies conducted in the US and Europe, surprisedly, they found that laser treatment group has less failure rate to maintain the VF stability (74 / 1000 vs 105 / 1000) and prevent the optic disc atrophy (73 / 1000 vs 100 / 1000) over 24-month follow up, compared to the medication treated group, despite the facts that higher AE incidence in laser group vs medication (294 / 1000 vs 25 / 1000), such as 5% IOP spike in post laser treatment. New laser technologies are also being developed, Ellios Laser uses excimer laser that reduces collateral damages, which has been in Ph2 / 3 clinical trials in the Europe and USA, its sustained clinical efficacy (up to 8 years) is the results of combination of mechanical drainage of the outflow and MMP upregulation towards TM rejuvenation (similar to SLT, but less damage and better efficacy). Nevertheless, Ellios laser does kill the sensing cells at the laser spot (1 / 4 circle of the TM is being treated), its clinical repeatability may be limited to early to moderate stage of glaucoma.

[0236] Hydrus® and MIGS on Reducing Vision Loss in Glaucoma

[0237] Minimally invasive glaucoma surgery (MIGS), such as Hydrus® (Alcon, TX), istent (a trabecular micro-bypass stent, Glaukos, CA), trabectome (NeoMedix, CA) has been a paradigm shift in glaucoma IOP management in the past 15 years, it has become the first line treatment, gradually replacing IOP lowering eye drops with poor patient compliance (>60% non- compliance). Its resulted IOP stability over a relatively long term (~3 years) is better than eye drops on IOP control, as it reduces the magnitude of the IOP spikes, however MIGS does not have the mechanism to remove the disease intricate pathological damage at the TM, specifically, the pressure sensor functional irregularities that causes the IOP diurnal irregularities, the rate limit disease root cause of RGC loss in glaucoma. Trabectome reduced the magnitude of diurnal IOP fluctuation at 12 months compared to the baseline. However, individual IOP diurnal irregularities remain after trabectome surgery (Pyfer MF, et al. Suppression of Diurnal (9AM-4PM) IOP Fluctuations with Minimally Invasive Glaucoma Surgery: An Analysis of Data from the Prospective, Multicenter, Single-Arm GEMINI Study. Clin Ophthalmol. 2021 Sep 24;15:3931- 3938). A five-year follow up on Hydrus Horizon study, which showed that Hydrus slowed down the visual field loss but cannot stop the progressive VF damage over the course of 5 years. The mechanism of its neural protection (partial, limited) is associated with the reduction of IOP magnitude, which subsequently reduces the magnitude of diurnal IOP fluctuation, but it does not treat the disease pathological processes, hence it is of symptom relief. The rate of progression in early-to-moderate-stage glaucoma is about 0.5dB per year (slope analysis), the rate of progression in patients with Hydrus is 0.35db per year, averaging from 5-year studies. (G Montesano et al. Five-Year Visual Field Outcomes of the HORIZON Trial, AJO 2023). The difference among variety of MIGS device lies at their TOP lowering strength and duration of the therapeutic effectiveness, it may not have significant impact to the visual field stability as none of them has the mechanism to repair the pressure sensor failure, however, any surgical intervention poses a stress or damage to the sensing cells lining at the Schlemm’s canal could have a detrimental consequence to the RGC health at the back of the eyes. Hydrus is inserted into the Schlemm’s canal (1 / 4 circle of TM), and Trabectome removes the TM tissue at 90-120 degree (1 / 4-1 / 3 circle), both are invasive to the pressure sensing cells. To early-stage glaucoma, which is most MIGS surgery targeted population, the sensing cell loss at 1 / 4 to 1 / 3 may not present a significant challenge for the remaining healthy cells to compensate, therefore different MIGS device so far has not showed significant difference on their impact to the VF stability at this early stage of the disease.

[0238] Discovery of Para inflammation in Glaucoma from Patients (Proof)

[0239] About 25-30% glaucoma patients have inflammatory predisposition with increased proinflammatory molecules, such as TNF-a, NF-KappaB, interleukins (IL-6 or IL-2) etc. circulating from the bloodstream entering into the aqueous humor at the anterior chamber, which accelerates the pressure sensor aging process and sensing cell edematous loss in glaucoma. This high risky group of patients will advance toward the advanced stage of glaucoma at an accelerated pace than patients who are otherwise without para inflammation. Such intricate inflammatory roots are the very reason behind the filtering bleb developing inflammatory scarring and tube shunt clotting, which led to uncontrolled IOP (or IOP failure) and patients becoming legally blind in glaucoma. Unfortunately, there is no biomarker to identify this high-risk group yet.

[0240] This subset group is often the targets and bearers of the side effects derived from other treatments for glaucoma. About 27% of Cypass patients suffer 30% cornea endothelium loss (CEL) in 5 years, which was caused by the metabolic inflammation or para inflammation in a slow accumulative fashion, because Cypass retained such inflamed aqueous fluids inside the globe (vs istent via a short-cut exit path). About 10% of patients receiving bimatoprost SR (a PGA drug) suffered inflammatory driven CEL damage at an alarming speed of 20% CEL at 20 months, compared to the CEL at 0.5%-l% rate in normal aging process (G Qiu, PCT No. 18 / 356874, filed on July 21st, 2023). Cypass was withdrawal from the market in 2019, and bimatoprost SR has FDA label warnings for single implant only. Previously, the root cause of CEL in CyPass and bimatoprost SR was thought to be a mechanic damage to the cornea, which is incorrect (TG Qiu, EC Ophthalmology, 2019). All commercially marketed PGA eye drops at a very low dose have FDA label warnings on cystoid macular edema and intraocular inflammation. Once daily dose of PGA eye drop has not caused alarming concerns, however, PGA in SR via intraocular implant may present clinically significant damage as evidenced by bimatoprost SR. PGA simulates very potent inflammatory and vascular constrictive molecules e.g., bradykinin. Except trabodenoson, PGA is the only FDA approved drugs that has the MOA to stimulate MMP at therapeutic level, but it requires a high dose in a sustained release intraocular delivery format. MMP therapeutic benefit delivered by PGA will be always accompanied by intraocular inflammation at time and dose dependent manner, proportionally. It is not advisable to put PGA drugs in SR via intraocular delivery.

[0241] Unoprostone isopropyl (Rescula) is a B-K channel activator, which can tighten up the gate of blood-aqueous barrier and prevent above-mentioned inflammatory molecules flooding into the anterior chamber, and preventing the intraocular inflammation from attacking the sensitive cornea endothelium and pressure sensing cell under oxidative stress (ES Arcieri et al. Arch Ophthalmol. 2005;123(2): 186-192; G Qiu, J Clin Exp. Ophthalmol. 2015, 6:473). Reacula has been demonstrated clinically for its therapeutic potency in treating refractory glaucoma and medication non-responders (Azuma I. J. Jpn Ophthalmol Soc 97:232-238,199). This evidence confirmed of glaucoma disease with its inflammatory nature. However, from decades of clinical experience with Rescula, it was learned that removing the intraocular para-inflammation is not a cure for glaucoma. As the first ‘therapeutic” drug, Rescula is only effective to a very small subset of refractory glaucoma with active inflammation, to majority of POAG / OH, Rescula is a weak IOP lowering drug (4mmHg reduction) and does not offer “therapeutic” benefit. In a similar vein of AMD drug discovery, complement therapies for geographic atrophy (GA) secondary to AMD (C3 and C5 inhibitors) may not be for everyone with GA / AMD, by removing the subretinal inflammation can only slow down at 20% of GA growth rate within 2 years, it cannot stop the disease progression, because inflammation is not the rate limiting root cause for AMD and glaucoma.

[0242] For any effective and curative treatment, it needs to identify and remove the rate limiting root cause. In this disclosure, Applicant has defined the two rate limiting root causes related to RGC loss in glaucoma: from the pressure sensor dysfunction / failure to IOP diurnal irregularities and RGC cell apoptosis has the direct causative link rooted in the progressive vision field loss in glaucoma. Trabodenoson derived MMP / Al AR therapeutics remove the first rate limiting root cause by repairing the pressure sensor, which ultimately removes the 2ndrate limiting root cause to the RGC cell loss underpinning the visual field loss in glaucoma. It offers the first cure for eradicating glaucoma blindness in majority patients. Drug holiday is the hallmark of neural protection in glaucoma via MMP therapeutics and plus. By inducing and stabilizing patient on extended drug holiday (forever) is so far the most effective treatment strategy to preserve vision in glaucoma, it is equivalent to glaucoma neural protection (lifetime).

[0243] Trabodenoson mediated Neurovascular Modulation for Glaucoma Neural Protection

[0244] One of the key IOP independent risk factors associated with RGC loss in glaucoma is the vascular ischemia -reperfusion damage (preconditioning) predominantly seen in NTG. Trabodenoson mediated A1AR activation is via Gi protein coupled muscarinic M2 receptor activation to release nitric oxidate (NO), similar to acetylecholine (Ach) effect on muscle relaxation with increased NO. Preclinical studies of Trabodenoson eye drops in various rodent models of NAION, light damage model mimicking AMD, and optic nerve crush model mimicking glaucomatous optic neuropathy have demonstrated its robust biological activities to rescue the RGC cells from apoptosis, also showed its strong therapeutic effects on protecting the retinal photoreceptors, suggesting the underlying MOA is via vascular dilation and neurovascular modulation to the choroidal vascular circulation, especially the microcapillaries, these evidences are pertinent and useful to aged related human diseases or conditions with ischemic-reperfusion damage (such as NTG) or macular ischemia in wet AMD (Y. Guo et al. Transl Vis Sci Technol. 2019; Alireza ghaffarieh et al. IOVS. 2014). Trabodenoson is neural protective to the RGCs in a rodent model of NAION (Non-arteritic Anterior Ischemic Optic Neuropathy), pathologically it is characterized as a typical ischemia-reperfusion and preconditioning damage, suggesting that neurovascular modulation and retinal blood vessel dilation plays a key role in RGC rescue. Shared in common with Rescula as a potent vascular dilator via inhibiting endothelium- 1 (ET-1) release, Rescula has demonstrated its clinical benefits of reducing atrophic lesions in wet AMD patients treated with long-term anti-VEGF drugs and patients with retinitis pigmentosa (Shiragami C et al. Medicine. 2017, Akiyama M, et al. Acta Ophthalmol. 2014). Trabodenoson is also a potent vascular modulator (dilator), thus, the clinical evidence from Rescula in RP and wAMD is highly relevant and supportive to Trabodenoson in glaucoma neural protection especially for NTG. Trabodenoson Therapeutic for Glaucoma Neural Protection via MMP / A1AR Normalizing IOP Diurnal Irregularities: A Competitive Landscape

[0245] Trabodenoson is able to remove the disease rate limiting root causes underpinning the RGC loss in glaucoma via MMP / A1AR normalizing the IOP diurnal irregularities, which is second to none. The fundamental root cause lies at pressure sensing cell metabolic stress or loss along with its underlying basement membrane thickening and rigidity, which results in pressure sensor functional irregularities or failure. Anti-VEGF therapy removes the rate limiting root cause of subretinal fluids in wet AMD, which improves vision at 90% patients. Trabodenoson derived MMP / A1AR therapeutic removes the ECM debris and restores pressure sensor functionality, offers the first cure for hypertensive glaucoma, including POAG, OH, PACG and secondary glaucoma as well as other hypertensive conditions.

[0246] Comparison of Trabodenoson MMP / A1 AR therapeutic with current standard of care has been illustrated herein in FIG. 8, with the estimated scoring system describing the relative therapeutic effectiveness based on its impact on the RGC health, and its ability to stop or slow down visual field loss in glaucoma. Current IOP lowering medication or eyedrops provides symptom relief and has the least effect on protecting RGC loss (S=l-3). Trabodenoson eye drop is the only drop that can deliver a potent MMP-14 / A1AR therapeutic leading to dose switch and IOP improvement by removing two rate-limiting root causes underpinning the visual field loss and RGC death, plus it has direct neural protection to the sensing cells and RGCs with antiinflammatory and vascular dilation benefits, therefore, it is the most effective neural protection drug so far (S=l 0). Its SR format provides a quick induction of drug holiday or therapeutic relief to advanced and end stage glaucoma. Bimatoprost SR is a slow release product, upregulates MMP without direct neural protection to the sensing cells. Also PGA triggers intraocular inflammation which compromises its MMP therapeutic toward the RGC protection benefit and destabilizes the sensing cell functionality (S=6), it can be only used as a single loading dose as drug holiday inducer, it cannot be repeated. MIGS, SLT and other laser (Ellios Laser) are better than eye drops but less effective than bimatoprost SR on reducing RGC loss in glaucoma (S=3). Both bimatoprost SR and MIGS offer patient drop free during its effective treatment period, that MIGS device reduces IOP is via a mechanic drainage of the outflow, whereas bimatoprost SR induced drug holiday is through a self-regulation of aqueous outflow drainage because of a functional pressure sensor, its diurnal irregularities have been normalized which removes the rate limiting root cause of RGC cell apoptosis, this is the most important attribute of MMP therapeutic in glaucoma, which is equivalent to RGC neural protection.

[0247] Trabodenoson is the only glaucoma drug with the potential to stop the disease progression and eliminate the RGC loss in glaucoma, preferably in hypertensive glaucoma. It is more potent, safer than bimatoprost SR, clinically it can be repeated either in eye drops or SR. Hydrus, Elios laser, SLT and potentially other PGA in SR intraocular delivery system will have limitation for repeated dosing (implants) due to clinical safety concerns, protecting the pressure sensing cell health (the rate limit) has not been appreciated before, its recoverability is the rate limit of glaucoma disease control.

[0248] Glaucoma caused blindness occurs at advanced stage when the sensing cells loss (low density) reaches to a threshold and functionally decompensated, patients become non-responders that requires mechanic outflow drainage by invasive surgeries, which is often too late to rescue these neural lineage derived cells, including pressure sensing cell and cornea endothelium cell. With Trabodenoson, things could change, trabodenoson could potentially seize and stop the progressive cell loss and reverse the disease progression at a certain degree at this late stage, however the severe damage may not be fully recovered, patients will still need additional eye drops or surgical drainage to control the IOP. In early-stage glaucoma, most patients are asymptomatic, similar to cornea endothelium loss at early stage, patients may not have clinical symptom, until the cornea become decompensated (e.g., less than 500 cells / mm2, at which point it is too late to pharmacologically intervene, patients will need a surgery.

[0249] Trabodenoson Therapeutic Strategy on Glaucoma Neural Protection via MMP / A1AR on IOP Normalization.

[0250] To early and moderate stage glaucoma, trabodenoson eye drops can be used in combination with MIGS and bimatoprost SR for early-moderate stage glaucoma (POAG, PACG, OH) as an early interventional strategy, which can fully stop the disease progression, and prevent and eradicate glaucoma related blindless. To late stage glaucoma, trabodenoson eye drop (1.5%BID) or SR implant (biodegradable AC rod) can be used in combination with tube shunt or trabeculectomy, it delivers the most effective therapeutic relief via its MMP / A1 AR cytoprotection to the sensing cells at the front of the eye, and restore the homeostasis of the remaining precious sensing cells, which is often under extreme oxidative stress in compensating for its IOP regulations (chief regulator), Trabodenoson could potentially reserve some of the reversable damage such as intracellular edema to seize and stop the disease deterioration toward an irreversible stage.

[0251] Trabodenoson eye drop also can be used as standalone treatment to deliver MMP / A1AR therapeutic neural protection to all types of glaucoma. Its maximal IOP reduction is 6-7mmHg at 28 days in early-to-moderate-stage glaucoma (Phase 2 results) once its IOP reduction strength is validated at a given dose of 1.5% BID (defined optimal dose) in well-controlled phase 3 trials. The optimal dosing of trabodenoson in eye drops and SR (1.5%, or range between 1.2%-3%) has been confirmed, which was discussed in Applicant's prior PCT application (PCT / US23 / 70729).

[0252] Trabodenoson SR intraocular implant provides a potent neural protection product that can be used as drug holiday inducer, it can shorten the IOP ramping up time, which takes 4 weeks in its eye drops formula to achieve 6-7 mmHg reduction. It can replace bimatoprost SR, MIGS, SLT, iDose, Elios laser and tube shunt and trabeculectomy, it also can be used in combination with current standard of care, including combo with IOP lowering eye drops such as ROCK inhibitor. The goal is to induce every glaucoma patient toward a disease free drug holiday status, during which patient preserve their visual field stability. Drug holiday is equivalent to RGC neural protection. Trabodenoson derived MMP / A1 AR offers the most effective, the first curative solution to glaucoma patient care.

[0253] In clinical IOP management, to define individual target IOP is a challenge. RGC cell health is closely intertwined with ophthalmic vascular blood perfusion, and it does not mean that the lower (IOP), the better. When a patient reaches a disease-free drug holiday status, their selfregulated IOP is the most accurate target IOP. For early-moderate stage glaucoma, Trabodenoson can help define that sweet spot (IOP on target).

[0254] Clinical Outcome Measures of MMP therapeutic on IOP Normalization

[0255] Visual Functional Outcomes of trabodenoson MMP / A1AR therapeutic via eye drops and / or SR intracameral implant will be Humphrey visual field tests, which has been used as clinical standard for glaucoma disease diagnosis and monitoring of the disease progression. For early to moderate stage of glaucoma, it takes 6 months to 12 months before the clinical significant changes can be detected. For advanced or end stage glaucoma, 3-6 months are sensitive time window to assess such functional changes. This is a direct functional assessment of the retinal ganglion cell (RGC) health (or loss) in patients with glaucoma. Based on bimatoprost SR Ph3 clinical trial evidence, 12 months is sufficient or sensitive enough to capture the MMP treatment benefit in early and moderate stage of POAG / OH.

[0256] Optical coherence tomography (OCT) provides noncontact and noninvasive retinal nerve fiber layer (RNFL) thickness measurements and has become an essential clinical measure for objective glaucoma assessment and disease monitoring, Time domain and spectrum domain OCT both have been employed for clinical diagnosis and glaucoma disease monitoring (Kim JS, et al. Invest Ophthalmol Vis Sci. 2010 Feb;51(2):896-902). OCT provides an anatomic assessment of RNFL loss, it is more sensitive to early-stage disease diagnosis compared to the VF tests, whereas to late stage or end stage glaucoma, VF / visual functional assessment is more sensitive than RNFL thickness measurement.

[0257] Detection of Apoptotic Retinal Cells (DARC) is a newly developed technology that identifies apoptotic retinal cells through the use of an intravenously administered fluorescent biomarker and confocal scanning ophthalmoscopy (M F Cordeiro. Investigative Ophthalmology & Visual Science July 2018, Vol.59, 1617), it is still in Ph2 clinical trials to validate the assessment parameters for early-stage glaucoma disease detection, potentially it could be used as a surrogate biomarker for assessing drugs or treatments for their RGC neural protection outcomes with better sensitivity, thus, it could potentially shorten the length of clinical trials, e.g. 6-12 months.

[0258] Whilst VF stability, OCT and DARC offers useful clinical biomarkers for assessing the damage of the retinal ganglion cell (loss) in patients with glaucoma, MMP therapeutic benefit also can be measured by dosing switch, reducing the needs for the number of medications (eye drops) or replacing invasive glaucoma drainage surgeries such as tube shunt or trabeculectomy. In particular of interest, the reduction of the medications from 4 meds to 3 meds or from 3 meds to 2 meds, from 2 meds to one med, from one med to zero called drug holiday, a disease free state where patients can self-regulate their IOP via intricate biological competence of the sensing cells. IDose Phase 2 and Phase 3 clinical trials results have demonstrated of such benefits of reducing medications as the results of travoprost SR induced MMP therapeutic benefit, in a small percentage of patients. Reducing the medication (number), similar to trabodenoson dosing switch from BID to QD observed in Phase 2 clinical trials, is a sign of the TM rejuvenation and the pressure sensor functional improvement towards a full recovery which is the drug holiday. The underpinning biology of phenomenon driven by MMP therapeutic has not been recognized before.

[0259] Sustained release (SR) Trabodenoson Product Design The SR delivery formats can be a rod (similar to bimatoprost SR), disc, istent (similar to iDose by Glaukos) via intracameral delivery route with the target site of action at the trabecular meshwork (the drug site of action is not at the retinal choroidal tissues as prior arts described). The rod, disc, stent can be made in biodegradable and non-biodegradable formats. The rod size can be ranged from 0.5mm to 2.0 mm in length, preferrable with 0.8mm-1.0mm in length; the diameter will be similar to 23G to 32G (gauge) needle or injector, preferably 27G-28G injector. SR duration will be 1-6 months, 3-6 months, preferably 2-3 months to early-stage glaucoma or eyes with shallow AC often seen in PACG; 3-4 months for advanced stage glaucoma.

[0260] SR dosing parameter: regardless of the size, shape, location and material composition matter for the SR formula, the total API loading dose, SR duration and daily release speed are determined by the optimal dose of 1.5% eye drops as the reference dosing guide, namely, the API in aqueous concentration released by the SR system (described above) must meet the same API dose level rendered by the optimal eye drop dosing delivered through concentration gradient mechanism from the cornea scleral surface reaching to the anterior chamber (AC), being diluted by the aqueous humor flow. The cornea epithelium cell is the key barrier of eye drop drug delivery through the cornea to the AC. The optimal eye drop dosing of Trabodenoson is 1.5% BID for 14- 28 days during which period, the API concentration achieved at the aqueous humor as the reference.

[0261] SP Product Design & Target Profile

[0262] Biodegradable Polymer Degradation and API Release Profile (Design)

[0263] Trabodenoson SR implant dimension: 0.5-2.0mm on length, preferably 0.8- 1.0mm length; it should fit into 22-32 gauge injector, preferably 27-28 gauge or 28-30 gauge injector. The API release profile should be on zero kinetic with steady state. Targeted API release duration can be ranged from 2-6 months or 6-12 months, preferably between 12-16 weeks for advanced stage glaucoma. The API release speed and the biodegradable polymer degradation should be in good correspondence, an ideal or targeted scenario will be that the API and biodegradable polymer (drug carrier) disappear at the same time or same day, if not within the same day, the complete API release (below the detection) should happen before the biodegradable polymer is gone in order to avoid residual API burst causing drug concentration surge at the site of action in the anterior chamber (AC). An early API release should not proceed more than 7 days before the drug carrier (biodegradable polymer) is gone, ideally it should be controlled within 1-3 days preferably, or 3- 5 days, no more than 7-14 days. The AC rod should be avoided with an empty rod (polymer) without the API for more than 1-2 weeks ideally. The advantage ofhavingthe 1.5% Trabodenoson eye drops dosing optimal as a reference dosage to guide the SR dosing parameter design and dose selection, namely, the API loading dose and release speed is the most important consideration and the first step for the SR product design, most companies may have not recognized it (e.g., bimatoprost SR implant seems to have left empty rod (implant) for >1 month). Such SR dosing design will ensure the reproducibility of a target IOP profile for trabodenoson that can deliver the MMP at a therapeutic level, equivalent to what 1.5% eye drop has achieved in prior Phase 2 monotherapy and combination therapy clinical trials. Trabodenoson has a distinct or unique IOP pattern behavior at the optimal dose (1.5% eye drops), one should not miss it from its SR formula too, though the time to the steady state for Trabo-SR therapeutic will be quicker than Trabo-eye drops, it is estimated within 3-4 months, >=80% patients at early to moderate stage should achieve a disease free drug holiday status, and such drug holiday could potentially sustain for 12 to 24 months at minimal, or longer up to 3-5 years, or 5-10 years, if with Trabo- eye drop as IOP drug holiday stabilizer.

[0264] In certain aspects, the drug target site of action has to be at the trabecular meshwork (TM endothelium or TM contractible tissue) and / or ciliary body (epithelium or vascular endotheium), the therapeutic protein is MMP family (MMP-14, MMP2, or others). The API concentration at these targeted tissues should be achieved by SR formula as the same as the optimal dosage of eye drop that has achieved, such concentration will generate the maximal therapeutic benefits and IOP reduction at the same concentration. The therapeutic benefits for Trabodenoson will be via Al AR activation that upregulates MMP 14 along with G protein coupled cell hyperpolarization on restoring the membrane homeostasis. The previously defined optimal dosing for Trabodenoson eye drop is 1.5% BID that is more effective than 0.6% BID on IOP normalization toward RGC protection in glaucoma (U.S. Serial No. 18 / 356,874).

[0265] MMP therapeutic on glaucoma neural protection: broadly speaking, glaucoma neural protection can also be achieved by endogenous delivery of MMP at a therapeutic level, resulting in IOP improvement and diurnal normalization towards a disease-free drug holiday status. For example, AAV-MMP genetic delivery (biofactory) with dosing switch on / off for treatment of glaucoma for 1-3 months or 1-6 months, preferably 3-4 months. The MMP therapeutic level is defined by the IOP improvement, achieved by Trabodenoson 1.5% BID dosing optimal (1-3 months or 1-6 months depending on the disease staging and the needs for such therapeutic MMP level will be assessed by clinical IOP profile.

[0266] The MMP therapeutic outcome or clinical results can be measured not only by the primary endpoint of RGC protection such as visual field stability and / or RNFL thickness by SD-OCT or DARC described above, it also can be measured by medication reduction, e.g. reducing glaucoma IOP medication from 4 medications to 3, or 2, or 1 medication, or from 3 medications to 2, or 1 medication, or from 2 medications to 1 medication. Alternatively, such MMP therapeutic benefit can also be measured for its ability to replace invasive glaucoma drainage surgeries such as trabeculectomy and tube shunt. Trabodenoson is the only eye drops that upregulates MMP at a therapeutic level. PGA eye drops at commercial low dose do not upregulate MMP at a therapeutic level.

[0267] Matrix metalloproteinases (MMPs) are a family of zinc-dependent extracellular matrix (ECM) remodeling endopeptidases that have the capacity to degrade almost every component of the ECM. MMP- 14 is membrane type MMP, one of the most potent MMP molecule with anti- inflamamtory activities, and MMP2, MM3 and MMP1 have been suggested of its roles in Bruch’s membrane remodeling and TM remodeling. Any genetic medicine involves with MMP family molecule, individual or multiple protein in combination, delivered at a therapeutic level will result in TM rejuvenation and IOP normalization towards RGC protection.

[0268] MMP therapeutic level is defined by its upregulation or secretion level exceeds the TIMP level, the output is the ECM protein degradation is faster than its synthesis at the TM / CB tissues, which results in ECM remodeling toward an increased elastance and improved outflow facility at the TM in glaucomatous human eyes.

[0269] Trabodenoson Impact on Fuch ’s Endothelial Dystrophy

[0270] Fuch’s endothelium corneal dystrophy (FECD) is a progressive neural degenerative blinding disease characterized by corneal endothelium cell apoptosis, it has genetic predisposition and considered a genetic disease. In the USA, FECD is the No. 1 cause for cornea transplant, accounts for about 1 / 3 of the DMEK (Descemet membrane endothelium keratoplasty) and DSEK (Descemef s stripping endothelial keratoplasty) procedures. In UK / EU, cornea keratoconus is the leading cause of cornea transplant, followed by Fuch’s and Pseudo phakic bullous keratopathy. The key pathological processes are possibly related to excessive oxidative damage and mitochondrial stress (Ula V. Jurkunas , et al. Am J Pathol 2010, 177:2278-2289), along with its underlying Descemet membrane thickening, collectively leading to endothelium edema and apoptosis, which is similar to TM sensing cell apoptosis in glaucoma, and RPE cell loss in AMD. Despite the original triggers and risk factors differ among AMD, glaucoma and FECD, the final pathway that drives these neural lineage cell toward apoptosis seems to be the same. Cornea endothelium cell has the closest proximity to the pressure sensing cell (as its neighboring cell) and shares a similar microenvironment niche and exposing to the aqueous humor, it has rich adenosine receptor (A1AR) distribution on the cornea and TM tissues, it is believed that Trabodenoson eye drops (e.g. E5%BID) should offer a therapeutic relief to help reducing the oxidative stress to FECD, by Gi protein driven cell hyperpolarization, which essentially put the cell under a resting stage, and restore cell homeostasis. Trabodenoson derived MMPs therapeutic also could be useful in removing the excessive ECM protein building up at the Descemet membrane. The drug MoA and disease pathological process is a great match.

[0271] Combination Therapies

[0272] In some embodiments, a MMP therapy of the instant disclosure - e.g., trabodenoson or other MMP agent disclosed herein, or a composition comprising the same - is administered in combination with an additional agent, e.g., additional therapy. In some embodiments, an additional therapy comprises a therapy for a disease or disorder, e.g., a standard of care (SOC) therapy, for a symptom, disease or disorder. In some embodiments, a MMP therapy is administered before, concurrently with or after administration of an additional therapy, e.g., an lOP-reducing therapy, MIGS procedure or device / system, etc.

[0273] Kits

[0274] In certain aspects, the instant disclosure provides kits that include a suitable container containing a pharmaceutical formulation of a MMP therapy (e.g., trabodenoson).

[0275] Such kits include one or more MMP agent(s) and instructions for use, e.g., instructions for administering a prophylactically or therapeutically effective amount of MMP agent(s). The MMP agent may be in a vial or a pre-filled syringe, or in an implantable device (optionally biodegradable). The kits may optionally further comprise means for administering the MMP agent (e.g., dropper bottle, or other device for injection or surgical implantation of the therapy, such as a pre-filled syringe or implantable device) or means for measuring IOP levels / normalization and / or RGC state / loss). The kits of the present disclosure may optionally further comprise means for determining the therapeutically effective or prophylactically effective amount. In certain embodiments, the individual components of the pharmaceutical formulation may be provided in one container, e.g., eye dropper bottle / vial, etc. Alternatively, it may be desirable to provide the components of the pharmaceutical formulation separately in two or more containers, e.g., one container for a MMP therapy preparation, and at least another for a carrier compound, implant, etc. The kit may be packaged in a number of different configurations such as one or more containers in a single box. The different components can be combined, e.g., according to instructions provided with the kit. The components can be combined according to a method described herein, e.g., to prepare and administer a pharmaceutical composition. The kit can also include a delivery device.

[0276] INCORPORATION BY REFERENCE

[0277] All publications, patent applications, patents, and other references mentioned herein, including GenBank Accession Numbers, are incorporated by reference in their entirety. In addition, the materials, methods, and examples are illustrative only and not intended to be limiting. Unless otherwise defined, all technical and scientific terms used herein have the same meaning as commonly understood by one of ordinary skill in the art to which this invention belongs. Although methods and materials similar or equivalent to those described herein can be used in the practice or testing of the present invention, suitable methods and materials are described herein.

[0278] This present disclosure is further illustrated by the following examples which should not be construed as limiting the scope or content of the disclosure in any way. The entire contents of all references, patents and published patent applications cited throughout this application, as well as the informal Sequence Listing and Figures, are hereby incorporated herein by reference.

[0279] EXAMPLES

[0280] Example 1: Identification of Trabodenoson as Capable of Protecting Retinal Ganglion Cells (RGCs) and Normalizing Intraocular Pressure (TOP) in Glaucomatous Eyes

[0281] Trabodenoson (FIG. 1), formerly known as INO-8875, is a potent and selective adenosine Al receptor agonist (Ki = 0.97 nM for A1AR). Trabodenoson's adenosine Al receptor binding affinity defines its on / off target drug metabolism and pharmacokinetics (DMPK) profile, as well as the drug's clinical efficacy and safety profile, and helps describe why optimal dosing is essential for trabodenoson exerting its physiological and biological effects in patients with glaucoma. In particular, as disclosed herein, trabodenoson's unique intra-ocular pressure (IOP) patten behavior is strictly defined by optimal dosing at a narrow range between 1.0-3.0%, optimally 1.2-1.5% in eye drops.

[0282] Applicant recently identified trabodenoson to have normalized IOP diurnal irregularities in glaucoma via matrix metalloproteinase (MMP) / AlAR-mediated trabecular meshwork (TM) repair and restoration of pressure sensor functionality (see PCT / US23 / 70729), and the recent analysis of previous clinical trial data demonstrated that a 1.5% BID dosage of trabodenoson was more effective for glaucoma patients than the 0.6% BID dosage previously identified in the art as optimal (FIG. 2; this recent analysis involved a more complete consideration of the (MMP)ZAlAR-mediated effects). Applicant identified updated clinical dosing principles for trabodenoson, where timing of progression to a steady-state IOP reduction level across various tested doses of trabodenoson was assessed, with MMP / A1 AR therapeutics (such as trabodenoson) newly considered ("slow mode" MMP / A1AR therapeutic effects with steady state - the MMP / A1AR steady state represents the maximal clinical therapeutic benefits, seen when the extracellular matrix (ECM) degradation and synthesis achieved equilibrium). When vascular effects of trabodenoson were considered, a bell-shaped dose-response curve for IOP reduction was observed for trabodenoson (these vascular effects were "fast mode" effects), which had previously resulted in identification of 0.6% trabodenoson as the alleged "sweet spot" for achieving IOP reduction in subjects, where only the vascular effect had been considered. Applicant specifically performed an updated analysis that included consideration of both the MMP / A1AR route effects and vascular effects (as a sum of IOP reduction by trabodenoson acting via dual mechanisms of action) of trabodenoson (FIG. 2). Phase 2 clinical trial results for trabodenoson IOP pattern behaviors in patients (POAG / OH dual) having both primary open angle glaucoma (POAG) and ocular hypertension (OH) were evaluated using these updated criteria, and it was recently revealed that 1.5% BID dosing would actually be the optimal dosing of trabodenoson in such patients (when both vascular effects that produced the bell-shaped curve and MMP / A1AR route effects were considered together, as shown in FIG. 2). The IOP profiles demonstrated a dose-dependent IOP improvement and a bell-shaped IOP reduction result (FIG. 2), which peaked at 0.6% BID. The same molecule (trabodenoson) was therefore identified as effectively two different drugs (the first drug acting via the "fast mode" vascular effects, and the second acting via "slow mode" MMP / A1AR effects). Applicant considered the relationship between pressure sensing cells (also called Schl emm’s canal endothelium, or SC endothelium) of the eye and the trabecular meshwork (TM) lamellae beams in pulsatile IOP regulation. SC endothelium loss is modeled as the result of oxidative stress and insults driven by the metabolic deficiency, possibly (and without wishing to be bound by theory) related to the SC chamber compression abnormalities observed in glaucomatous eyes. The pulsatile flow into aqueous veins involves three specific structural outflow systems (refer to FIG. 3): 1) compressible chamber (Schlemm’s canal (SC)), 2) valves - corresponding to episcleral venous pressure (EVP); and 3) the energy source (cardiac driven force). Abnormal compression of the SC results in a shear force damage to the pressure sensing cells; this likely creates a prolonged physical contact stretch between the cells at the SC inner wall and the SC outer wall under an irregular lOP-driven force. In response to cardiac-dependent changes in choroidal volume, the anterior chamber experiences continuous pulsatile alteration in pressure oscillation force, the TM outward in systole, followed by recoil in diastole, and SC volume oscillates as a result.

[0283] Analysis of clinical trial results demonstrated the neural protection benefit to retinal ganglion cells (RGCs) of achieving a drug holiday state (essentially a disease-free state) in patients with glaucoma, via use of MMP -targeting therapeutics (e.g., trabodenoson) that act to normalize IOP diurnal irregularities (FIG. 4). As identified herein, the rate limiting root cause of visual field loss in patients (POAG / OH) having both primary open angle glaucoma (POAG) and ocular hypertension (OH) was identified to be intraocular pressure diurnal irregularities and IOP stress (FIG. 4) A comprehensive map of various risk factors attributing to glaucomatous neural degeneration, resulting from RGC apoptosis and optic neuropathy, was compiled (FIG. 4). IOP- dependent (lOP-driven) downstream risk factors were newly identified herein - these were previously believed to be lOP-independent risk factors (Qiu. EC Ophthalmology. 2.2 (2015): 81- 91), e.g., neuroinflammation driven by microglia astrocyte activation releasing a cluster of cytokines and neurotoxins (e.g., glutamate). The neurovascular inflammation or imbalance triggered release of a variety of harmful molecules and cytokines from the diseased RGC and its supporting cells (astrocyte, microglia, oligodendrocytes), leading to RGC apoptosis, axon degeneration and dendritic synapse inflammation. Importantly, the IOP stress or irregularities also activated microglial transformation and released harmful neurotoxins and cytokines, such as glutamates, NF-KappaB, TNF-alpha, and interleukins, particularly IL-6. Astrocytes around the optic disc and optic neural fiber layers also became agitated and released a cluster of cytokines, which caused neurovascular inflammation around the optic disc chasm and neurofilament fibers. IOP stress was likely the primary driving force and triggered a cascade of cellular response at the back of the eye, in the retina and the choroid, where the ischemia-reperfusion damage took place, affecting the metabolic health of the optic discs (FIG. 4). These lOP-driven downstream risk factors included those associated with hypertensive glaucoma, such as POAG, OH, PACG and secondary glaucoma or other hypertensive conditions, such as steroid-induced IOP elevation. Trabodenoson-derived MMP therapeutic and cytoprotective effects have been shown clinically to normalize the diurnal irregularities of patients by improving pressure sensor functionality toward inducing a full recovery, at which point drug holiday became possible. A dosing switch from BID to QD suggested a partial functional recovery even before the ECM reached steady state, in which the protein degradation and synthesis were in balance, thereby maintaining the structural integrity of the trabecular meshwork in patients with glaucoma. 20-month Phase 3 clinical trial results for a bimatoprost (a structural analog of prostaglandin F2«) sustained release (SR) intracameral implant in patients with POAG / OH, indicated that patients treated with the SR implant for 12 months had their vision or visual field (VF) better preserved, with stability, as compared to a control group treated with timolol (beta-blocker) eye drops BID for 20 months, in which patients’ VF deteriorated over time, with clinical significance observed at 12 months (*p=0.037 vs. timolol based on a mixed-effect model for repeated measures including treatment, visit, treatment-by-visit interaction, baseline MD, and visit-by-baseline interaction). Results of measuring mean change in the visual field mean deviation (MD) from baseline by Humphrey perimetry in study eyes were plotted (FIG. 4). Test results from eyes that had received rescue lOP-lowering treatment were excluded from the original analysis. The number of eyes included in the analysis of change in MD from baseline at visits from week 28 to month 20 ranged from 101 to 143 in the 10 pg bimatoprost implant group, 102 to 143 in the 15 pg bimatoprost implant group, and 123 to 144 in the timolol BID group (BID indicates twice daily; BL indicates baseline; SEM indicates standard error of the mean). During an eight-month drug holiday period without MMP therapeutic in the absence of active pharmaceutical ingredient (API), patients sustained a strong positive trend with mild VF decline. It was identified herein that the visual field stability seen in patients treated with bimatoprost intracameral implant appeared to have been produced by an MMP therapeutic effect upon IOP normalization, which produced neural protection benefits, which is an effect that had not been previously recognized - indeed, the authors of Bacharach et al. (Drugs 81 : 2017-2033), from which the right panel of FIG. 4 is copied, believed that the observed bimatoprost intracameral implant effect was the result of a slow release effect (similar to MIGS procedure), which Applicant has now identified was not correct. The extended IOP stability seen in bimatoprost intracameral implant-treated patients was initially attributed to the bimatoprost free acid inducing lymphangiogenesis in the human ciliary body, as set forth in L Charters (Ophthalmology Times. 47(5), citing Dr. Douglas Rhee's original assessment of clinical results). It has been newly identified herein that such VF stability benefit more likely resulted from the MMP therapeutic aspect of the bimatoprost sustained release (SR) intracameral implant when delivered at a high dose API (not via eye drops). By the current analysis, the slight decline of the VF stability at twelve months has now been attributed to the following three reasons: 1) the high dose API triggered clinically significant inflammation that killed the RGCs at the back of the eye (main reason); 2) some of the patients may not have been in a “true” drug holiday state, as the current limits of IOP monitoring have been based on selective 2-3 timepoints, not upon 24-hour monitoring, which meant that the IOP diurnal irregularities might still have been present in some individuals included in the original analysis; 3) during the first 2-3 months, treated patients were still losing vision, before their lOPs were being normalized or before reaching the drug holiday state. In principle, once a patient reaches the drug holiday state or their IOP has been normalized, that patient should not continue to lose their vision, and their RGCs should be protected under a true drug holiday status (as effectively a disease-free state). Based upon the current reassessment of the data now shown in FIG. 4, Applicant estimated that if bimatoprost were to have been replaced by trabodenoson in the SR system, the VF stability results would likely have been much better, because of the paired trabodenoson advantages of excellent clinical safety and higher therapeutic potency (as a MMP / A1 AR therapeutic), as compared to bimatoprost SR. It was thereby identified herein that by normalizing IOP irregularities and inducing patients into an extended drug holiday state, trabodenoson administration would likely eliminate glaucoma-induced visual field loss and effectively halt disease progression entirely, in trabodenoson-treated glaucoma patients.

[0284] Past research in the MMP field (e.g., that performed by Prof. John Marshall) had, for example, investigated the impact of matrix metalloproteinases (MMPs) upon Bruch’s membrane rejuvenation in the retina, where it was demonstrated that MMP treatment could make a 60-y ear- old Bruch’s membrane regain the hydraulic conductance and elasticity levels typical of a 40-year- old Bruch’s membrane. As noted above, Applicant recently discovered that MMP therapies, particularly formulations of the adenosine mimetic trabodenoson, could act through the MMP pathway to produce a disease-free drug holiday state in a treated patient (see PCT / US23 / 70729, where Applicant's further assessment of bimatoprost sustained release intracameral implant clinical trial results also evidenced the role of MMP therapies in treating glaucoma). However, the instant disclosure represents a significant advance over even Applicant's recent discoveries, as the instant disclosure documents a progression from Applicant's having previously identified trabodenoson (at an improved dosage) as an effective disease-modifying agent, to the discovery and identification herein of trabodenoson as the most effective neuroprotection agent available for treating glaucoma, one that is specifically capable of effectively halting disease progression. Trabodenoson has been identified herein to specifically remove the rate-limiting root cause of vision loss in glaucoma. It has the ability to block all currently known or unknown downstream risk factors and signaling pathways that would otherwise cause retinal ganglion cell (RGC) apoptotic or necrotic cell death. MMP treatment more generally is therefore also newly identified herein as a platform therapy for inducing glaucoma neural protection via IOP normalization, and the trabodenoson MMP / A1AR therapeutic is the preferred choice for delivering MMP treatment via eye drops or SR anterior chamber (AC) rod, possessing superiority over other glaucoma therapies, with advantages including trabodenoson's excellent clinical safety and MMP potency, along with its AlAR-induced neural protection (dual) of both RGC and pressure sensing cells.

[0285] The prior art related to MMP therapies described ECM remodeling at the TM in patients receiving bimatoprost SR implant (Durysta®); however, Applicant recently identified that the observed MMP biological effect had been incorrectly identified as a fast mode vascular effect of “reducing” the IOP, as a one-time occurrence (FA Medeiros et al, Ophthal. June 2020). In addition, prevalent prior art had previously attributed the extended lOP-lowering benefits observed in patients treated with a bimatoprost SR implant to lymphangiogenesis in the human ciliary body (stating that bimatoprost SR drug holiday induction related to intraocular lymphocyte drainage), which had allegedly created the endothelial-lined passages (L Charter Ophthalmology Times, June 2, 2022, reviewed by Dr. Douglas Rhee). Applicant has identified that the visual field benefit observed in ARTEMIS-2 clinical trial data (shown in FIG. 4) was also mistakenly viewed as the result of sustained release drug delivery (similar to MIGS). Applicant's discovery of trabodenoson- driven effects as a MMP therapeutic having impact on IOP normalization toward neural protection (see PCT / US23 / 70729) provides a scientifically sound explanation for previous misconceptions in the art for the IOP drug holiday observed in patients treated with a bimatoprost SR implant.

[0286] While a MMP biological effect was previously observed for both bimatoprost SR implant and trabodenoson therapies, Applicant has now identified that trabodenoson appears to be the more advantageous therapy for protecting RGCs, halting progression of visual field degeneration, and effectively treating glaucoma over longer time courses, at least in view of the clinical trial finding that bimatoprost SR triggered intraocular inflammation (FIG. 5), which caused alarming corneal endothelium loss (>20% in less than 2 years, compared to 1% annual loss due to aging), that also would have caused damage to the retinal ganglion cell (RGCs) at the back of the eye. Such inflammatory cascade effects act in a slow accumulative mode - even after the API (bimatoprost) was gone, there were de novo effects (or damage to the RGCs). Applicant has identified that bimatoprost SR does not simply "reduce" IOP but removes glaucoma pathologies, improves pressure sensor functionality, repairs the damage of the TM and sensor caused by aging and oxidative damage. This new interpretation explains why patients treated with bimatoprost SR and who reached a drug holiday status continued to lose vision at 20 months. Data were generated from patients with diabetic eyes, and protein concentration levels in aqueous humor (AH) and vitreous humor (VH) revealed significant overlaps on the principal components. In total, 841, 917 and 1133 protein samples assessed in FIG. 5 were from AH, VH and serum (SE), respectively, which included three important categories: angiogenesis regulators, immune-related proteins, and matrix metalloproteinases (MMPs). Any protein secreted locally with a long half-life would likely have travelled from the anterior chamber toward the vitreous cavity, and vice versa.

[0287] Minimally invasive glaucoma surgery (MIGS, in which a surgeon makes a small incision to remove tissue debris that blocks the flow of fluid in the eye) has been previously described for glaucoma treatment; however, MIGS cannot stop glaucoma disease progression and accompanying neuronal cell death. Trabodenoson was therefore newly contemplated as a therapy that could replace MIGS, or that could be employed supplemental to a MIGS therapy (as MIGS therapies tend to alleviate symptoms, without addressing the root cause of glaucoma). Clinical data of a single arm GEMINI study (derived from Pyfer et al. Clin Ophthalmol . 15: 3931-3938) that employed one type of the modem micro invasive glaucoma surgery (MIGS), an OMNI® device that accesses, catheterizes, and viscodilates the Schlemm's canal, and also the distal outflow system, beginning with the collector channels, which was used to perform a sequential ab interno canaloplasty followed by a trabeculotomy, was examined. This MIGS process demonstrated its impact upon glaucoma patients’ IOP diurnal profile. Individual diurnal IOP irregularities in patients with POAG persisted after canaloplasty / trabeculotomy surgeries, at 12-month follow-up vs baseline (FIG. 6, shown is the variability observed in the three diurnal IOP measurements - at 9 am, noon, and 4 pm - for each patient at preoperative (squares) and month 12 (circles)). It was interpreted herein from these data that MIGS was lacking in the mechanism to treat the rate limiting root cause (IOP irregularities) that kills the RGCs in glaucoma (in contrast to the activities of trabodenoson disclosed herein), hence MIGS could only slow down disease progression to a limited extent. Hydrus® (microstent) glaucoma surgery also slowed down (but could not stop) the visual field loss observed in early-stage glaucoma (POAG / OH) patients (FIG. 7).

[0288] Based upon the above, Applicant modeled the effect of trabodenoson treatment (which exerts MMP and Al AR effects) to promote glaucoma neural protection and trabodenoson's related therapeutic potency, in comparison with a bimatoprost SR implant (bimatoprost intracameral implant), with trabodenoson acting as a MMP therapeutic, which imparted symptom relief for IOP irregularities when administered as eye drops, also as compared with patients that received MIGS surgeries (FIG. 8). A simple scoring system was employed to highlight the superiority advantage of trabodeoson when administered as the first drug capable of effecting neural protection as a drug for glaucoma, acting via MMP / A1 AR effects as an effective therapeutic, and beyond. Score ranges from S=1 to S=10 were assigned, with S=1 being least effective and S=10 being the most effective (an S score of 10 indicating that the treatment could fully stop and cease the visual field loss in a subject that would otherwise occur as the result of progressive RGC neuronal cell apoptosis and axon degeneration). The current scoring criteria was based on assessment of product attributes, primarily the molecule that could eliminate and remove the two rate limiting root causes, which were the MMP-meditated therapies (e.g., trabodenoson). Trabodenoson was observed to have induced MMP-14 / MMP-2-mediated removal of the ECM debris and to have rejuvenated the basement membrane underlying the pressure sensing cells at the TM. Trabodenoson's A1AR activation also provided a direct cytoprotection effect to the sensing cells (at the front of the eyes, with Phase 3 evidence). It has been identified herein that both modes of action exert a positive synergy in treating the pressure sensor pathological processes that occur in glaucoma. Other mechanistic components of trabodenoson's (A1AR activity) therapeutic efficacy include trabodenoson's roles in anti-inflammation, vascular dilation, and AlAR-mediated neural protection provided to the RGC cells (at the back of the eye, even when trabodenoson eye drops as disclosed herein are applied to the front of the eye and / or a trabodenoson implant is positioned at the front of the eye), as well as neurovascular modulations via choroidal vascular dilation (preclinical evidence). Hence, trabodenoson was ascribed the highest score of S=10. The bimatoprost intracameral implant was ascribed a score of S=6, mainly attributing to its SR acting via MMP at a therapeutic level, which was sufficient to address the rate limiting root cause of glaucoma progression by repairing the pressure sensor damage seen in early-to-moderate stage glaucoma (70-80% patients achieved a drug holiday), but the bimatoprost intracameral implant therapy is likely limited to use for an advanced stage of TM repair, due to the bimatoprost implant's inflammatory side effects. But given its MMP effect, bimatoprost intracameral implant therapy (as a single implant) is better than MIGS, which is given a score of 5 (S=5). This scoring system is for illustrative purposes, and while subjective, represents a spectrum of treatment benefits based on the overall risk / benefit profile to patients.

[0289] Drug holiday induction results were compared for bimatoprost SR implants and trabodenoson eye drops (FIG. 9). In glaucoma treatment, achieving a status of drug holiday reflects a disease-free state of TM health, where a full functional recovery of the pressure sensor has been obtained in glaucomatous eyes. Achieving a durable drug holiday state in a patient reflects the intricate biological competence of pressure sensing cells that can self-regulate the IOP, without the need for the extra help of traditional, symptom-relieving IOP medications. It also represents the steady state of MMP / A1AR therapeutic, during which the ECM synthesis and degradation reaches an equilibrium. In normal healthy eye, such equilibrium is regulated by MMPs and tissue inhibitors of metalloproteinases (TIMPs) in balance. In particular, achieving a drug holiday status is determined by two key aspects: the first aspect, related to glaucoma disease staging, is defined by pressure sensor cell recoverability (it is estimated herein that effective pressure sensing requires maintaining at least 50-70% of pressure sensing cells in glaucomatous eyes, to be able to achieve a full functional recovery and a stable drug holiday for 6-12 months or longer, when treated with a MMP therapy (e.g., trabodenoson). Parameters for detecting a drug holiday -ready state should also include the percentage of patients: e.g., 50%-80%, time to start (e.g., 1-3 month or 3-6 month induction), and the durability of the holiday period to be achieved (e.g., 3-6M or 12-24M or 3-5 years). The second aspect relates to therapeutic potency and treatment time. Potency includes MMP potency and neural protection potency, and it was identified that bimatoprost SR does not exert an Al AR-mediated cytoprotection of the pressure sensing cells, plus bimatoprost SR also increased inflammation and metabolic stress to the pressure sensing cells. Therefore, trabodenoson was far more potent than prostaglandin analog (PGA) drugs in SR formulations, e.g., bimatoprost SR implant. Therapeutic benefits of trabodenoson were observed to have increased with treatment time, hence it is identified herein that a trabodenoson SR formulation (e.g., an implant such as used for bimatoprost SR) would likely be even more effective than trabodenoson eye drops for induction of drug holiday in a treated subject. Within the currently defined therapeutic dose window for trabodenoson, high concentration trabodenoson eye drops were more effective than low concentration trabodenoson eye drops, e.g., 1.5% trabodenoson was identified as more effective than 0.6% for induction of drug holiday in a subject. However, if the concentration exceeds a certain limit, the higher dose or concentration of trabodenoson does not generate or trigger higher MMP release at a given timepoint, likely due to the negative loop feedback from its substrates such as fibronectin, collagen IV and lamina etc. In principle, a trabo-SR (sustained release trabodenoson) format can induce a drug holiday in a subject at a faster speed, across a higher percentage of patients - including those patients having a more advanced stage of glaucoma (e.g. patients with 3-4 medications or glaucomatous eyes currently have received trabeculectomy or IDose implants, which have often failed) - and with a longer duration, as compared to bimatoprost SR implant. Also in trabodenoson SR's favor, longer SR induction should induce a higher percentage of patients to a more durable drug holiday, as compared to a shorter term SR format (e.g., 6M of treatment is better than 3M of treatment for severe glaucoma). However, bimatoprost SR's MMP therapeutic benefit is proportionally tempered given the sight-threatening side effects to the cornea and TM health observed for current bimatoprost SR implants, hence, the bimatoprost SR MMP benefit is compromised.

[0290] A durable drug holiday was achieved with a single dose implant of bimatoprost SR (FIG. 9, top left, involving 4.2 month loading of respective 10 pg and 15 pg amounts of bimatoprost as the API), as an estimated 68%, 47%, 40%, and 28% of patients, respectively, were observed to be on drug holiday at respective 6M, 9M, 12M, and 20M timepoints post-implantation. The timing of bimatoprost SR induction of drug holiday in treated subjects was also assessed (FIG. 9, lower left). While a single bimatoprost SR implant that dosed for 4.2 months and was loaded with 10 pg or 15 pg led to achievement of drug holiday at six months in approximately 68% of treated subjects, longer treatments (e.g.., with two consecutive implants, which extended dosing to approximately eight months, or with three consecutive implants, which extended dosing to approximately twelve months) induced drug holiday in an increasing proportion of treated subjects - e.g., treatment with three consecutive implants over the span of twelve months resulted in approximately 80% of treated subjects achieving drug holiday, while two consecutive implants achieved approximately 70% of treated patients on drug holiday (FIG. 9, lower left). It was also shown that trabodenoson administered as low dose eye drops (1.5% BID) was so effective that it allowed for a unique dosing switch from BID to QD in treated subjects, as early as day 29 of treatment in subjects having mild-to-moderate POAG / OH, and at eight weeks in subjects who had previously responded poorly to a commonly prescribed PGA treatment, latanoprost (FIG. 9, top right). This dosing switch was a clinical biomarker of improved TM durability for treated subjects, a precursor of drug holiday. Applicant then estimated that administration of trabodenoson eye drops to patients that have already received a single implant of bimatoprost SR could significantly improve both the proportion of treated patients that achieve drug holiday and the duration of drug holiday in drug-responsive subjects (FIG. 9, lower right). Thus, it is estimated that trabodenoson eye drops can promote drug holiday induction and durability, the latter of which is achieved by stabilizing the condition of patients with glaucoma, when combined with a SR MMP therapeutic as a loading dose (e.g., bimatoprost SR). With sequential dosing, at least 80% of treated patients in total (including patients treated with trabodenoson eye drops during the drug holiday period) are identified to achieve a stable, durable drug holiday at 12 months, and even maintained until 24 months or more, e.g., for three to five years or more. Graphs at top left and lower left are noted as derived from bimatoprost SR implant phase 2 and phase 3 clinical trial results, while the graph at top right was created using trabodenoson eye drop phase 2 clinical trial results.

[0291] AlAR-mediated neuromodulation is inhibitory by nature (FIG. 10). A1AR pathway activation coupled to G protein Gi / Gs inhibits adenylyl cyclase, drives cell membrane hyperpolarization (producing a resting stage), with membrane homeostasis subsequently restored by inhibiting calcium influx and reducing glutamate neural transmitter release, thereby increasing K+-ATP pump conductance. Therefore, Al AR activation has strategic importance for protecting neuronal cells from ischemia reperfusion damage and oxidative stress, which distinguishes the A1AR activation effects observed for trabodenoson from those drugs that activate the MMP therapeutic pathway (alone, without activating Al AR), such as SR bimatoprost and other PGA drugs. Neurotrophic receptors are distributed at the brain (visual cortex), via a retrograde transport and propagation mechanism (FIG. 11). Neurotrophins therefore exert their biological activities towards the RGC in the retina. Tyrosine kinase A, B, and C receptors, and p75 are the primary receptors for nerve growth factor (NGF), brain derived neurotrophic factor (BDNF), neurotrophin 3 (NT3), and neurotrophin 4 / 5 (NT4 / 5), respectively. These receptors are distributed at the axon terminals in the brain. Ciliary neurotrophic factor (CNTF) does not express in the neurons but via retinal pigment epithelium (RPE), muller glia and astrocyte regulation on photoreceptors. More than 50% of the neurotrophins and cytokines or proteins act via a retrograde mode from the brain to the retina to nourish RGC health. If the retrobulbar ophthalmic artery and vein of a subject suffer compression (ischemia-reperfusion), it blocks the pathway that neurotrophins take to the RGC bodies. IOP elevation, spikes and diurnal irregularities can cause a vascular perfusion defect at the optic nerve head, along with the aging rigidity of the lamina cribrosa, which blocks nutrient flow through the optic disc to the retina, and subsequently triggers RGC apoptosis. Retrobulbar vascular perfusion problems are often seen in normal tension glaucoma. In glaucomatous eyes, the rate of visual field loss was approximately 5.5 times faster in optic disc hemorrhagic (ODH) eyes than in non-ODH eyes. The instant diagram also indicates that intravitreal delivery of BDNF proteins or gene therapy for treating glaucoma will find it difficult to achieve pharmacological or therapeutic concentrations at the targeted receptor sites in the human brain, which likely explains why past efforts to use various neurotrophins therapeutically for glaucoma treatment failed in clinical trials.

[0292] Cardiac-induced pulsatile aqueous outflow in the eye serves as a water pump system, which causes choroidal vascular volume changes during diastole and systole phases (FIG. 12). The cardiac cycle results in pulsatile blood flow into the choroid, causing a rise in IOP. The IOP increase causes the TM to move outward, compressing Schlemm's canal (SC). The oscillatory SC compression causes a pulsatile wave of aqueous to enter the episcleral veins. In glaucoma patients, TM elasticity decreases and the pressure sensor of the eye becomes dysfunctional with irregularities, which causes abnormal vascular perfusion (defects), clinically referred to as ischemia-reperfusion damage at the optic nerve head, which subsequently blocks the retrograde transportation of neurotrophins such as BNDF through the RGC exons in the optic nerve bundles from the brain to the retina. The age-related TM rigidity and loss of tissue elastic compliance in response to normal cardiac pulses has direct links to optic nerve damage as a result of the vascular volume changes at the retrobulbar and choroidal space in patients having glaucoma, especially those patients having normal tension glaucoma. In addition to the abnormal vascular perfusion around optic nerve head, the deformation and rigidity of the lamina cribrosa also affects retrograde nutrient transport, which is the main mechanism responsible for neuronal cell survival in the retina (see above).

[0293] Based upon the above, it was reasoned that a preferred target for IOP levels is the one that allows a glaucoma patient to achieve a drug holiday status (not necessarily simply lowering of IOP levels, but normalizing IOP, making IOP less irregular). Glaucomatous optic neuropathy (disc / cupping ratio), as compared with a normal optic disc was considered (FIG. 13A). Early-stage glaucoma with a target IOP range at 15-17mmHg, moderate glaucoma (middle) with a target IOP at 12-15mmHg, and severe glaucoma (at right) with a target IOP at 10-12mmHg, was assessed (FIG. 13B). This provides a reference guide, along with Humphrey VF testing and / or OCT to help a physician to set the IOP management strategy: one bottle or two bottles of eye drops, or surgeries, etc. Target IOP varies from eye to eye, individual to individual. In clinical practice, the target IOP is defined based upon the damage of optic disc and nerve fibers, as assessed using the Humphrey visual field test, which is retrospective, as readings are delayed by 6-12 months. The best guideline for a therapeutic is therefore that of determining when a patient has achieved drug holiday status, at which point the IOP is the most accurate target IOP.

[0294] The current analysis challenges the currently most prevalent principle of clinical IOP management: “the lower, the better”. Current clinical best practice is to compete and identify which drug or treatment lowers the IOP more than the other in a subject as a guide of good IOP control. Rather, the current figure tells an opposite story, by showing that the ideal target IOP may be higher than that obtained by treatment with a potent IOP lowering drug such as bimatoprost, Patients’ IOP levels under bimatoprost SR treatment at week 2 and at week 6 with the API present (FIG. 14A; 7-8mmHg reduction compared to baseline) were about 1.0 mmHg lower than patients that achieved a drug holiday state at week 12 (FIG. 14A; when the API was not present: 6-7mmHg reduction compared to baseline). A comparison of bimatoprost SR treatment and timolol BID treatments was also considered (FIG. 14B) The drug holiday was therefore the result of bimatoprost SR-derived MMP therapeutic benefits. It seems that few in the art realized or appreciated this fact before Applicant. The ideal target IOP for an individual patient should be identified as the level when the individual patient or eye achieves a disease-free state, with this state also referred to herein as a “drug holiday” state. Trabodenoson therapy as described herein sets a principle or rule with a new standard of glaucoma disease management by introducing TOP drug holiday and its resulting IOP target, which is the ideal target IOP, under which the RGC neurons feel most comfortable and are being protected.

[0295] The transformative impact of trabodenoson on glaucoma treatment has therefore been identified herein, specifically considered against the backdrop of the current IOP management drug landscape (FIG. 15). The current standard of care for IOP management in glaucoma is of symptom relief to lower the IOP, which cannot stop disease progression and therefore does not provide a curative solution for patients with glaucoma. About 30-40% patients will become legally blind at the advanced or end stage of glaucoma. As identified herein, trabodenoson can reverse the aging of TM degeneration, stop the neuronal cell death, and thus offers the first cure and most effective glaucoma neural protection available, via its exerting a combined MMP / A1AR therapeutic effect upon IOP normalization. Trabodenoson can therefore solve two major problems in glaucoma specialty care: 1) poor or non-responders to IOP lowering medications or glaucoma drainage surgeries; 2) the holy grail of actually robustly protecting against neural degeneration and RGC loss in patients with glaucoma.

[0296] MMP therapeutics (e.g., trabodenoson) have thus been discovered herein to protect against the rate limiting root cause of glaucoma, which is RGC loss (resulting from progressive pressure sensor damage). Three major pathways of the RGC cell death rooted by or started from the IOP stress (FIG. 16). IOP diurnal irregularities are the rate limiting root cause of RGC loss at the back of the eyes, and the IOP problem is caused by the pressure sensing cell loss and the sensor dysfunction as the result of the TM aging. The three pathways to trigger the RGC cell loss are intertwining and connected to each other, providing a global picture of the IOP problem - specifically IOP diurnal irregularities as the rate limiting root cause of glaucomatous vision loss. In clinics, ocular hypertension does not lead to the optic necrophagy at early stage, whereas normal tension glaucoma kills the RGC at the very start. It is the diurnal irregularities that pose the biggest threat to RGC health at the back of the eye. First, IOP stress triggers microglia and astrocyte activation and proliferation that produces a cluster of harmful neurotoxin and cytokines such as glutamate, TNF-a, ILs and NF-KappaB. These proinflammatory molecules trigger RGC cell apoptosis, also accelerating the ECM deformation at the lamina cribrosa. The ECM thickening and deformation at the optic nerve head constitute the 2ndpathway of RGC death triggered by the IOP irregularities. Thirdly, IOP irregularities induced ischemia-reperfusion damages to the optic nerve head, subsequently affecting the retrograde transport of neurotrophins (>50%) from the brain to the retina, which triggers the deprivation of nutrient supplies to the RGC, impacting RGC health and contributing to the RGC cell body metabolic inflammation and dendritic inflammation (synapse pathologies). If IOP stress and diurnal irregularities can be removed, the RGC will be protected from these damages by all above three domains of the downstream signaling pathways. The trabodenoson therapies disclosed herein (e.g., eye drops or SR intracameral implant (or AC rod)) offer the most effective or curative solution to prevent and stop RGC loss in patients with glaucoma.

[0297] Example 2: Trabodenoson SR Intracameral Implant - Particularly Useful for Rescuing NonResponders and Refractory Glaucoma at Advanced to End-stage Glaucoma

[0298] SR Product Design & Target Profile

[0299] Biodegradable Polymer Degradation and API Release Profile (Design)

[0300] Trabodenoson SR implant dimension: 0.5-2.0 mm in length, preferably 0.8- 1.0 mm length; it should fit into 22-32 gauge injector, preferably 27-28 gauge or 28-30 gauge injector. The API release profile should be on zero kinetic with steady state. Targeted API release duration can range from 2-6 months, preferably between 12-16 weeks. The API release speed and the biodegradable polymer degradation should be in good correspondence, an ideal or targeted scenario are that the API and biodegradable polymer (drug carrier) disappear at the same time or same day, if not within the same day, the complete API release (below the detection) should happen before the biodegradable polymer is gone, to avoid residual API burst causing drug concentration surge at the site of action in the anterior chamber (AC). An early API release should not proceed for more than 7 days before the drug carrier (biodegradable polymer) is gone, ideally it should be controlled within 1-3 days preferably, or 3-5 days, no more than 7-14 days. The AC rod should be avoided with an empty rod (polymer) without the API for more than 1-2 weeks. The advantage of having the 1.5% Trabodenoson eye drops dosing optimal as a reference dosage to guide the SR dosing parameter design and dose selection, namely, the API loading dose and release speed is the most important consideration and the first step for the SR product design, most companies may have not recognized it (e.g., bimatoprost SR implant seems to have left empty rod (implant) for >1 month). Such SR dosing design will ensure the reproducibility of a target IOP profile for trabodenoson that can deliver the MMP at a therapeutic level, equivalent to what 1.5% eye drop has achieved in prior Phase 2 monotherapy and combination therapy clinical trials. Trabodenoson has a distinct or unique TOP pattern behavior at the optimal dose (1.5% eye drops), one should not miss it from its SR formula too, though the time to the steady state for Trabo-SR therapeutic will be quicker than Trabo-eye drops, it is estimated within 3-4 months, >=80% patients at early to moderate stage should achieve a disease free drug holiday status, and such drug holiday could potentially sustain for 12 to 24 months at minimal, or longer up to 3-5 years, or 5-10 years, if with Trabo- eye drop as IOP drug holiday stabilizer.

[0301] SR dosing parameter design

[0302] The 1.5% eye drop dosing optimal is the guiding principle for SR prototype dosing parameter design with three key components: 1) total API loading dose, 2) daily release speed and 3) API duration, which are determined by the API concentration at aqueous humor delivered by the 1.5% eye drops. Under the principle of the SR dosing design, in vivo prototyping test will be based on the IOP reduction profile as the guide to find the right SR dosing optimal.

[0303] Despite the fact that there are over ten FDA-approved glaucoma medications (eye drops), SLT and MIGS, including trabeculectomy and tube shunt, which all have been employed in clinics to address one single objective: reducing the IOP of a treated eye, under current clinical rationale of “the lower the better”, glaucoma patients continue to lose their vision. None of these treatments is able to stop the disease progression. Patients start from one medication at early stage of the disease, then slowly advance to the need for 2, or 3, or 4 medications at maximal, at which point patients become non-responders and an invasive drainage surgery such as tube shunt becomes inevitable. However, such MIGS approaches fail at >50% rates in 3-5 years, often as the result of post-op complication (inflammatory scarring). At this late stage of the disease, if the surgery fails to control the IOP to a target level (sometimes the IOP is too low), the turbulent IOP diurnal spikes will quickly lead patients to the tipping points of becoming legally blind in 3-6 months. These non- responders and filtering surgical failures (refractory glaucoma) have been troubling glaucoma surgeons for decades, with little understanding of the reason why. There is nothing they can offer or do that can prevent such drastic occurrences once patients reach to the tipping point. The discovery herein of the pressure sensor as the first rate limiting root cause of blindness in glaucoma provides a promising horizon for developing a new therapeutic strategy capable of treating and preventing glaucoma blindless. MMP therapy is identified herein as the most advantageous / preferred therapy. Trabodenoson derived MMP / A1AR therapeutics solve the two key problems confronted in glaucoma therapy: non-responders and unstoppable visual field deterioration that leads to patients becoming legally blind.

[0304] Trabodenoson in a sustained release (SR) intracameral implant (called “AC rod”) offers a quick onset (2-3 months) to rescuing and stopping neuronal cell loss at the back of the eye - within 2-3 months, a treated patient can achieve the maximal therapeutic outcome (steady state), which is essentially critical to non-responders and refractory glaucoma at this late stage of the disease. Trabodenoson AC rod is more effective and safer than Durysta and iDose in delivering MMP- 14 / MMP-2 therapeutics with its Al AR-driven direct cytoprotection to the remaining sensing cells that are under extreme oxidative stress or edema in this late-stage disease. With its derived MMP- 14 removing the ECM debris and the A1AR (membrane hyperpolarization) restoring the sensing cell homeostasis, some edemous pathologies within the sensing cells could likely be reversed before reaching to an irreversible phase of cell apoptotic or necrotic death. Trabodenoson as a drug is anti-inflammatory in nature compared to proinflammatory PGA drugs. Such inflammation threatens the very survival of the remaining RGCs, hence trabodenoson implant offers a superiority advantage to advanced stage refractory glaucoma. Durysta and iDose commonly have little benefit to this group of patients, who have already suffered significant metabolic inflammation or parainflammation at the aging TM and aqueous humor. Such inflammation is the very reason for failure of the old tube shunt and trabeculectomy (filtering bleb scarring) approaches. About 30% of glaucoma patients are at an advanced stage and becoming non-responders. Trabodenoson AC rod offers the last hope to such patients, by preventing patients from undergoing highly risky and invasive drainage surgeries and saving the remaining sight (stabilizing the remaining visual field). As needed or appropriate, Trabodenoson AC rod can be used in combination with current standard of care (eye drops, MIGS or laser) to this advanced stage disease population, including dosing of trabodenoson eye drops, optionally with a flexible dosing regimen.

[0305] For early- and moderate-stage glaucoma, trabodenoson, or MMP therapy more broadly, has the ability to repair and restore pressure sensor functionality at a full extent, for which a significant majority of the patients (>80%) at this stage could achieve a disease-free drug holiday, during which they can preserve their visual field stability, potentially for a life-time. Trabodenoson AC rod is used as a loading dose to quickly stop the disease progression and the RGC loss (neural protection). Within 2-3 months (eye drop may take 6 months or longer), patients can enjoy an extended IOP drug holiday, of a duration from 6 months to up to 3 years or longer. The re- administration of the AC rod is based on the drug holiday duration in each individual patient. With trabodenoson AC rod therapy, a glaucoma patient only needs to visit their doctor once or twice a year to receive their loading dose by an office-based procedure, or once every two to three years, or once every three to five years or longer, depending upon individual patient needs and disease staging. Unlike stent therapies, iDose and many MIGS devices that require operating room (OR) procedures, both for implants and removal, the trabodenoson AC rod disclosed herein is made of biodegradable materials; there is no need for removal. Trabodenoson is therefore the future for glaucoma patient care.

[0306] Example 3: Trabodenoson Eye Drops (with Flexible Dosing) as IOP Drug Holiday Stabilizer for Early- to Moderate-Stage Glaucoma with Life-Long Neural Protection Benefits

[0307] Trabodenoson eye drops are developed as the first curative glaucoma neural protection drug by inducing and stabilizing patients on extended (forever) disease-free drug holiday status, optionally in combination with trabodenoson SR (preferred), bimatoprost SR in relay, MIGS, Tube shunt or trabeculectomy. Trabodenoson is a NDA stage asset in this combination setting, used as a MMP / A1AR drug, not a symptom relief IOP drug. Based on a previous four randomized control clinical trials of trabodenoson eye drops (at low dose) in early and moderate stage POAG / OH including poor responders, trabodenoson demonstrated the ability to act via MMP / A1AR at a therapeutic level, which drives the TM repair and restoration, namely pressure sensor functional recovery, leading to dosing switch and IOP improvement, the unique signature event of trabodenoson treatment, which sets it apart from the rest of the IOP drugs in current use, and from bimatoprost SR.

[0308] Trabodenoson eye drops (1.5% BID or 1.5% QD) are used as a drug holiday stabilizer or inducer as a standalone therapy or in combination settings, e.g., as a drug holiday stabilizer in combination with BIMATOPROST SR® (in relay) as the loading dose to deliver MMP therapeutic, followed by Trabodenoson eye drop (1.5% QD) to stabilize and maintain the drug holiday status for those who have already achieved a drug holiday via a single implant, estimated for > 2 / 3 of bimatoprost SR treated patients as reaching drug holiday around 4 months post-implant. To the remaining 1 / 3 of patients who are in the process of recovery, they are administered 1.5% BID (fixed dose regimen) trabodenoson eye drops to continue the induction process towards a full recovery. The holiday duration in this group is estimated to be at least 3-5 years, or it could be a lifetime disease-free. Early intervention can eradicate glaucoma-caused blindness. As a drug holiday stabilizer, trabodenoson eye drops dosing and regimen can be flexible - no strict compliance is required.

[0309] Once a patient reaches drug holiday, indicating that a MMP / A1AR therapeutic reaches steady state, at this point the ECM degradation and synthesis at TM also should reach equilibrium (TIMP / MMP in balance), and a patient then only needs a small stream of MMP therapy (e.g., trabodenoson eye drops) to supplement the deficiency of MMP production in glaucomatous eyes, to prevent excessive ECM building up that clots the TM mesh pores again. Prior clinical trials of trabodenoson eye drops in POAG / OH has already validated its ability to deliver MMP / A1 AR at a therapeutic level, evidenced by dosing switch and robust IOP improvement in PGA poor responders.

[0310] Under the negative loop feedback regulated by the ECM substrates, surplus MMP upregulations via intensive bimatoprost SR around the clock is unnecessary. In other words, the 2ndand 3rdimplants in ARTEMIS- 1 and ARTEMIS-2 trials were unnecessary or overtreated. Trabodenoson eye drops deliver potent MMP-14 / MMP-2 safely and effectively at a therapeutic level, which is a better and safer alternative to the 2ndand 3rdimplant of bimatoprost SR. The MMP treatment essentially is delivered by two products, bimatoprost SR (SR) followed by trabodenoson eye drops, at day 1 and month-4 respectively.

[0311] Trabodenoson eye drops (1.5% BID or QD) are also used in combination with MIGS surgeries (istent, Hydrus®), or Elios Vision laser, tube shunt, or trabeculectomy, where there is no need for IOP drug (as add-on). Trabo-eye drops are used as a drug holiday inducer during the first 12-24 months to drive the pressure sensor repair and functional recovery. It is estimated within 12- 24 months, a significant majority of the patients treated with trabodenoson eye drops can achieve a drug holiday state, in other words, the pressure sensor can self-regulate the IOP without the need for additional treatments. This timeframe fits well with MIGS-associated clinical effectiveness, as within 1-2 years, most MIGS patients do not need a rescue. For MIGS (e.g., istent, Hydrus®) and trabodenoson eye drops are an excellent combination for early-stage disease intervention. Trabodenoson eye drop dosing / regimen in combination with MIGS can be flexible at the start, as there is no need for strict compliance, and it can be BID or QD - missing a few drops does not harm a subject.

[0312] Drug holiday is equivalent to glaucoma neural protection, once patients achieve drug holiday or MMP / A1 AR treatment steady state, it can stop the disease progression as long as this status sustains. Most early and moderate glaucoma (>80%) can be completely cured by trabodenoson as a life-long neural protection treatment. So far, trabodenoson is the most effective neural protection drug for glaucoma, especially hypertensive glaucoma, as it normalizes diurnal irregularities, which are the rate limiting root cause of RGC loss. For late-stage glaucoma, including patients with tube shunt or trabeculectomy, trabodenoson as a combination agent can stop or even reverse some of the reversible damage within the neurons (sensing cells and RGC). Accordingly, it can stop severe condition deterioration and prevent advanced stage patients from becoming legally blind.

[0313] The discovery of MMP therapy as one that can fully stop the visual field deterioration observed in patients at early to moderate-stage glaucoma is based on biomatoprost SR Phase 3 clinical trials led by Jason Bacharach et al (Drugs 81, 2017-2033 (2021), with a compromised VF result. Indeed, patients on IOP drug holiday should not lose their visual field because their IOP has been normalized by the SR MMP treatment, the slight VF decline or loss at 12 months in patients treated with bimatoprost SR (P=0.037 between bimatoprost SR vs timolol eye drops) is the result of SR PGA triggered significant intraocular inflammation that had increased proportionally with the API dose level (15ug >10ug) and damaging the RGC cells at the back of the eye at the same degree as the cornea endothelium loss at an alarming rate ( 20% loss in 20 months, compared to 1% normal aging loss annually). Using trabodenoson SR implant as a loading dose followed by trabodenoson eye drops as IOP drug holiday stabilizer, the VF result at 12 months is estimated as better than p=0.037 at 12 months, also significantly better at 20 months than what was seen for Durysta® at 20 months without the API compared to timolol eye drops (shown in FIG. 4). In this study, some patients enrolled in this statistical analysis may not be on “true” drug holiday because of the shortcomings of the IOP monitoring not being based on 24-hour IOP stability but only upon a limited selection of 3 timepoints.

[0314] Early intervention to stop glaucoma disease progression is currently the only pathway to eradicate glaucoma-induced blindness, and trabodenoson offers the most effective and life-long neural protection to prevent glaucoma vision loss via its dual-pathway MMP / A1AR therapeutic effects that act to normalize IOP diurnal irregularities, with IOP irregularities (not just IOP increases) constituting the rate limiting root cause of the RGC loss observed at the back of the eye. Trabodenoson eye drops were previously demonstrated to repair, rejuvenate and restore the pressure sensor functionality, which has led to the unique dosing switch from BID to QD in poor responders and early-stage good responders. The dosing switch is an indicator of the pressure sensor durability being increased, a precursor to inducing an IOP drug holiday. Once the MMP / A1 AR treatment reaches steady state (maximal therapeutic outcome), it is herein estimated that 80% or more of patients at early to moderate stage (1-2 medications) could achieve a disease- free drug holiday status, for 6 to 12 months or longer before re-administration of a MMP therapy.

[0315] Trabodenoson eye drop-mediated induction of drug holiday is slower than with a trabodenoson SR AC rod, with eye drops possibly requiring 6-12 months for early-to-moderate glaucoma, as compared to a 2-3-month induction time for Trabodenoson SR AC rod. Therefore, using a SR system such as Trabo- AC rod or Durysta® to deliver MMP as a loading dose is highly recommended. Once a patient reaches drug holiday status, the ECM degradation and synthesis at the TM tissue reaches equilibrium, and such equilibrium is regulated by MMP / TIMP in physiological condition. In patients with glaucoma, MMP secretion is downregulated or could not meet the higher demand in patients with glaucoma with increased pathological ECM building up. In order to maintain the ECM equilibrium in glaucomatous eyes and prevent the ECM being clotted or damaged (thickening or atrophy) again, trabodenoson eye drop can be used as IOP drug holiday stabilizer, to extend IOP drug holiday duration by supplementing the MMP deficits to glaucomatous eyes at dosing of once daily or twice daily, or once every another day, or once every week, optionally where there is no need for dosing compliance, which is a very attractive product attribute for glaucoma specialty care. For early-stage glaucoma, with trabodenoson eye drops, patients may never need another medication or IOP lowering surgeries for years, whilst enjoying disease-free and healthy sight. Trabodenoson eye drops alone may therefore offer a life-long neural protection benefit.

[0316] Either Trabodenoson eye drops or SR AC rod has no limits and can be used (readministration) for treating ALL types of glaucoma across all stages of the disease, from early to moderate and late stage glaucoma with superiority advantages of its safety and MMP / A1AR therapeutic potency / clinical efficacy. The above examples are typical: trabodenoson is currently the best solution for glaucoma care, with trabodenoson eye drops the only drops currently available that can deliver MMP therapy. Trabodenoson SR can be effective for patients reaching to the tipping point of RGC loss (where every day counts), for which trabodenoson could potentially turn around and prevent deteriorating visual field loss that otherwise leads to a patient being legally blind. References

[0317] A: References for the Figure Citations.

[0318] 1. FIGs. 3 and 13 from Johnstone, M.; Xin, C.; Martin, E.; Wang, R. Trabecular Meshwork Movement Controls Distal Valves and Chambers: New Glaucoma Medical and Surgical Targets. J. Clin. Med. 2023, 12, 6599. doi.org / 10.3390 / jcml2206599. Copyrights © 2023 by the authors. Open Access, Licensee MDPI, Basel, Switzerland. Image courtesy provided by Murray Johnstone, MD.

[0319] 2. FIG. 4, left panel from Tina Guanting Qiu. “New Frontiers of Retinal Therapeutic Innovation & Strategic Insights”. EC Ophthalmology 2.2 (2015): 81-91.

[0320] 3. FIG. 4, right panel, and FIG. 15 from Bacharach J, Tatham A, Ferguson G, Belalcazar S, Thieme H, Goodkin ML, Chen MY, Guo Q, Liu J, Robinson MR, Bejanian M, Wirta DL; ARTEMIS 2 Study Group. Phase 3, Randomized, 20-Month Study of the Efficacy and Safety of Bimatoprost Implant in Patients with Open-Angle Glaucoma and Ocular Hypertension (ARTEMIS 2). Drugs. 2021 Nov;81(17):2017-2033. doi: 10.1007 / s40265- 021-01624-9. Epub 2021 Nov 1. PMID: 34724172; PMCID: PMC8602154. Copyrights @ authors 2021. Images granted by Springer Nature (ref: Elise Lagden). This article is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License (http : / / creativecommons . org / licenses / by-nc / 4.0 / ) .

[0321] 4. FIG. 5 from Wilson S, Siebourg-Polster J, Titz B, Jiang Z, Bartolo F, Lavergne V, Gayan J, Garweg JG, Fauser S, Dieckmann A. Correlation of Aqueous, Vitreous, and Serum Protein Levels in Patients With Retinal Diseases. Transl Vis Sci Technol. 2023 Nov 1; 12(11):9. doi: 10. 1167 / tvst.12.11.9. PMID: 37930665; PMCID: PMC10629536. Copyright @ the authors, 2023. Image courtsey by Andrea Dieckmann. Open access.

[0322] 5. FIG. 6 from Pyfer MF, Gallardo M, Campbell A, Flowers BE, Dickerson JE Jr, Talla A, Dhamdhere K. Suppression of Diurnal (9AM-4PM) IOP Fluctuations with Minimally Invasive Glaucoma Surgery: An Analysis of Data from the Prospective, Multicenter, Single-Arm GEMINI Study. Clin Ophthalmol. 2021 Sep 24;15:3931-3938. doi: 10.2147 / OPTH.S335486. PMID: 34594099; PMCID: PMC8478499. Copyright @ 2021 Pyfer et al. This work is published and licensed by Dove Medical Press Limited. The full terms of this license are available at www.dovepress.com / terms.php and incorporate the Creative Commons Attribution - Non Commercial (unported, v3.0) License (creativecommons, org / licenses / by-nc / 3.0 / ).

[0323] 6. FIG. 7 from Montesano G, Ometto G, Ahmed IIK, Ramulu PY, Chang DF, Crabb DP, Gazzard G. Five-Year Visual Field Outcomes of the HORIZON Trial. Am J Ophthalmol. 2023 Jul;251:143-155. doi: 10.1016 / j.ajo.2023.02.008. Epub 2023 Feb 21. PMID: 36813144. Copyright © 2023 The Author(s). Image granted by Elsevier Inc (ref: Roopa Lingayath). this work is open access under Creative Commons Attribution (CC BY 4.0) (https: / / creativecommons.Org / licenses / by / 4.0 / ).

[0324] 7. FIG. 14 from Sihota R, Angmo D, Ramaswamy D, Dada T. Simplifying "target" intraocular pressure for different stages of primary open-angle glaucoma and primary angle-closure glaucoma. Indian J Ophthalmol. 2018 Apr;66(4):495-505. doi: 10.4103 / ij o.IJO l 130 17. Copyright : © 2018 Indian Journal of Ophthalmology. Open Access. Image courtesy by Dr. R Sihota.

[0325] B: General References:

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[0337] • Thieme H, et al. Muscarinic receptors of the M2 subtype in human and bovine trabecular meshwork. Graefes Arch Clin Exp Ophthalmol. April 2001, 239(4):310-5.

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[0341] • Bacharach J, et al. ARTEMIS 2 Study Group. Phase 3, Randomized, 20-Month Study of the Efficacy and Safety of Bimatoprost Implant in Patients with Open- Angle Glaucoma and Ocular Hypertension (ARTEMIS 2). Drugs. 2021 Nov;81(17):2017-2033.

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[0351] EQUIVALENTS

[0352] Those skilled in the art will recognize or be able to ascertain using no more than routine experimentation, many equivalents to the specific embodiments and methods described herein. Such equivalents are intended to be encompassed by the scope of the following claims.

Claims

I claim:

1. A method for reducing or preventing retinal ganglion cell (RGC) loss in an eye of a subject having or at risk of developing glaucoma, the method comprising administering trabodenoson formulated as eye drops to the front of the eye of the subject, wherein the trabodenoson is administered at a dose of about 1.0% to about 3.0%, thereby reducing or preventing RGC loss in the eye of the subject.

2. The method of claim 1, wherein the trabodenoson is administered to the front of the eye of the subject twice per day, once per day, or by a flexible dosing regimen, optionally wherein administration occurs without requiring compliance with a fixed regimen, optionally wherein the subject has achieved a drug holiday treatment status.

3. A method for reducing or preventing retinal ganglion cell (RGC) loss in an eye of a subj ect having or at risk of developing glaucoma, the method comprising administering trabodenoson within a sustained release (SR) intraocular delivery system to the front of the eye of the subject, wherein the trabodenoson is administered as a SR formulation that releases an equivalent concentration of trabodenoson into the aqueous humor as eye drops formulated at about 1.0% to about 3.0% trabodenoson, thereby reducing or preventing RGC loss in the eye of the subject.

4. The method of any one of the preceding claims, wherein reducing or preventing RGC loss in the eye of the subject is measured by determining visual field stability in the eye of the subject, as compared to an appropriate control, optionally wherein the visual field of the eye of the subject is stable at a six- to twelve-month endpoint and / or at a twelve- to 24-month endpoint (optionally at a twelve- to eighteen-month endpoint) of administering the trabodenoson to the front of the eye of the subject.

5. The method of any one of the preceding claims, wherein reducing or preventing RGC loss in the eye of the subject is measured by detection of apoptotic retinal cells (DARC) and / or optical coherence tomography (OCT) detection of retinal nerve fiber layer (RNFL) thickness and / or other visual functional biomarkers and / or biomarkers of RGC numbers and / or biomarkers of RGC neuroprotection / stability status.

6. The method of any one of the preceding claims, wherein intraocular pressure (TOP) irregularity is normalized in the eye of the subject administered trabodenoson to sufficient extent that the subject is removed from one or more other drugs, optionally wherein the other drugs are selected from the group consisting of topical P-adrenergic antagonists (e.g., timolol, betaxolol), carbonic anhydrase inhibitors (e.g., dorzolamide, brinzolamide), cholinergics (e.g., pilocarpine), a-adrenergic agonists (e.g., brimonidine), prostaglandins (e.g., latanoprost, travoprost, lantanoprost bunod), Rho kinase inhibitors (e.g. Rhopressa, ROCKLATAN), omidenepag isopropyl, and prostamides (e.g., bimatoprost), optionally wherein the response of the subject to the one or more other drugs is improved in the eye of the subject by administration of trabodenoson, as compared to an appropriate control.

7. The method of any one of the preceding claims, wherein pressure sensor functionality is improved in the eye of the subject administered trabodenoson to sufficient extent that the subject avoids an invasive surgical procedure to reduce IOP, optionally wherein the invasive surgical procedure is an insertion of a tube shunt or a trabeculectomy.

8. The method of any one of the preceding claims, wherein the trabodenoson administration normalizes IOP diurnal irregularities in the eye of the subject, optionally wherein the normalizing of IOP diurnal irregularities in the eye of the subject results in RGC rescue and glaucomatous neural protection in the eye of the subject.

9. The method of any one of the preceding claims, wherein the trabodenoson administration reduces optic neuropathy in the subject, optionally wherein the trabodenoson administration stops deterioration of the optic nerves in the subject.

10. The method of any one of the preceding claims, wherein the trabodenoson administration treats the subject for one or more conditions selected from the group consisting of primary angle closure glaucoma (PACG), primary open angle glaucoma (POAG), ocular hypertension (OH), normal tension glaucoma (NTG), and secondary glaucoma, optionally wherein the secondary glaucoma is uvetic glaucoma, pseudo exfoliation glaucoma, or refractory glaucoma.

11. The method of any one of the preceding claims, wherein the subject is a poor or nonresponder to one or more symptom relief IOP lowering drugs and / or other non-trabodenosonglaucoma therapy, optionally wherein the subject has uncontrolled IOP or IOP failure before the trabodenoson administration.

12. The method of any one of the preceding claims, wherein the trabodenoson administration results in an IOP drug holiday in the subject, optionally wherein the trabodenoson administration provides an extended duration of RGC protection without undesirable side effects to the subject, optionally wherein the extended duration is selected from the group consisting of 6 months or longer, 12 months or longer, 18 months or longer, two years or longer, three years or longer, four years or longer, five years or longer, six years or longer, seven years or longer, eight years or longer, nine years or longer, and ten years or longer.

13. The method of any one of the preceding claims, wherein the trabodenoson administration restores pressure sensor functionality or pressure sensing cell intricate metabolic competence in the eye of the subject.

14. The method of any one of the preceding claims, wherein the subject has early-stage or midstage glaucoma.

15. The method of any one of the preceding claims, wherein the subject has late-stage glaucoma.

16. The method of any one of claims 3-15, wherein the trabodenoson is administered within a sustained release (SR) intraocular delivery system or implant for a time period selected from the group consisting of 1-3 months, 3-6 months, 6-9 months and 9-12 months, optionally for a time period of 3-4 months of treatment duration.

17. The method of claim 16, wherein the trabodenoson is administered in an amount sufficient to induce an IOP drug holiday in the subject, optionally wherein the subject is administered a further course of trabodenoson as an eye drop formulation, optionally wherein administration of the trabodenoson eye drop formulation prolongs the IOP drug holiday in the subject, as compared to an appropriate control.

18. The method of any one of the preceding claims, wherein the trabodenoson administration reduces or eliminates vision loss in the eye of the subject, optionally wherein the subject has hypertensive glaucoma and / or OH.

19. The method of any one of the preceding claims, wherein the trabodenoson administration halts glaucoma disease progression in the eye of the subject, optionally wherein the disease progression is halted at an early or moderate stage of glaucoma, optionally wherein the glaucoma is selected from the group consisting of hypertensive glaucoma, OH, and PACG.

20. The method of claim 19, wherein the disease progression is halted at an advanced stage of glaucoma, optionally wherein the glaucoma is hypertensive glaucoma or OH.

21. The method of any one of the preceding claims, wherein the trabodenoson administration reduces visual field loss in normal tension glaucoma in the eye of the subject, optionally wherein said reduction in visual field loss is more effective than the current standard of care, optionally wherein the current standard of care is selected from the group consisting of an implant of bimatoprost sustained release intracameral delivery, selective laser trabeculoplasty (SLT), and administration of a prostaglandin analog (PGA), optionally wherein the PGA is in a sustained release format (optionally iDose), optionally wherein the PGA is selected from the group consisting of a latanoprost microdose delivery with Optejet (Microprost, Eyenovia), a latanoprost delivery via an intracameral implant (OTX-TIC, Ocular Therapeutix), a latanoprost or travoprost delivery via a punctal plug (L-evolute and T-evolute, Mati Therapeutics), travoprost in an ENV515 delivery vehicle (Envisia Therapeutics) and travoprost in an iDose (Glaukos) delivery format.

22. The method of any one of the preceding claims, wherein the trabodenoson administration reduces or eliminates visual field loss in the eye of the subject better than current standard of care, wherein the current standard of care is selected from the group consisting of MIGS, tube shunt, trabeculectomy, and IOP lowering eye drops, optionally wherein the current standard of care IOP lowering eye drops are selected from the group consisting of latanoprostene bunod ophthalmic solution (0.024%, Vyzulta, Bausch + Lomb) and netarsudil ophthalmic solution (0.02%, Rhopressa, Alcon), and prostaglandin analog (PGA) eye drops.

23. The method of any one of the preceding claims, wherein the trabodenoson administration increases matrix metalloproteinase (MMP) levels and / or activates Ai adenosine receptor (A1AR) in the eye of the subj ect in an amount sufficient to maintain extracellular matrix (ECM) equilibrium at the trabecular meshwork (TM) of the eye of the subject, optionally wherein MMP secretion is deficient and the MMP-to-tissue inhibitor of metalloproteinase (MMP / TIMP) ratio in the eye of the subject is in imbalance (low) as compared to an appropriate control, optionally wherein MMP- 14 and MMP-2 are increased in the eye of the subject.

24. The method of any one of the preceding claims, wherein the trabodenoson is administered to the subject at a dose of 1.0%-3.0% in an eye drop formulation, optionally wherein the trabodenoson is administered to the subject at a dose of about 1.0% to about 2.5%, optionally at a dose of about 1 ,2%-l .5%, optionally selected from the group consisting of about 1.2% and about 1.5%, optionally wherein the trabodenoson is administered BID, optionally for a duration of about 14-28 days.

25. A method for stabilizing the visual field of an eye of a subject having glaucoma in the eye, the method comprising administering trabodenoson formulated as eye drops to the front of the eye of the subject, wherein the trabodenoson is administered at a dose of 1.0% to 3.0%, thereby stabilizing the visual field of the eye of the subject.

26. The method of claim 25, wherein the trabodenoson is administered to the front of the eye of the subject twice per day, once per day, or by a flexible dosing regimen, optionally wherein administration occurs without requiring compliance with a fixed regimen, optionally wherein the subject has achieved a drug holiday treatment status.

27. A method for stabilizing the visual field of an eye of a subject having glaucoma in the eye, the method comprising administering trabodenoson within a sustained release (SR) intracameral delivery system to the front of the eye of the subject, wherein the trabodenoson is administered as a SR formulation that releases an equivalent concentration of trabodenoson into the aqueous humor as eye drops formulated at 1.0% to 3.0% trabodenoson, thereby stabilizing the visual field of the eye of the subject.I l l28. The method of any one of claims 25-27, wherein visual field stability is determined in the eye of the subject, as compared to an appropriate control, optionally wherein the visual field of the eye of the subject is stable at a six- to twelve-month endpoint and / or at a twelve- to 24-month endpoint (optionally at a twelve- to eighteen-month endpoint) of administering the trabodenoson to the front of the eye of the subject.

29. The method of any one of claims 25-28, wherein intraocular pressure (IOP) irregularity is normalized in the eye of the subject administered trabodenoson to sufficient extent that the subject is removed from one or more other drugs, optionally wherein the other drugs are selected from the group consisting of topical P-adrenergic antagonists (e.g., timolol, betaxolol), carbonic anhydrase inhibitors (e.g., dorzolamide, brinzolamide), cholinergics (e.g., pilocarpine), a-adrenergic agonists (e g., brimonidine), prostaglandins (e.g., latanoprost, travoprost, lantanoprost bunod), Rho kinase inhibitors (e.g. Rhopressa, ROCKLATAN), omidenepag isopropyl, and prostamides (e.g., bimatoprost), optionally wherein the response of the subject to the one or more other drugs is improved in the eye of the subject by administration of trabodenoson, as compared to an appropriate control.

30. The method of any one of claims 25-29, wherein intraocular pressure (IOP) irregularity is normalized in the eye of the subject administered trabodenoson (e.g., as an SR formulation or as an eye drop formulation) for a period of time selected from the group consisting of from 2-3 months, 3-6 months, 6-12 months or 12-18 months or longer.

31. The method of any one of claims 25-30, wherein pressure sensor functionality is improved in the eye of the subject administered trabodenoson to sufficient extent that the subject avoids an invasive surgical procedure to reduce IOP, optionally wherein the invasive surgical procedure is an insertion of a tube shunt or a trabeculectomy.

32. The method of any one of claims 25-31, wherein the trabodenoson administration normalizes IOP diurnal irregularities in the eye of the subject, optionally wherein the normalizing of IOP diurnal irregularities in the eye of the subject results in RGC rescue (preventing or stopping the RGC cells from undergoing irreversible apoptosis or necrotic cell death or cell loss) and glaucomatous neural protection in the eye of the subject.

33. The method of any one of claims 25-32, wherein the trabodenoson administration reduces optic neuropathy in the subject, optionally wherein the trabodenoson administration stops deterioration of the optic nerves in the subject.

34. The method of any one of claims 25-33, wherein the trabodenoson administration treats the subject for one or more conditions selected from the group consisting of primary angle closure glaucoma (PACG), primary open angle glaucoma (POAG), ocular hypertension (OH), normal tension glaucoma (NTG), and secondary glaucoma, optionally wherein the secondary glaucoma is uvetic glaucoma, pseudo exfoliation glaucoma, or refractory glaucoma.

35. The method of any one of claims 25-34, wherein the subject is a poor or non-responder to one or more symptom relief IOP lowering drugs and / or other non-trabodenoson glaucoma therapy, optionally wherein the subject has uncontrolled IOP or IOP failure before the trabodenoson administration.

36. The method of any one of claims 25-35, wherein the trabodenoson administration stabilizes IOP in the subject and allows for an IOP drug holiday in the subject, optionally wherein the trabodenoson administration provides an extended duration of visual field stability without undesirable side effects to the eye of the subject, optionally wherein the extended duration is selected from the group consisting of 6 months or longer, 12 months or longer, 18 months or longer, two years or longer, three years or longer, four years or longer, five years or longer, six years or longer, seven years or longer, eight years or longer, nine years or longer, and ten years or longer.

37. The method of any one of claims 25-36, wherein the trabodenoson administration improves or restores pressure sensor functionality or pressure sensing cell intricate metabolic competence in the eye of the subject.

38. The method of any one of claims 27-37, wherein the trabodenoson is administered within a sustained release (SR) intraocular delivery system or implant (optionally a biodegradable AC rod) for a time period selected from the group consisting of 1-3 months, 3-6 months, 6-9 months and 9-12 months, optionally for a time period of 3-4 months of treatment duration.

39. The method of any one of claims 27-38, wherein the trabodenoson is administered within a sustained release (SR) intracameral delivery system (optionally a biodegradable AC rod) that administers trabodenoson at a consistent daily release rate under a zero-order kinetic, optionally wherein trabodenoson administration achieves a trabodenoson concentration in the aqueous humor at a level that is approximately equivalent to the trabodenoson concentration achieved in the aqueous humor of an eye delivered trabodenoson eye drops at 1.0%-3.0% BID for 1-7 days, for 7- 14 days, or for 4-12 weeks, optionally for 14-28 days, optionally wherein a drug holiday is induced in the subject, optionally wherein the subject is administered a further course of trabodenoson as an eye drop formulation, optionally wherein administration of the trabodenoson eye drop formulation stabilizes or prolongs the drug holiday in the subject, as compared to an appropriate control.

40. The method of any one of claims 1, 2, 4-26 and 28-37, wherein the trabodenoson eye drops are administered to the subject at about 1.5% BID.

41. The method of any one of claims 25-40, wherein the trabodenoson administration cures blindness caused by primary hypertensive glaucoma and / or OH in the eye of the subject.

42. The method of any one of claims 25-41, wherein the trabodenoson administration halts glaucoma disease progression in the eye of the subject, optionally wherein the disease progression is halted at an early or moderate stage of glaucoma, optionally wherein the glaucoma is hypertensive glaucoma or OH.

43. The method of claim 42, wherein the disease progression is halted at an advanced to end stage of glaucoma, optionally wherein the glaucoma is hypertensive glaucoma or OH.

44. The method of any one of claims 25-43, wherein the trabodenoson administration improves upon the current standard of care for reducing or stopping the visual field loss or deterioration, optionally wherein the current standard of care is selected from the group consisting of an implant of bimatoprost sustained release intracameral delivery, selective laser trabeculoplasty (SLT), and a prostaglandin analog (PGA), optionally wherein the PGA is in a sustained release format, optionally wherein the PGA is selected from the group consisting of an atanoprost microdose delivery with Optejet (Microprost, Ey enovia), a latanoprost delivery via an intracameral implant(OTX-TIC, Ocular Therapeutix), a latanoprost or travoprost delivery via a punctal plug (L-evolute and T-evolute, Mati Therapeutics), travoprost in an ENV515 delivery vehicle (Envisia Therapeutics), and travoprost in an iDose (Glaukos) delivery format.

45. The method of any one of claims 25-44, wherein the trabodenoson administration reduces or stops the visual field loss or deterioration in the eye of the subject better than a current standard of care treatment, wherein the current standard of care treatment is selected from the group consisting of bimatoprost sustained release intracameral implant (Durysta) or iDose, MIGS, tube shunt, trabeculectomy, and IOP lowering eye drops, optionally wherein the current standard of care IOP lowering eye drops are selected from the group consisting of latanoprostene bunod ophthalmic solution (0.024%, Vyzulta, Bausch + Lomb) and netarsudil ophthalmic solution (0.02%, Rhopressa, Alcon), and prostaglandin analog (PGA) eye drops.

46. The method of any one of claims 25, 26, 28-37 and 40-45, wherein the trabodenoson administration as eye drops increases matrix metalloproteinase (MMP) and / or Ai adenosine receptor (A1AR) levels in the eye of the subject in an amount sufficient to maintain extracellular matrix (ECM) equilibrium at the trabecular meshwork (TM) of the eye of the subject, optionally wherein MMP- 14 and MMP -2 are increased in the eye of the subject.

47. The method of any one of claims 25, 26, 28-37 and 40-46, wherein the trabodenoson is administered to the subject at a dose of 1.0%-2.5%, optionally wherein the trabodenoson is administered to the subject at a dose selected from the group consisting of about 1.2% and about 1.5%.

48. The method of any one of the preceding claims, wherein the trabodenoson administration induces consistent IOP improvement (optionally time, dose and / or disease stage-dependent) in the subject.

49. The method of any one of claims 16-48, wherein the subject has early-stage or mid-stage glaucoma.

50. The method of any one of claims 16-48, wherein the subject has late-stage glaucoma.51 . The method of any one of the preceding claims, wherein the trabodenoson administration provides neural protection benefit to RGCs in the eye of the subject for a duration of time selected from the group consisting of about 3-6 months, about 6-9 months, about 9-12 months, about 12- 18 months, and about 18-24 months or longer.

52. The method of any one of the preceding claims, wherein trabodenoson is administered to a population of subjects and the trabodenoson administration achieves a drug holiday state in a majority of the subjects in the trabodenoson-administered population, optionally wherein a drug holiday state is achieved in about 80% or more of the subjects in the trabodenoson-administered population.

53. The method of any one of the preceding claims, wherein the trabodenoson administration achieves a disease-free drug holiday in the subject within about 3-4 months of initiating the trabodenoson administration, optionally wherein the trabodenoson administration is SR trabodenoson.

54. A method for treating or preventing corneal endothelium loss in an eye of a subject, the method comprising administering trabodenoson formulated as eye drops or within a sustained release (SR) intraocular delivery system to the front of the eye of the subject, wherein the trabodenoson is administered at a dose of 1.0% to 3.0% to the front of the eye of the subject, thereby treating or preventing corneal endothelium loss in the eye of the subject.

55. The method of claim 40, wherein the trabodenoson is administered to the subject at a dose of 1 0%-2.5%, optionally wherein the trabodenoson is administered to the subject at a dose selected from the group consisting of about 1.2% and about 1.5%.

56. The method of claim 54 or claim 55, wherein the subject has or is at risk of developing Fuchs endothelial dystrophy, bullous keratopathy or cornea endothelium decompensation in conditions of cornea graft failure.

57. A method for reducing or preventing retinal ganglion cell (RGC) loss in an eye of a subject having or at risk of developing glaucoma, the method comprising administering one or more matrix metalloproteinases (MMPs), an Ai adenosine receptor (Al AR), and / or an Al AR biosimilar to the eye of the subject in an amount sufficient to maintain extracellular matrix (ECM) equilibrium atthe trabecular meshwork (TM) of the eye of the subject, thereby reducing or preventing RGC loss in the eye of the subject.

58. The method of claim 57, wherein MMP-1, MMP-2, MMP-3 and / or MMP-14 is administered to the front of the eye of the subject.

59. The method of claim 57 or claim 58, wherein the one or more MMPs, Al AR and / or Al AR biosimilar is administered as a polypeptide or as a polynucleotide, optionally wherein the one or more MMPs, A1AR and / or A1AR biosimilar is administered to the subject via viral vector- (optionally AAV) or nanoparticle-mediated delivery, optionally wherein the polynucleotide is RNA.

60. The method of any one of claims 57-59, wherein the one or more MMPs, A1AR and / or A1AR biosimilar is / are delivered to the eye of the subject via a system selected from the group consisting of an adeno-associated virus (AAV), nanoparticle eye drops, a sustained release (SR) implant (optionally to the anterior chamber of the eye) and / or a genetic biofactory, optionally wherein the delivery system comprises a dosing switch on / off mechanism, optionally for a period of 1-6 months, optionally for a period of 2-3 months.

61. A method for reducing or preventing retinal ganglion cell (RGC) loss in an eye of a subj ect having or at risk of developing glaucoma, the method comprising administering an Ai adenosine receptor (Al AR) agonist to the eye of the subject, thereby reducing or preventing RGC loss in the eye of the subject.

62. The method of claim 61, wherein the A1AR agonistis a small molecule, optionally wherein the Al AR agonist comprises the structure:wherein:Ri is an optionally substituted (C5-C6) cycloalkyl (optionally substituted with one or more OH, orR2 is H or a halogen atom (F, Cl, Br, or I); andR3 is H or NO2, optionally wherein the Al AR agonist is selected from the group consisting of trabodenoson, cyclopentyladenosine (CPA), 2-chlorocyclopentyladenosine (CCPA) and cyclohexyladenosine (CHA).

63. The method of claim 61 or claim 62, wherein the A1AR agonist is administered as an eye drop formulation to the eye of the subject.

64. The method of claim 61 or claim 62, wherein the Al AR agonist is administered as an SR formulation via intracameral delivery route to the eye of the subject.

65. The method of any one of claims 61-64, wherein the A1AR agonist is administered to the subject in an amount sufficient to upregulate MMP secretion in the eye of the subject, optionally wherein the administration of the Al AR agonist induces and maintains extracellular matrix (ECM) equilibrium at the trabecular meshwork (TM) of the eye of the subject.

66. The method of any one of claims 61-65, wherein the A1AR agonist is administered to the subject in an amount sufficient to stabilize IOP in the eye of the subject.

67. A biodegradable intracameral implant for dosing to the aqueous humor of the eye of a subject, the implant comprising SR trabodenoson at a dose level equivalent to that observed in a subject administered trabodenoson eye drops at about 1.0%-2.0% concentration for a period of 1- 16 weeks.

68. A method for treating a subject having or at risk of developing glaucoma, the method comprising:(a) identifying the presence of two or more of the following in an eye of the subject: (i) IOP diurnal irregularities in the eye of the subject (optionally in a longitudinal assessment); (ii) non-responsiveness of the eye of the subject to lOP-lowering drugs; and (iii) identification of surgery as a next therapeutic step for the eye of the subject or the eye of the subject has already been subjected to surgical intervention for glaucoma treatment (optionally without significant benefit); and(b) administering an Al AR agonist to the eye of the subject, thereby treating the subject having or at risk of developing glaucoma.

69. The method of claim 68, wherein the Al AR agonist is trabodenoson.

70. The method of claim 68 or claim 69, wherein the A1AR agonist is administered to the subject as an eye drop formulation, optionally wherein the Al AR agonist is administered at a concentration of about 1 ,0%-3.0%, optionally of about 1.5%.

71. The method of claim 68 or claim 69, wherein the Al AR agonist is administered to the subject via an implant, optionally an intracameral implant, optionally wherein the A1AR agonist is administered to the aqueous humor of the eye of the subject.

72. The method of any one of claims 68-71, wherein the Al AR agonist administration prevents blindness in the eye of the subject at a timepoint of six months or more post-administration, optionally at nine months or more, optionally at twelve months or more, optionally at 18 months or more, optionally at 24 months or more.

73. The method of any one of claims 68-72, wherein A1AR agonist administration reduces or eliminates visual field loss in the eye of the subject better than current standard of care, wherein the current standard of care is selected from the group consisting of MIGS, tube shunt,trabeculectomy, and TOP lowering eye drops, optionally wherein the current standard of care TOP lowering eye drops are selected from the group consisting of latanoprostene bunod ophthalmic solution (0.024%, Vyzulta, Bausch + Lomb) and netarsudil ophthalmic solution (0.02%, Rhopressa, Alcon), and prostaglandin analog (PGA) eye drops.

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