MULTINATIONAL, MULTICENTRE, PROSPECTIVE, LONG-TERM SAFETY AND EFFICACY FOLLOW-UP STUDY AFTER AUTOLOGOUS CULTIVATED LIMBAL STEM CELLS TRANSPLANTATION (ACLSCT) FOR RESTORATION OF CORNEAL EPITHELIUM IN PATIENTS WITH LIMBAL STEM CELL DEFICIENCY DUE TO OCULAR BURNS

Loss of LSCD (Limbal Stem Cell Deficiency, LSCD) may be primary or secondary to
systemic diseases or local injuries. Among secondary LSCD conditions, those due
to ocular burns are rare,but amongst the most devastating in terms of quality
of life, visual impairment, loss of work capability, and social costs.The
clinical features of LSCD include pain, burning, and photophobia, chronic
inflammation, tearing and -in the end- reduced or no visual acuity.
Currently, there are no approved medicinal products for the treatment of this
specific condition.

Various surgical corneal procedures have been attempted in the past to
reconstitute the corneal surface of patients with severe LSCD. All these
procedures aim at transplanting a new source of epithelium from the fellow eye
or a donor with the removal of the host*s altered one.
Among these options, autologous limbal transplantation is probably the best
currently available option for ocular surface reconstruction. Nevertheless,
this procedure requires a large limbal graft from the fellow eye with a
potential risk of damaging the healthy eye.

Autologous Cultivated Limbal Stem Cell Transplantation (ACLSCT) is an advanced
treatment for LSCD that implies the sampling of a small limbal-biopsy specimen
of the fellow eye, followed by in vitro expansion to produce a cell sheet of
corneal epithelium including both differentiated and stem cells. The final
product is an Ophthalmic Insert consisting of an epithelial sheet of autologous
corneal epithelium attached on a supportive fibrin layer in nutrient transport
medium. The product is intended to be used in patients with moderate or severe
LSCD secondary to chemical or physical ocular burns. After 2007, specific
improvements in quality and manufacturing have been introduced to comply with
the current legislation and regulations regarding Advanced Therapy Medicinal
Products (ATMPs). Holoclar has been approved by EMA only recently and it is
currently not marketed in any country world-wide. After the implementation of
the ATMP Regulation, the autologous tissue engineered product for corneal
reconstruction (now Holoclar) was nervetheless considered clinically and
scientifically acceptable in Italy as a *consolidated use* therapy, and
approved for reimbursement.

The results of retrospective studies with Holoclar show that after the
improvements in quality and manufacturing of ACLSCT introduced after 2007, the
large majority of patients with moderate to severe limbal stem-cell deficiency
due to ocular burns, who received cultured limbal stem-cell grafts for corneal
transplantation, achieved a positive clinical outcome with a favourable safety
profile. These data are included as clinical data into the marketing
authorization application (MAA) for the Tissue Engineered Product named
Holoclar.The Committee for Medicinal Products for Human Use (CHMP) released
positive opinion to the applicant and has recommended Holoclar, the first
advanced therapy medicinal product (ATMP) containing stem cells, for approval
in the European Union (EU).

The CHMP considered that Holoclar provided a first treatment option for this
rare eye condition and recommended a conditional marketing authorisation
because, although the data supplied by the applicant show that the medicine's
benefits outweigh its risks, the data are based on retrospective studies and
are not yet comprehensive. Therefore, an additional prospective study on the
follow-up of the use of Holoclar should be conducted and this clinical trial
has been agreed with the regulatory body in order to satisfy the need of
additional and more comprehensive data obtained in a controlled setting.

Primary Objective:
To demonstrate the long term safety of one or two ACLSCT(s) in patients
suffering from moderate to severe LSCD secondary to ocular burns.
Secondary Objectives:
• To evaluate the long-term efficacy of one or two ACLSCT(s), the degree of
superficial corneal neo-vascularization and corneal epithelial stability,
clinical symptoms, conjunctival (both limbal and bulbar) inflammation, visual
acuity, tear secretion and quality of life compared to baseline (i.e. before
the first ACLSCT), long-term efficacy based on the clinical judgment of the
investigator;
• To evaluate safety and clinical outcomes (i.e. superficial corneal
neo-vascularization, epithelial defects, visual acuity, conjunctival
inflammation, and symptoms) after keratoplasty in patients previously treated
with Holoclar.

Multinational, multicenter, prospective, long-term safety and efficacy
follow-up study.

It is expected that all patients who completed the HOLOCORE study -
approximately 65 adults and 5 paediatric patients - will participate in the
study. This study will be conducted in about 20 hospital centres in 8 European
countries.

In NL this will be 4 adult patients.

The patient will have to visit the clinic every six months for a minimum of 1
year until a maximum of 5 years (depending on the time point he/she enters the
FU study after having finalised the participation in the Holocore study).

The patients will have to visit the clinic every six months for a minimum of 1
year until a maximum of 5 years (depending on when entering the study after
finalisation in the Holocore study)

As in the previous HOLOCORE study, some information will be collected by the
medical staff during the study visits about adverse events the patients may
experience and the medication the patient takes during the study (regardless
the disease and the treatment of Holoclar).
Patients will also perform an ophtalmologic assessment at each visit to
evaluate:
• epithelial defects by fluorescein staining;
• neo-vascularization assessment;
• Best-Corrected Visual Acuity;
• ocular tonometry;
• slit lamp examination;
• conjunctival (both bulbar and limbal) inflammation assessment;
• corneal sensitivity and central corneal involvement assessment;
• symptoms (pain, burning and photophobia);
• digital photographies of the eye for assessment of neo-vascularization;
• clinical outcome based on investigator*s judgment.

Moreover, patients will be asked to fill-in quality of life evaluation using
NEI VFQ 25 and EQ-5D-3L. They are the same questionnaires already completed for
the HOLOCORE study.

In case during the study the patient have to undergo a planned keratoplasty
surgery, some related information will be collected and the patient will be
followed-up for 12 months after the intervention.
No examination or interventional assessments will be taken for the purpose of
this research.