medwireNews: Intravitreous aflibercept and vitrectomy with panretinal laser photocoagulation appear to have similar efficacy over 24 weeks when used for the treatment of vitreous hemorrhage from proliferative diabetic retinopathy, researchers report.
The study, conducted at 39 DRCR Retina Network sites in the USA and Canada included 205 adults (mean age 57 years, 56% men) with type 1 or type 2 diabetes and vison loss (mean visual acuity letter score, 34.5 [Snellen equivalent, 20/200]) due to vitreous hemorrhage from proliferative diabetic retinopathy.
Adam Glassman (Jaeb Center for Health Research, Tampa, Florida, USA) and co-researchers report in JAMA that the mean visual acuity letter score over 24 weeks was 59.3 (Snellen equivalent, 20/63) in the 100 participants randomly assigned to receive four monthly intravitreous injections of aflibercept 2 mg.
This was not significantly different from the score of 63.0 (Snellen equivalent, 20/63) observed among the 105 participants randomly assigned to receive vitrectomy with panretinal laser photocoagulation.
However, Glassman et al note that the 95% confidence intervals were wide and suggest that “the study may have been underpowered to detect a clinically important benefit in favor of initial vitrectomy with panretinal photocoagulation.”
In spite of this, the team found that visual acuity improved faster with vitrectomy than with aflibercept; at 4 weeks the mean visual acuity letter score was 52.6 (Snellen equivalent, 20/100) in the aflibercept group compared with a significantly higher 62.3 (Snellen equivalent, 20/63) in the vitrectomy group.
By 12 weeks there was no significant difference between the groups, and the outcomes remained similar up to 2 years.
During the course of the study, 33% of eyes assigned to aflibercept and 32% of those assigned to vitrectomy subsequently received the alternative treatment.
Glassman and co-authors conclude: “Although visual outcomes were not significantly different between treatment groups from 12 weeks through 2 years, additional findings from this study may help clinicians guide therapeutic decisions for individuals with vitreous hemorrhage.”
For example, the team found that the “benefits of vitrectomy in this study included faster restoration of vision, reduced likelihood of recurrent vitreous hemorrhage, and greater resolution of neovascularization. In contrast, the aflibercept group experienced less frequent center-involved diabetic macular edema and avoided vitrectomy in two-thirds of participants.”
However, in an accompanying editorial, Tien Yin Wong (Singapore National Eye Centre) and co-authors say the study “provides no compelling evidence to change present management from vitrectomy to anti-VEGF therapy to clear vitreous hemorrhage for patients with proliferative diabetic retinopathy.”
They add that “both clinical approaches have benefits and risks, and physicians treating patients with vitreous hemorrhage from proliferative diabetic retinopathy can and should personalize the initial therapeutic choice based on individual patient circumstances and influencing factors.”
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JAMA 2020; 324: 2383–2395
JAMA 2020; 324: 2375–2377