Abstract
Importance: Intravitreous injections of antivascular endothelial growth factor agents are effective for treating diabetic macular edema (DME) involving the center of the macula (center-involved DME [CI-DME]) with visual acuity impairment (20/32 or worse). The best approach to treating patients with CI-DME and good visual acuity (20/25 or better) is unknown. Objective: To compare vision loss at 2 years among eyes initially managed with aflibercept, laser photocoagulation, or observation. Design, Setting, and Participants: Randomized clinical trial conducted at 91 US and Canadian sites among 702 adults with type 1 or type 2 diabetes. Participants had 1 study eye with CI-DME and visual acuity of 20/25 or better. The first participant was randomized on November 8, 2013, and the final date of follow-up was September 11, 2018. Interventions: Eyes were randomly assigned to 2.0 mg of intravitreous aflibercept (n = 226) as frequently as every 4 weeks, focal/grid laser photocoagulation (n = 240), or observation (n = 236). Aflibercept was required for eyes in the laser photocoagulation or observation groups that had decreased visual acuity from baseline by at least 10 letters (≥ 2 lines on an eye chart) at any visit or by 5 to 9 letters (1-2 lines) at 2 consecutive visits. Main Outcomes and Measures: The primary outcome was at least a 5-letter visual acuity decrease from baseline at 2 years. Antiplatelet Trialists' Collaboration adverse events (defined as myocardial infarction, stroke, or vascular or unknown death) were reported. Results: Among 702 randomized participants (mean age, 59 years; 38% female [n=264]), 625 of 681 (92% excluding deaths) completed the 2-year visit. For eyes with visual acuity that decreased from baseline, aflibercept was initiated in 25% (60/240) and 34% (80/236) in the laser photocoagulation and observation groups, respectively. At 2 years, the percentage of eyes with at least a 5-letter visual acuity decrease was 16% (33/205), 17% (36/212), and 19% (39/208) in the aflibercept, laser photocoagulation, and observation groups, respectively (aflibercept vs laser photocoagulation risk difference, -2% [95% CI, -9% to 5%]; relative risk, 0.88 [95% CI, 0.57-1.35; P =.79]; aflibercept vs observation risk difference, -3% [95% CI, -11% to 4%]; relative risk, 0.83 [95% CI, 0.55-1.27; P =.79]; laser photocoagulation vs observation risk difference, -1% [95% CI, -9% to 6%]; relative risk, 0.95 [95% CI, 0.64-1.41; P =.79]). Antiplatelet Trialists' Collaboration vascular events occurred in 15 (7%), 13 (5%), and 8 (3%) participants in the aflibercept, laser photocoagulation, and observation groups. Conclusions and Relevance: Among eyes with CI-DME and good visual acuity, there was no significant difference in vision loss at 2 years whether eyes were initially managed with aflibercept or with laser photocoagulation or observation and given aflibercept only if visual acuity worsened. Observation without treatment unless visual acuity worsens may be a reasonable strategy for CI-DME. Trial Registration: ClinicalTrials.gov Identifier: NCT01909791.
| Original language | English (US) |
|---|---|
| Pages (from-to) | 1880-1894 |
| Number of pages | 15 |
| Journal | JAMA - Journal of the American Medical Association |
| Volume | 321 |
| Issue number | 19 |
| DOIs | |
| State | Published - May 21 2019 |
Funding
receipt of grants for clinical research from Regeneron, Genentech, Allergan, and Novartis. Mr Glassman reports receipt of grants from the National Eye Institute, Regeneron, and Genentech. Dr Beaulieu reports receipt of grants to his institution from the National Eye Institute and Regeneron. Dr Antoszyk reports receipt of grants from Roche Genentech and Clearside and personal/ consultant fees from Jaeb Center for Health Research, Opthea, Clearside, and Roche Genentech. Dr Jampol reports receipt of grants from the National Eye Institute and personal fees from Sanofi and Appelis. Dr Jhaveri reports receipt of personal fees from Novartis and Allergan. Ms Melia reports receipt of grants from the National Eye Institute, National Institute of Diabetes and Digestive and Kidney Diseases, Juvenile Diabetes Research Foundation, and Regeneron as well as nonfinancial support from Regeneron in the form of study drug to her institution to distribute to clinical sites for conduct of clinical trials. Ms Stockdale reports receipt of grants from the National Eye Institute and Regeneron as well as nonfinancial support from Regeneron in the form of study drug to her institution to distribute to clinical sites for conduct of clinical trials. Dr Martin reports receipt of grants from the National Institutes of Health. Dr Sun reports receipt of grants from Roche Genentech, Juvenile Diabetes Research Foundation, and Kalvista; personal fees from Current Diabetes Reports, JAMA Ophthalmology, and Merck; and nonfinancial support from Optovue (equipment loaned for research), Roche Genentech (food/beverage), and KalVista (travel support). No other disclosures were reported. publication was supported by the National Eye Institute and the National Institute of Diabetes and Digestive and Kidney Diseases under award numbers UG1EY014231 and UG1EY023207. Regeneron provided aflibercept for the study and funds to the DRCR Retina Network to defray the study’s clinical site costs.
ASJC Scopus subject areas
- General Medicine
