Initial management with aflibercept, laser photocoagulation or observation in patients with diabetic eye disease?

This article investigated the rate of vision loss at 2 years among eyes with center involved-diabetic macular edema (CI-DME; vision loss in people with diabetes) initially managed with aflibercept (Eylea), laser photocoagulation (LP) or observation. The authors concluded that there was no significant difference in vision loss at 2 years between the three initial treatments or if aflibercept was given only when sight worsened. 

Diabetes involves blood glucose levels to rise higher than normal. The high blood glucose damages the tiny blood vessels in the eye. This can lead to CI-DME, causing vision loss. The current management options include aflibercept injections into the eye, LP and observation (watch and wait). LP is a type of eye surgery using a laser to shrink or destroy abnormal structures in the retina. It is unknown which of these management options results in better long term visual acuity (VA; ability to see clearly) outcomes.

The study involved 702 patients with a VA of 20/25 or better and one eye with CI-DME. The patients were broken into 3 groups. Group 1 (226) received aflibercept every 4 weeks. Group 2 (240) received LP and group 3 (236) received observation. If patients in groups 2 or 3 developed decreased VA they also received aflibercept. They were followed up for 2 years.

25% of group 2 and 34% in group 3 needed aflibercept treatment during the study. At 2 years, group 1 had a 16% decrease in VA. Group 2 had a 17% decrease and group 3 had a 19% decrease in VA after 2 years. The risk of VA decreasing in group 1 was 12% lower compared to group 2 and 17% lower compared to group 3. However, these differences were not significant.

The authors concluded that in patients with CI-DME and good VA, there was no significant difference in vision loss at 2 years whether eyes were initially managed with aflibercept, LP or observation and given aflibercept only if VA worsened. 

Funding was received from Regeneron, the manufacturer of the drug aflibercept. 

This study group had relatively good blood glucose control and excellent visit adherence. Outcomes might differ among patients with worse glucose control or inconsistent follow-up.