Aflibercept, bevacizumab, or ranibizumab for diabetic macular edema

Ranibizumab with luseogliflozin in type 2 diabetes with diabetic macular oedema: A randomised clinical trial

AIMS

Anti-vascular endothelial growth factor (VEGF) therapy is the standard treatment for diabetic macular oedema (DMO); however, unmet needs remain. This study aimed to assess the effectiveness of sodium-glucose cotransporter 2 inhibitors (SGLT2i) in treating DMO.

MATERIALS AND METHODS

This multicentre randomised open-label trial included 60 patients with DMO who were eligible for anti-VEGF therapy. Patients were randomised to receive luseogliflozin or glimepiride. Ranibizumab was administered initially to the target eye, with additional doses per protocol. The number of ranibizumab doses up to week 48, and re-admission rates were evaluated. Fellow eye injections were also assessed.

RESULTS

Sixty participants, mostly with diabetic retinopathy and half previously treated with anti-VEGF therapy, were included. SGLT2i and sulfonylurea (SU) groups achieved equivalent glycated haemoglobin, central retinal thickness (CRT), and best-corrected visual acuity improvements. Injection frequency for the target eye was similar between groups (SGLT2i vs. SU: 3.9 ± 0.7 vs. 4.7 ± 0.7 times, p = 0.36). Re-administration rates were decreased significantly after the fourth injection in the SGLT2i group (p = 0.030, hazard ratio: 0.45, 95% confidence interval: 0.22-0.92). Fellow eyes in the SGLT2i group showed significant CRT reduction and fewer injections compared with those in the SU group (1.3 ± 0.6 vs. 3.4 ± 0.8, p = 0.016).

CONCLUSIONS

Although the overall number of anti-VEGF injections in the target eye showed no significant difference, some patients responded favourably to SGLT2i and required fewer injections. The reduction in fellow eye injections suggests SGLT2i's efficacy in treating early-stage DMO.

TRIAL REGISTRATION

University Hospital Medical Information Network Clinical Trial Registry (UMIN000033961); Japan Registry of Clinical Trials (jRCTs031180210).

Race and Vision Outcomes in Ranibizumab-Treated Participants With Diabetic Macular Edema: A Meta-Analysis

Importance

Vision outcomes in response to anti-vascular endothelial growth factor therapy for diabetic macular edema (DME) may differ between races. This meta-analysis investigated whether vision outcomes differed among racial subgroups treated with ranibizumab for DME in a clinical trial setting.

Objective

To assess the impact of race on vision outcomes in participants with DME treated with ranibizumab.

Data Sources

Five randomized clinical trials were preselected for analysis, including the RIDE and RISE trials (Ranibizumab Injection in Subjects With Clinically Significant Macular Edema With Center Involvement Secondary to Diabetes Mellitus); Protocol I (Intravitreal Ranibizumab or Triamcinolone Acetonide in Combination With Laser Photocoagulation for Diabetic Macular Edema), Protocol S (Prompt Panretinal Photocoagulation Versus Intravitreal Ranibizumab With Deferred Panretinal Photocoagulation for Proliferative Diabetic Retinopathy), and Protocol T (A Comparative Effectiveness Study of Intravitreal Aflibercept, Bevacizumab and Ranibizumab for Diabetic Macular Edema).

Study Selection

Targeted meta-analysis of data from 5 trials.

Data Extraction and Synthesis

Total enrollment numbers allowed for comparison of Black and White participants with DME who were treated with ranibizumab (0.3 mg or 0.5 mg) and had best-corrected visual acuity (BCVA) data at baseline and month 24. Lower total enrollment of participants of other races precluded statistical analysis. All ranibizumab-treated arms were pooled. Differences in vision outcomes between Black and White participants were evaluated, adjusting for baseline vision. Propensity score-matched models for participants in RIDE/RISE were used to control for differences in baseline and on-study characteristics.

Main Outcomes and Measures

Mean BCVA over time and mean change from baseline at month 24 by race (Black and White).

Results

Among the 1109 participants, the mean age was 60.0 years (95% CI, 59.4-60.7); 621 participants were male and 488 were female; 181 participants were Black and 928 were White. BCVA was better at baseline in Black vs White participants (mean Early Treatment Diabetic Retinopathy Study [ETDRS] letter score, 66.7 [95% CI, 65.0-68.4] vs 62.0 [95% CI, 61.1-62.8], respectively) but similar at month 24 (mean ETDRS letter score, 72.8 [95% CI, 70.2-75.4] vs 72.2 [95% CI, 71.2-73.1]). Mean BCVA change from baseline at month 24 was lower in Black vs White participants (6.1 ETDRS letters [95% CI, 3.6-8.6] vs 10.2 ETDRS letters [95% CI, 9.3-11.1]) and after adjusting for differences in baseline BCVA (7.7 ETDRS letters [95% CI, 5.8-9.7] vs 9.9 ETDRS letters [95% CI, 9.0-10.7]). When groups were propensity score-matched in RIDE/RISE, mean BCVA change from baseline appeared similar between Black vs White participants (10.6 ETDRS letters [95% CI, 7.1-14.1] vs 10.1 ETDRS letters [95% CI, 7.3-12.9]; P = .83).

Conclusions and Relevance

This meta-analysis evaluating ranibizumab for DME found that baseline BCVA was better in Black vs White participants, and BCVA change from baseline at month 24 was smaller in Black vs White participants. No difference in BCVA was observed in Black vs White participants at 2 years. Smaller enrollment numbers precluded analysis of participants of other races, suggesting lack of robust diversity beyond Black and White participants in these trials.

Assessing variation in US payer coverage of anti-vascular endothelial growth factor therapies for the treatment of age-related macular degeneration, diabetic retinopathy, and diabetic macular edema

BACKGROUND

Timely anti-vascular endothelial growth factor (anti-VEGF) therapy is recommended to preserve vision in age-related macular degeneration (AMD), diabetic retinopathy (DR), and diabetic macular edema (DME). Coverage of anti-VEGF agents for the treatment of retinal diseases varies, resulting in administrative burdens for providers and treatment delays for patients.

OBJECTIVE

To examine how US commercial and Medicare Advantage (MA) health plans cover anti-VEGF therapies for the treatment of retinal diseases using information from the Tufts Medical Center Specialty Drug Evidence and Coverage Database.

METHODS

This descriptive study evaluated coverage of US Food and Drug Administration (FDA)-approved anti-VEGF drugs for AMD, DR, and DME current as of April 2024 using the Specialty Drug Evidence and Coverage Database from 18 of the largest US commercial health plans and MA offerings from a subset of 6 of these plans.

RESULTS

Substantial variation exists in commercial coverage across FDA-approved anti-VEGF therapies for AMD, DR, and DME. Descriptive assessment showed that approximately 65% of commercial coverage decisions and approximately 52% of MA decisions included restrictions beyond the FDA label. Coverage decisions for originator products were more likely to include restrictions compared with those for biosimilar products. Step therapy protocols were found in up to 75% of plans but were variable by drug, with most requiring a first-line trial of bevacizumab. Evidence cited to support coverage restrictions was likewise variable.

CONCLUSIONS

Descriptive data show that US commercial and MA coverage and step therapy protocols vary substantially across health plans, which may potentially contribute to administrative burdens and treatment delays.

Impact of a Patient Portal-Based Telehealth Outreach Program on Recall of Patients with Diabetic Retinopathy

Purpose: To evaluate the effectiveness of a patient portal telehealth outreach program to return patients with diabetic retinopathy (DR) lost to follow-up (LTFU) for eye care. Methods: Patients with DR receiving intravitreal injection (IVI) therapy who were >90 days beyond recommended return were deemed LTFU. Outreach messages were sent via a patient portal, when available, or through the U.S. mail. Patients received information on how to schedule a retinal examination and a symptom-screening questionnaire. The adherence rate to scheduled appointments was assessed 90 days postintervention. Labor costs were estimated based on communication time. Results: Among 359 patients with DR receiving IVIs, 22% were LTFU, overdue by a median of 362 days. Receiving fewer IVIs was the factor most strongly associated with becoming LTFU (8.9  ±  9.1 injections vs. 22 ± 20 injections, p < 0.001). The outreach program engaged 39 patients via the patient portal and 28 patients via the U.S. mail. A similar number of patients in each cohort was scheduled (13% vs. 14%, p = 0.862) and completed appointments (10% vs. 14%, p = 0.616). Whereas patient-portal messages took an average of 64 s to send at a labor cost of $0.35/message, each letter sent by mail took approximately 5 min to prepare at a total cost of $2.19. Conclusions: A patient portal-based telehealth outreach program is effective at returning patients with DR to eye care and can be implemented at a lower cost, compared with conventional mailed recall letters. Efforts are needed to increase digital health literacy and access to improve the efficiency of health care delivery.

Transforming retinal disease management through diabetes care

In September 2024, AMCP and Impact Education, LLC, held a virtual Market Insights summit with chief medical and pharmacy officers and other senior health care executives to discuss the management of retinal diseases in patients with diabetes. The summit aimed to explore the impact of current policies on treatment access and costs, identify best practices for anti-vascular endothelial growth factor (anti-VEGF) coverage, and address barriers related to social determinants of health (SDOH). Anti-VEGF therapy, although effective for conditions such as diabetic macular edema and age-related macular degeneration, may require monthly injections that impose a significant burden on patients and caregivers, affecting adherence and outcomes. Key topics included examining the impact of current policies on treatment access and total cost of care, exploring opportunities for management of patients at increased risk for blindness, outlining the benefits of durable treatment approaches, addressing strategies to overcome access barriers related to SDOH, and identifying best practices in coverage policies for anti-VEGF agents. Strategies for addressing barriers to care were explored, including the potential use of gold carding, contingent on establishing clearer definitions of good care in retinal disease management, understanding prescribing variation, gaining standardized of definitions or guidelines for good" care, and practical strategies for using extended dosing to support adherence and access. Health care executives reached agreement on the central role of ophthalmologists in preventing blindness in patients with diabetes and retinal diseases and the importance of timely access to appropriate treatments.

Fluid Aspiration From Intraretinal Cysts for Refractory Diabetic Macular Edema

PURPOSE

To report the surgical outcome of fluid aspiration in intraretinal cysts as a novel treatment approach for the refractory cystoid macular edema associated with diabetic retinopathy.

METHODS

This retrospective consecutive case series examined eight patients with refractory cystoid macular edema who underwent intraretinal cyst fluid aspiration using a 38-gauge subretinal infusion needle during pars plana vitrectomy. This study reviewed changes in central retinal thickness, best-corrected visual acuity, and central sensitivity among patients followed up for 12 months postsurgery.

RESULTS

Central retinal thickness on optical coherence tomography (μm) significantly improved at 12 months after surgery (308 ± 99) compared with before surgery (480 ± 141) ( P < 0.005). During the follow-up period, cystoid macular edema relapsed in one eye. The best-corrected visual acuity (logarithm of the minimal angle of resolution) at 12 months postsurgery (0.23 ± 0.32, Snellen equivalent: 20/50) was significantly better than the preoperative best-corrected visual acuity (0.39 ± 0.29, Snellen equivalent: 20/63) ( P < 0.01). The mean deviation value of central sensitivity did not significantly change between preoperative (-2.5 ± 2.1) and postoperative (-2.2 ± 2.2) assessments ( P = 0.07).

CONCLUSION

Fluid aspiration in intraretinal cysts may be a treatment option for refractory cystoid macular edema in eyes with diabetes.

Current Treatment Options for Diabetic Retinal Disease

The global incidence of diabetes is rising steadily and with it the number of people living with diabetic retinal disease (DRD) is increasing. Like diabetes, DRD can be treated but not cured. In response, therapies to address DRD include targeted ocular and systemic medications. This review discusses diabetes and DRD in terms of current screening recommendations, treatments, and considerations related to those therapies and future drug targets and trials on the horizon. This discourse is targeted at all members of the diabetes care team, including primary care providers, optometrists, and ophthalmologists. The dynamic landscape of diabetic retinopathy treatment is promising for the prevention and improvement of visually significant disease.

Evolution of ophthalmological care in adult with diabetes in France between 2010 and 2022: a nationwide study

PURPOSE

The aim of this study is to describe ophthalmological care of adults with diabetes in France and its evolution between 2010 and 2022.

METHODS

In this study, we used the ESND, a representative permanent random sample of 2/100th of the entire French population. Ophthalmological care was defined by the combination of ophthalmological procedures (fundus examination, color fundus photography, Optical Coherence Tomography..) and/or ophthalmological treatment (intravitreal injection or laser treatment) during the year. Changes in annual rates during the study period were assessed using linear regression models excluding 2020.

RESULTS

From 2010 to 2022, the number of adults treated for diabetes in the ENSD increased from 48 329 patients (mean age 65.3 ± 13.0, 46.3% women) to 68 397 patients (mean age 67.0 ± 13.2, 44.8% women). Among them, the annual rate of ophthalmological care was stable (46.5% in 2010 and 48.5% in 2022) and the difference was not significant (β = 0.10% per year, p = 0.11). The yearly ophthalmological treatment rate increased significantly (3.3% in 2010 and 5.3% in 2022, β = 0.2% per year, p < 0.0001). Rates were lower during the COVID-19 outbreak in 2020.Women, individuals aged between 66-80 years, those living in the least deprived areas and those treated with combined insulin and non-insulin treatment had higher yearly ophthalmological care rate.

CONCLUSION

In this large nationwide representative study with recent and updated data, although ophthalmological treatment rate has increased over the decade mainly due to intravitreal injections, less than half of the diabetic patients receive yearly ophthalmological care.

Photodiagnosis with deep learning: A GAN and autoencoder-based approach for diabetic retinopathy detection

BACKGROUND

Diabetic retinopathy (DR) is a leading cause of visual impairment and blindness worldwide, necessitating early detection and accurate diagnosis. This study proposes a novel framework integrating Generative Adversarial Networks (GANs) for data augmentation, denoising autoencoders for noise reduction, and transfer learning with EfficientNetB0 to enhance the performance of DR classification models.

METHODS

GANs were employed to generate high-quality synthetic retinal images, effectively addressing class imbalance and enriching the training dataset. Denoising autoencoders further improved image quality by reducing noise and eliminating common artifacts such as speckle noise, motion blur, and illumination inconsistencies, providing clean and consistent inputs for the classification model. EfficientNetB0 was fine-tuned on the augmented and denoised dataset.

RESULTS

The framework achieved exceptional classification metrics, including 99.00 % accuracy, recall, and specificity, surpassing state-of-the-art methods. The study employed a custom-curated OCT dataset featuring high-resolution and clinically relevant images, addressing challenges such as limited annotated data and noisy inputs.

CONCLUSIONS

Unlike existing studies, our work uniquely integrates GANs, autoencoders, and EfficientNetB0, demonstrating the robustness, scalability, and clinical potential of the proposed framework. Future directions include integrating interpretability tools to enhance clinical adoption and exploring additional imaging modalities to further improve generalizability. This study highlights the transformative potential of deep learning in addressing critical challenges in diabetic retinopathy diagnosis.

Intravitreal therapy-success stories and challenges

Intravitreal injections have revolutionized the treatment of various sight-threatening diseases of the posterior segment of the eye. Initially explored for treatment of bacterial endophthalmitis, intravitreal injections rapidly expanded to combat retinal vascular disease in particular. Especially anti-vascular endothelial growth factor agents have emerged as a cornerstone of intravitreal therapy, targeting neovascular age-related macular degeneration and diabetic macular edema as important examples. Advances continue, with novel therapies such as complement inhibitors now available as treatment for geographic atrophy secondary to non-neovascular age-related macular degeneration, offering hope for a previously untreatable condition. Pioneering approaches such as the port delivery system and intravitreal gene therapy aim to improve treatment efficacy while minimizing patient burden. Despite notable successes, challenges for intravitreal therapies persist, including ocular and systemic complications and high treatment burden. Future research endeavors aim to address these challenges and enhance treatment outcomes. This comprehensive review critically evaluates the efficacy, safety, and cost-effectiveness of intravitreal injections, delving into emerging trends and future directions.

Exploring the factors influencing the timely intravitreal anti-VEGF treatment in patients with diabetic macular edema: a qualitative interview study using the COM-B model

PURPOSE

To explore the factors influencing the untimely receipt of intravitreal anti-vascular endothelial growth factor (VEGF) injections in patients with diabetic macular edema (DME), based on the capability, opportunity, and motivation-behavior (COM-B) model.

DESIGN

An exploratory qualitative study was conducted with semi-structured interviews with DME patients who had received at least one injection of anti-VEGF therapy within one year. The COM-B model was utilized to guide both data collection and analysis.

RESULTS

Themes and subthemes were identified. Psychological capability for timely intravitreal anti-VEGF treatment included lack of relevant knowledge and choice of more convenient treatments. Social opportunity included no mention of intravitreal anti-VEGF therapy and effective doctor-patient communication; physical opportunity included unavailability of anti-VEGF and high treatment costs. Reflective motivation included lack of confidence in the efficacy and unmet expectations; automatic motivation included fear of injections, and fear of blindness.

CONCLUSION

This study identified the facilitators and barriers that influenced the timely intravitreal anti-VEGF injections, which lays the foundation for the development of future interventions.

What have we learned from a decade treating patients with diabetic macular oedema with 0.19 mg fluocinolone acetonide intravitreal implant?

Diabetic macular oedema [DMO] is a prevalent and sight-threatening condition among diabetic patients, which can cause irreversible blindness. Since angiogenesis and inflammation are two key elements in the etiopathogenesis of DMO, intravitreal injections of vascular endothelial growth factor inhibitors [anti-VEGF] and sustained released intravitreal corticosteroid implants are currently considered as treatments of choice. The introduction, 10 years ago, of the 0.19 mg fluocinolone acetonide [FAc] implant for treating eyes with vision impairment associated with recurrent and persistent DMO represented an important advance. Since then, two randomized-control trials and many real-world studies have shown its good efficacy/safety profile and the replicability of its treatment regimen. The FAc implant is, in general terms well tolerated, although it is associated with intraocular pressure-[IOP] and cataract-related adverse events [AEs]. Most IOP-related AEs are effectively controlled with ocular-hypotensive therapies. The objective of this paper is to review the role of FAc implant in the treatment of DMO over the 10 years since its launch, as well as its impact on clinical practice outcomes.

Efficacy and safety of dexamethasone or triamcinolone in combination with anti-vascular endothelial growth factor therapy for diabetic macular edema: A systematic review and meta-analysis with trial sequential analysis

BACKGROUND

The clinical efficacy of anti-vascular endothelial growth factors (anti-VEGFs), corticosteroids, and their combined treatment for diabetic macular edema (DME) has been substantiated by numerous studies. However, it remains uncertain whether the therapeutic benefits of the combined treatment with corticosteroids and anti-VEGFs is superior to those of anti-VEGF monotherapy. Consequently, we conducted a meta-analysis to compare the efficacy and safety of combined treatment with dexamethasone or triamcinolone and anti-VEGF versus anti-VEGF monotherapy in DME treatment.

METHODS

An exhaustive search of the literature was performed on February 23, 2024, scanning through the databases including PubMed, Web of Science, Embase, and the Cochrane Library, with the aim of identifying all relevant studies. The combined results for efficacy and safety were analyzed using the standard mean difference (SMD) and relative risk (RR), both of which were presented with 95% confidence interval (CI). The assessment of heterogeneity was conducted via Cochran's Q test, I2 statistics, and the implementation of a 95% prediction interval (PI). All analyses were performed by R 4.3.1, Stata 12.0, and TSA v0.9.5.10 Beta software.

RESULTS

This meta-analysis incorporated 21 eligible studies. The overall analysis revealed that combined treatment of dexamethasone or triamcinolone with anti-VEGF agents did not demonstrate superiority over anti-VEGF monotherapy in improving best-corrected visual acuity (BCVA) (Dexamethasone: SMD -0.266, 95% CI -1.001 to 0.468, 95% PI -2.878 to 2.346; Triamcinolone: SMD -0.340, 95% CI -1.230 to 0.550, 95% PI -3.554 to 2.874) and reducing central macular thickness (CMT) (Dexamethasone: SMD -1.255, 95% CI -2.861 to 0.350; Triamcinolone: SMD -0.207, 95% CI -0.895 to 0.481, 95% PI -2.629 to 2.215). However, the combination therapy significantly increased the risk of elevated intraocular pressure (RR 5.783, 95% CI 3.007 to 11.121, 95% PI 0.520 to 56.931) and ocular hypertension (RR 8.885, 95% CI 2.756 to 28.649, 95% PI 1.262 to 39.208). Subgroup analysis suggests that dexamethasone plus anti-VEGF therapy showed a greater reduction in central subfield thickness (SMD -0.440, 95% CI -0.755 to -0.126) compared to anti-VEGF monotherapy among patients with persistent DME.

CONCLUSION

Our study confirmed that dexamethasone or triamcinolone plus anti-VEGF therapy did not show superior efficacy in improving BCVA and reducing CMT in DME patients compared with anti-VEGF monotherapy. Clinicians should weigh the pros and cons comprehensively when implementing combined therapy.

Application of deep learning algorithm for judicious use of anti-VEGF in diabetic macular edema

Diabetic Macular Edema (DME) is a major complication of diabetic retinopathy characterized by fluid accumulation in the macula, leading to vision impairment. The standard treatment involves anti-VEGF (Vascular Endothelial Growth Factor) therapy, but approximately 36% of patients do not respond adequately, highlighting the need for more precise predictive models to guide treatment. This study aims to develop a Hybrid Deep Learning model to predict treatment responses in DME patients undergoing anti-VEGF therapy, thereby improving the accuracy of treatment planning and minimizing the unnecessary use of costly anti-VEGF agents. The model integrates both Optical Coherence Tomography (OCT) images and clinical data from 181 patients, including key parameters such as serum VEGFR-2 concentration and the duration of DME. The architecture combines convolutional neural networks (CNNs) for image data with multi-layer perceptron (MLP) for tabular clinical data, allowing for a comprehensive analysis of both data types. These pathways converge into a unified predictive framework designed to enhance the model's accuracy. This study utilized a Hybrid Deep Learning model that achieved an 85% accuracy, with additional metrics including precision, recall, and the area under the receiver operating characteristic curve (AUC-ROC) confirming its robustness and reliability. The findings suggest that the model accurately predicts patient responses to anti-VEGF therapy, paving the way for more personalized and targeted treatment strategies. This approach has the potential to enhance patient outcomes and minimize unnecessary administration of anti-VEGF agents, thereby optimizing therapeutic interventions in ophthalmology.

Endothelial AGGF1 promotes retinal angiogenesis by coordinating TNFSF12/FN14 signalling

Abnormal angiogenesis is a key process associated with ischaemic retinopathies such as diabetic retinopathy, for which the underlying pathological mechanisms are still poorly understood. Here, we confirm that angiogenic factor 1 with a G patch and FHA domain (AGGF1) is elevated in the diabetics and induces retinal angiogenesis. Mechanistic investigations demonstrate that HIF-1α directly regulates AGGF1 expression. AGGF1 upregulates the expression of cell cycle proteins by increasing the binding of tumour necrosis factor ligand superfamily member 12 (TNFSF12) to fibroblast -growth -factor-inducible 14 (FN14, TNFRSF12A). Furthermore, targeting AGGF1 attenuates pathological neovascularisation in ischaemic retinopathy. Additionally, we discover that sodium-glucose cotransporter 2 inhibitors (SGLT2i) could inhibit the AGGF1 signalling pathway early to achieve therapeutic effects. Overall, we elucidate the mechanism underlying pathological retinal angiogenesis involved in endothelial AGGF1-dependent events and highlight a therapy for the effective treatment of ischaemic retinopathy.

Anti-VEGF Injections vs. Panretinal Photocoagulation Laser Therapy for Proliferative Diabetic Retinopathy: A Systematic Review and Meta-Analysis

TOPIC

To evaluate the efficacy and safety of anti-VEGF and panretinal photocoagulation (PRP) for the treatment of proliferative diabetic retinopathy (PDR). The outcomes examined are changes in best-corrected visual acuity (BCVA), neovascularization (NV), central macular thickness (CMT), and adverse outcomes.

CLINICAL RELEVANCE

Diabetic retinopathy is the leading cause of blindness in working-aged adults globally. At present, no consensus has been reached on the optimal choice for the treatment of PDR.

METHODS

Cochrane, Embase, PubMed, Scopus, Web of Science, and CiNAHL were searched for articles from their inception to June 2023 according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis. The review was registered prospectively with PROSPERO (CRD42023437778). Tool data analysis was performed using RevMan software version 5.4 (Review Manager [RevMan] [computer program], The Cochrane Collaboration, 2020). Randomized control trials (RCTs) of PDR patients treated with anti-VEGF, PRP, or a combination were included. Risk of bias was assessed using the Rob2 assessment tool (revised tool for risk of bias in randomized trials), and certainty of evidence was assessed with the Grading Recommendations Assessment, Development and Evaluation (GRADE) approach.

RESULTS

Nineteen studies were included, with 1361 patients (n = 1788 eyes) treated for PDR with either anti-VEGF (n = 274), PRP (n = 482), or combination (n = 320). Our results show more favorable BCVA outcomes with anti-VEGF compared with PRP at 3 months (mean difference [MD] = 2.35 letters; 95% confidence interval [CI], 1.18-3.52; I2 = 0%) and 12 months follow-up (MD = 3.39 letters; 95% CI, 0.63-6.14; I2 = 26%). Combination treatment showed better BCVA outcomes compared with PRP at 12 months (MD = 4.06 letters; 95% CI, 0.26-7.86; I2 = 0%). Combination showed lower CMT at 3 months (MD = -33.10 μm; 95% CI, -40.12 to -26.08; I2 = 25%) and 6 months (MD = -34.28 μm; 95% CI, -55.59 to -12.97; I2 = 85%) compared with PRP, but CMT results were similar at 12 months. Complete regression of total NV (NVT) was more likely with anti-VEGF compared with PRP (odds ratio = 6.15; 95% CI, 1.39-27.15; I2 = 80%). Posttreatment vitreous hemorrhage, vitrectomy, and increased intraocular pressure events were similar between the anti-VEGF and combination groups compared with PRP; however, macular edema results favored the anti-VEGF over the PRP group. Using the GRADE assessment, BCVA evidence was rated to be of moderate certainty, whereas CMT and NVT evidence certainty was rated as very low.

CONCLUSION

Anti-VEGF and combination treatments could be regarded as alternative approaches to PRP alone in the management of PDR after engaging in a shared decision-making process based on patients' adherence, diabetic macular edema status, and preference. Limitations of this meta-analysis include the heterogeneity in participants' characteristics, treatment regimens, and outcome reporting between studies. Further RCTs should be conducted to compare the effectiveness of these treatments in the long term.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Subthreshold Micropulse Laser for Eyes: With Center Involving Diabetic Macular Edema With Good Visual Acuity: The PULSE Study, a Randomized Clinical Trial

BACKGROUND AND OBJECTIVE

To determine if subthreshold micropulse laser (SML) therapy can prevent or delay vision loss in diabetic macular edema (DME) with good visual acuity (VA).

PATIENTS AND METHODS

Prospective, single-masked, sham-controlled trial in 27 eyes of 19 adult patients with treatment-naïve, center-involved DME, and VA of 20/25 or better. Measures included best-corrected visual acuity (BCVA), low-luminance visual acuity (LLVA), contrast sensitivity (CS), average threshold on microperimetry, and central subfield thickness (CST). The primary outcome measure was median time to vision loss of 10 letters at any visit or 5 to 9 letters at two consecutive visits ≤ 28 days apart.

RESULTS

Eight eyes met vision loss criteria during the 2-year study, with similar proportions for SML (n = 5) and sham (n = 3). Median time to vision loss was 5 months for both groups. At 6 months, there were no statistical differences in BCVA, LLVA, CS, microperimetry threshold, and CST between SML and sham arms (P > 0.05 in all measures).

CONCLUSION

In eyes with center-involved DME and good VA, SML did not prevent or delay the vision loss threshold for initiating anti-VEGF therapy. However, these results may be affected by a high rate of early participant dropout from the study. [Ophthalmic Surg Lasers Imaging Retina 2025;56:86-93.].

Cross-cutting effect of type 2 diabetes on the sensorimotor control of balance

Type 2 Diabetes is a highly prevalent chronic disorder that affects multiple systems through microvascular complications. Complications such as diabetic peripheral neuropathy, diabetic retinopathy, and diabetic vestibular dysfunction (vestibulopathy) all directly interfere with the sensory components of balance and postural stability. The resulting impairments cause increased falls risk and instability, making it difficult to perform daily task or exercise. This commentary will provide clarity on the causes and relationship between the sensory complications of T2D, balance, and excise, while also providing recommendations and precautions for exercising with one of these sensory complications.

Identification of macrophage polarisation and mitochondria-related biomarkers in diabetic retinopathy

BACKGROUND

The activation of macrophages or microglia in patients' whole body or local eyes play significant roles in diabetic retinopathy (DR). Mitochondrial function regulates the inflammatory polarization of macrophages. Therefore, the common mechanism of mitochondrial related genes (MRGs) and macrophage polarisation related genes (MPRGs) in DR is explored in our study to illustrate the pathophysiology of DR.

METHODS

In this study, using common transcriptome data, differentially expressed genes (DEGs) were firstly analysed for GSE221521, while module genes related to MPRGs were obtained by weighted gene co-expression network analysis (WGCNA), intersections of DEGs with MRGs were taken, intersections of DEGs with module genes of the MPRGs were taken. After that, correlation analyses were performed to obtain candidate genes. Key genes were obtained by Mendelian randomisation (MR) analysis, then biomarkers were obtained by machine learning combined with receiver operating characteristic (ROC) and expression validation between DR and control cohorts in GSE221521 and GSE160306 to obtain biomarkers. Finally, biomarkers were subjected to immune infiltration analysis, gene set enrichment analysis (GSEA), and gene-gene interaction (GGI) analysis.

RESULTS

A number of 784 of DEGs were taken to intersect with 1136 MRGs and 782 MPRGs, respectively, after which 89 genes with correlation were taken as candidate genes. MR analysis yielded 13 key genes with clear causal links to DR. The expression trends of PTAR1 and SLC25A34 were consistent and notable between DR cohort and control cohort in GSE221521 and GSE160306. So PTAR1 and SLC25A34 were used as biomarkers. Immune infiltration analysis showed that activated NK cell and Monocyte were notably different between DR cohort and control cohorts, and PTAR1 showed the strongest positive correlations with activated NK cell. Both biomarkers were enriched in lysosome and insulin signaling pathway. The GGI network showed that biomarkers associated with prenyltransferase activity and prenylation function.

CONCLUSION

This study identified two biomarkers (PTAR1 and SLC25A34) which explore the pathogenesis of DR and provide reference targets for drug development.

Cardiovascular and Cerebrovascular Adverse Events Associated with Intravitreal Anti-VEGF Monoclonal Antibodies: A World Health Organization Pharmacovigilance Study

PURPOSE

To analyze cardiovascular and cerebrovascular adverse drug reactions (ADRs) after intravitreal anti-VEGF (aflibercept, bevacizumab, brolucizumab, and ranibizumab) treatment.

PARTICIPANTS

VigiBase, a World Health Organization (WHO) global safety report database.

DESIGN

Pharmacovigilance study.

METHODS

The individual case safety reports (ICSRs) of cardiovascular and cerebrovascular ADRs after intravitreal anti-VEGF treatment were compared with those reported in the full database. From 2004 to 2023, there were 23 129 ADRs after intravitreal anti-VEGF therapy and 25 015 132 ADRs associated with any drug (full database).

MAIN OUTCOME MEASURES

The reporting odds ratio (ROR) and information components (ICs) were calculated, and the 95% lower credibility interval end point of the information component (IC025) was used for disproportionate Bayesian reporting. Inter-drug comparisons were performed using the ratio of odds ratio (rOR).

RESULTS

Compared with the full database, anti-VEGFs were associated with an increased reporting of myocardial infarction (IC025 0.75; ROR: 1.78 [95% CI, 1.70-1.86]), angina pectoris (IC025 0.53; ROR: 1.61 [95% CI, 1.47-1.77]), arrhythmias including atrial fibrillation, atrial flutter, ventricular fibrillation, supraventricular tachycardia (all IC025 > 0, ROR>1), hypertension (IC025 2.22; ROR: 4.91 [95% CI, 4.82-5.01]), and hypertensive crisis (IC025 1.97; ROR: 4.49 [95% CI, 4.07-4.97]). Moreover, anti-VEGFs were associated with a higher reporting of cerebrovascular ADRs such as cerebral infarction (IC025 4.34; ROR: 23.19 [95% CI, 22.10-24.34]), carotid artery stenosis (IC025 1.85; ROR: 5.24 [95% CI, 3.98-6.89]), cerebral hemorrhage (IC025 2.29; ROR: 5.38 [95% CI, 5.03-5.76]), and subarachnoid hemorrhage (IC025 1.98; ROR: 4.81 [95% CI, 4.14-5.6]). Inter-drug comparison indicated that compared with ranibizumab, patients receiving aflibercept showed overall under-reporting of cardiovascular and cerebrovascular ADRs such as myocardial infarction (rOR 0.55 [95% CI, 0.49-0.52]), atrial fibrillation (rOR 0.28 [95% CI, 0.23-0.35]), cerebrovascular accident (rOR, 0.15 [95% CI, 0.14-0.17]), and cerebral hemorrhage (rOR, 0.51 [95% CI, 0.40-0.65]).

CONCLUSIONS

In this pharmacovigilance case-noncase study, there was significantly increased reporting of cardiovascular and cerebrovascular ADRs after intravitreal anti-VEGF treatment. Although ranibizumab may exhibit superior systemic safety regarding its biological characteristics, it is crucial not to overlook the occurrence of cardiovascular and cerebrovascular ADRs considering its higher reporting rate than bevacizumab or aflibercept.

FINANCIAL DISCLOSURE(S)

The author(s) have no proprietary or commercial interest in any materials discussed in this article.

ANTERIOR SUBTENON TRIAMCINOLONE INJECTION FOR REFRACTORY MACULAR EDEMA: A Retrospective Case Series

PURPOSE

To evaluate the effectiveness of anterior subtenon triamcinolone (AST) injections in the management of refractory macular edema.

METHODS

This is a retrospective case series of consecutive eyes with refractory macular edema treated with AST at a single vitreoretinal surgeon's practice at Toronto Western Hospital, University of Toronto, Canada in 2018 to 2023. Refractory was defined as persistent macular edema with a central subfield thickness of 250 µ m or greater over a 24-week period, receiving at least four intravitreal antivascular endothelial growth factor injections. Vision outcomes and optical coherence tomography features for all eyes were compared for three visits pre-AST treatment and two visits post-AST treatment.

RESULTS

Ninety-three patients (119 eyes); diabetic macular edema (26%), and pseudophakic cystoid macular edema (74%), with a mean follow-up duration of 161 days were included. The presence of subretinal fluid ( P = 0.0013), central subfield macular thickness ( P < 0.0001), cube average thickness ( P = 0.0024), and macular cube volume ( P = 0.0017) significantly improved from pre-AST to post-AST treatment. Visual acuity also significantly improved from pre-AST treatment to post-AST treatment ( P < 0.0001). There was no significant change in the intraocular pressures from pre-AST to post-AST ( P = 0.7920), and no complications were noted throughout the follow-up period.

CONCLUSION

The findings from this study suggest that AST injections show modest improvement in anatomical and functional outcomes and are safe for the treatment and management of refractory macular edema.

Diabetic Retinopathy - Pathophysiology to Treatment: A Review

Diabetic retinopathy (DR) is a microvascular disease affecting the eyes of diabetic patients, and is the most prevalent complication of diabetes mellitus. Vision improvement is not possible in the majority of DR patients. Several studies have indicated that microvascular changes, inflammation, oxidative stress, and retinal neurodegeneration are involved in the pathogenesis of DR. Therefore, there is an urgent need for the development of new and effective treatment for DR. Understanding the molecular mechanisms involved in the pathogenesis of disease will pave a way for better treatment and management of DR. This article has emphasized the molecular pathogenesis and treatment of DR.

Identification of Potential Inhibitors from Medicinal Plant-based Phytochemicals for the Influential C4 Target of Diabetic Retinopathy by Molecular Docking Studies

INTRODUCTION

Diabetic retinopathy is the major cause of vision failure in diabetic patients, and the current treatment involves the practice of glucocorticoids or VEGF antagonists that are "off-label". A few small organic molecules against DR were discovered many years ago. Nutraceuticals are naturally available functional foods that endorse different health benefits, including vitamins, antioxidants, minerals, fatty acids, and amino acids that can defer the development of some diseases.

METHODS

Numerous studies reported that nutraceuticals encourage multiple therapeutic benefits and provide protection against various diseases. In diabetes, nutraceuticals contribute to improving insulin sensitivity, metabolism regulation, and lower hyperglycemia. The major aim of this study is to discover the most active drug from natural or plant sources. In this work, 42 phytochemical constituents from 4 kinds of plants were docked with the C4 target of diabetic retinopathy by an in silico molecular docking study.

RESULTS

According to the binding energy, all the phytoconstituents possessed good to high attraction towards the target, and 6 phytochemicals, such as terchebulin, punicalagin, chebulagic acid, casuarinin, punicalin, and pedunculagin, disclosed superior binding energy towards the target than standard ruboxistaurin via the interactions of conventional hydrogen bonding, pi-alkyl interactions, etc. Molecular dynamic simulation studies further established the stability of the phytoconstituents, and ADMET studies proved the safety profile of these phytoconstituents.

CONCLUSION

Hence, the current study suggested that the phytochemicals from various herbs inhibit the C4 target of diabetic retinopathy and can be utilized as lead compounds to develop analogs or repurposed for the treatment of DR.

Immediate response to intravitreal treatment for macular edema due to diabetes and retinal vein occlusion

PURPOSE

To objectively assess the immediate response to intravitreal treatment for macular edema and compare it across different agents.

METHODS

This retrospective, comparative study included patients with macular edema due to diabetic retinopathy (DME) or vein occlusion who were treated with intravitreal injections of either steroids (triamcinolone acetonide or dexamethasone sustained release implant) or anti-vascular endothelial growth factor antibodies (VEGF). The central retinal thickness (CRT) and the best corrected visual acuity (BCVA) were measured 1 day after the injection and compared with immediate pre-injection values.

RESULTS

There were 79 eyes (57 patients) including 51 eyes with DME, 18 with branch retinal vein occlusion edema (BRVO-ME), and 10 eyes with central retinal vein occlusion edema (CRVO-ME). The intravitreal agents were triamcinolone acetonide (TA)(n = 15), dexamethasone sustained release implant (DEX)(n = 22), ranibizumab (n = 19), and bevacizumab (n = 23). Statistically significant improvement in CRT was seen in all injection groups (p < 0.05) while improvement in mean BCVA was significant only in the TA group (p = 0.009). The mean change in CRT was maximum with steroids than with anti-VEGFs; viz. 159.47 µ in TA, 115.45 µ in DEX, 86.10 µ in ranibizumab, and 78.78 µ in bevacizumab group. Least amount of change was noted in the spongy type of macular edema (18.73 µ) while improvement in mean BCVA was statistically significant only in the cystoid group (p = 0.01).

CONCLUSIONS

Comparatively, steroid agents showed better immediate response to therapy than anti-VEGFs. Maximum reduction in central retinal thickness was seen following triamcinolone acetonide injection. Cystoid edema showed better immediate response than spongy retinal thickening.

12. Retinopathy, Neuropathy, and Foot Care: Standards of Care in Diabetes-2025

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Randomised, multicentre, placebo-controlled trial of fenofibrate for treatment of diabetic macular oedema with economic evaluation (FORTE study): study protocol for a randomised control trial

INTRODUCTION

Diabetic macular oedema (DMO), a serious ocular complication of diabetic retinopathy (DR), is a leading cause of vision impairment worldwide. If left untreated or inadequately treated, DMO can lead to irreversible vision loss and blindness. Intravitreal injections using antivascular endothelial growth factor (anti-VEGF) and laser are the current standard of treatment for DMO. These treatments are costly and invasive and must be repeated over several years with a high service load. Fenofibrate has been shown to reduce the progression of DR. However, there is a lack of high-quality data on the effects of fenofibrate on established DMO. This study aims to evaluate the effectiveness of oral fenofibrate for the treatment of DMO.

METHODS AND ANALYSIS

This randomised double-blind, placebo-controlled trial recruited 204 patients with DMO across three different clinics in Sydney. Participants will be randomly allocated in a 1:1 ratio to intervention and control groups. The intervention group will receive oral fenofibrate (145 mg) taken once daily for 24 months, while the control group will receive placebo tablets taken once daily for 24 months. Standard care with anti-VEGF injections, focal lasers or observation will also be provided to all participants regardless of their group allocation. The primary outcome is the reduction in DMO measured using central macular subfield thickness (CSMT) on optical coherence tomography imaging at 24 months. Secondary outcomes at 24 months include the proportion of eyes with CSMT <250 µm, number of anti-VEGF injections, number of laser sessions needed, best-corrected visual acuity letter score gains, rates of adverse events, progression in DR lesions and changes in quality of life measures. Comparison between groups will be evaluated using analysis of variance. Multiple regression analyses adjusting for age, glycated haemoglobin, number of injections and other covariates will also be performed.

ETHICS AND DISSEMINATION

Ethics approval has been granted by the University of Sydney Human Ethics Committee (HREC-2019/892), and the trial has been registered with the Australia New Zealand Clinical Trials Registry (ACTRN12618000592246). The study adheres to the principles of the Helsinki Declaration and the National Health and Medical Research Council National Statement on Ethical Conduct in Human Research. Trial results will be disseminated to the public in de-identified form through publications in peer-reviewed journals.

TRIAL REGISTRY NAME

Australian New Zealand Clinical Trials Registry.

TRIAL REGISTRATION NUMBER

ACTRN12618000592246.

Diabetic retinopathy: A review on its pathophysiology and novel treatment modalities

Diabetes mellitus (DM) is a chronic metabolic non-communicable disease with the ability to cause serious microvascular and macrovascular complications throughout the body, including in the eye. Diabetic retinopathy (DR), present in one-third of patients with diabetes, is a vision-threatening complication caused by uncontrolled diabetes, which greatly affects the retinal blood vessels and the light-sensitive inner retina, eventually leading to blindness. Several epidemiological studies elucidate that DR can vary by age of onset, duration, types of diabetes, and ethnicity. Recent studies show that the pathogenesis of diabetic retinopathy has spread its roots beyond merely being the result of hyperglycemia. The complexity of its etiopathology and diagnosis makes therapeutic intervention challenging. This review throws light on the pathological processes behind DR, the cascade of events that follow it, as well as the available and emerging treatment options.

Intravitreal therapy for the management of diabetic retinopathy: A concise review

Diabetic retinopathy (DR) is a serious microvascular complication of diabetes mellitus and may result in irreversible visual loss. Laser treatment has been the gold standard treatment for diabetic macular edema and proliferative diabetic retinopathy for many years. Of late, intravitreal therapy has emerged as a cornerstone in the management of DR. Among the diverse pharmacotherapeutic options, anti-vascular endothelial growth factor agents have demonstrated remarkable efficacy by attenuating neovascularization and reducing macular edema, thus preserving visual acuity in DR patients.

Analysis of topical conjunctival microbiotic cultures in patients treated with intravitreal injections using antibiotic prophylaxis with 0.3% ofloxacin eye drops

BACKGROUND

Intravitreal injections, a relatively recent treatment in ophthalmology, is being adopted rapidly worldwide and becoming one of the most common therapies in the field. Numerous complications are associated with this treatment, ranging from minor inflammatory ailments to endophthalmitis. We analyzed the conjunctival flora of patients treated with intravitreal injections and topical antibiotics.

METHODS

The study was a longitudinal prospective analysis of cultures and antibiograms collected from patients who underwent intravitreal injections and topical antibiotics afterwards at the retina clinic in ABC's Medical University.

RESULTS

A total of 148 swabs obtained from 98 patients were cultured and underwent antibiotic sensitivity testing. All bacteria were sensitive to vancomycin, and with the exception of Escherichia coli samples, they were also sensitive to a third-generation cephalosporin (ceftriaxone-same class and generation as ceftazidime), both of which are important antibiotics for the treatment of endophthalmitis. The bacteria species were specifically coagulase-negative Staphylococcus sp. 92% of which was penicillin-resistant and 56.9% was resistant to ciprofloxacin, a second-generation fluoroquinolone. The culture results were similar to that described in the literature and showed the same higher prevalence of coagulase-negative Staphylococcus sp. and S. epidermidis. Regarding the antibiotic resistance profiles, vancomycin, a third-generation cephalosporin, and penicillin showed almost identical results to those reported previously. Regarding fluoroquinolones, the incidence of resistant coagulase-negative Staphylococcus sp. was lower than the findings worldwide, but the resistance rates found were: S. aureus (26.7%), S. epidermidis (61.3%), and Staphylococcus sp. (coagulase negative, 56.9%).

CONCLUSIONS

The current results showed that the typical conjunctival bacteria had higher resistance to fluoroquinolones (although they were not tested specifically to ofloxacin), suggesting a possible selection of resistant bacteria that should not be taken for granted in clinic. However, the same bacteria did not exhibit cross-resistance in the analysis of vancomycin and third-generation cephalosporins. This real-world, longitudinal, prospective study on conjunctival flora analyzed bacterial resistance profiles and contemporary antibiotic use, offering deeper insights into this subject.

Mitigation of AI adoption bias through an improved autonomous AI system for diabetic retinal disease

Where adopted, Autonomous artificial Intelligence (AI) for Diabetic Retinal Disease (DRD) resolves longstanding racial, ethnic, and socioeconomic disparities, but AI adoption bias persists. This preregistered trial determined sensitivity and specificity of a previously FDA authorized AI, improved to compensate for lower contrast and smaller imaged area of a widely adopted, lower cost, handheld fundus camera (RetinaVue700, Baxter Healthcare, Deerfield, IL) to identify DRD in participants with diabetes without known DRD, in primary care. In 626 participants (1252 eyes) 50.8% male, 45.7% Hispanic, 17.3% Black, DRD prevalence was 29.0%, all prespecified non-inferiority endpoints were met and no racial, ethnic or sex bias was identified, against a Wisconsin Reading Center level I prognostic standard using widefield stereoscopic photography and macular Optical Coherence Tomography. Results suggest this improved autonomous AI system can mitigate AI adoption bias, while preserving safety and efficacy, potentially contributing to rapid scaling of health access equity. ClinicalTrials.gov NCT05808699 (3/29/2023).

Biosimilar Candidate CT-P42 in Diabetic Macular Edema: 24-Week Results from a Randomized, Active-Controlled, Phase III Study

OBJECTIVE

To demonstrate the therapeutic similarity of CT-P42 compared with reference aflibercept (Eylea) in adult patients with diabetic macular edema (DME).

DESIGN

Randomized, active-controlled, double-masked, phase III clinical trial PARTICIPANTS: Patients with a diagnosis of either type 1 or 2 diabetes mellitus with DME involving the center of the macula.

METHODS

Patients were randomized (1:1) to receive either CT-P42 or reference aflibercept (2 mg/0.05 ml) by intravitreal injection every 4 weeks (5 doses), then every 8 weeks (4 doses), in the main study period. Results up to week 24 are reported herein.

MAIN OUTCOME MEASURES

The primary end point was mean change from baseline at week 8 in best-corrected visual acuity (BCVA) using the ETDRS chart. Equivalence between CT-P42 and reference aflibercept was to be concluded if the 2-sided 95% confidence interval (CI) (global assumptions) and 2-sided 90% CI (United States Food and Drug Administration [FDA] assumptions) for the treatment difference fell entirely within the equivalence margin of ±3 letters, as assessed in the full analysis set.

RESULTS

Overall, 348 patients were randomized (CT-P42: 173; reference aflibercept: 175). Best-corrected visual acuity improved from baseline to week 8 in both groups, with a least squares mean (standard error) improvement of 9.43 (0.798) and 8.85 (0.775) letters in the CT-P42 and reference aflibercept groups, respectively. The estimated between-group treatment difference was 0.58 letters, with the CIs within the predefined equivalence margin of ±3 letters (95% CI, -0.73 to 1.88 [global]; 90% CI, -0.52 to 1.67 [FDA]). Through week 24, other efficacy results for the 2 groups, in terms of change in BCVA and retinal central subfield thickness, as well as ETDRS Diabetic Retinopathy Severity Scale score, supported therapeutic similarity. Pharmacokinetics, usability, safety (including the proportions of patients experiencing ≥1 treatment-emergent adverse event [CT-P42: 50.3%; reference aflibercept: 53.7%]), and immunogenicity were also comparable between groups.

CONCLUSIONS

This study in patients with DME demonstrated equivalence between CT-P42 and reference aflibercept (2 mg/0.05 ml) in terms of efficacy, with similar pharmacokinetic, usability, safety, and immunogenicity profiles.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Anti-VEGF therapy for the long-term management of diabetic macular edema: a treat-to-target strategy based on macular morphology

In an aging population, the prevalence and burden of diabetes mellitus, diabetic retinopathy, and vision-threatening diabetic macular edema (DME) are only expected to rise around the world. Similarly to other complications of diabetes mellitus, DME requires long-term management. This article aims to review the current challenges associated with the long-term management of DME, opportunities to improve outcomes for patients, and to develop a treat-to-target strategy based on macular morphology. At present, intravitreal anti-vascular endothelial growth factor (VEGF) therapy is the standard of care for the management of DME; however, best-achievable vision outcomes with treatment are reliant on frequent injections and close monitoring, which are difficult to maintain in current clinical practice because of the burden this imposes on patients. Achieving and maintaining good vision with treatment are the most important factors for patients with DME. Landmark trials have shown that vision gains with anti-VEGF therapy are typically accompanied by anatomical improvements (e.g., reductions in retinal thickness); therefore, multimodal imaging measures of macular morphology are often used in patients with DME to guide real-world treatment decisions. We would like to propose a hypothetical treat-to-target algorithm to guide physicians on treatment strategies for the long-term management of DME. Alternative measures of retinal fluid (e.g., persistence, stability, location) may be stronger predictors of visual acuity in DME, although further research is required to confirm whether alternate quantifiable biomarkers such as subretinal fluid and intraretinal fluid volumes can be used as a biomarker of clinical improvement. Identifying novel biomarkers and treatments that target neuroinflammation and neurodegeneration, improving patient-physician communication around treatment adherence, and using treat-to-target measures may help to ensure that the long-term benefits of treatment are realized.

Impact of Aflibercept vs Dexamethasone Treatment on Epiretinal Membrane Formation in Eyes with Diabetic Macular Edema

INTRODUCTION

This study aimed to investigate the impact of aflibercept and dexamethasone (DEX) on the formation of epiretinal membrane (ERM) and their treatment outcomes in eyes with diabetic macular edema (DME).

METHODS

In this retrospective cohort study, medical records of 124 eyes from 429 patients diagnosed with DME were reviewed between June 2017 and June 2019. Patients were categorized into two groups: the aflibercept group (67 eyes) and the DEX group (57 eyes). The primary endpoint was the secondary ERM incidence following intravitreal treatments and its correlation across different medications. Secondary endpoints included longitudinal changes in best-corrected visual acuity (BCVA) and central macular thickness (CMT).

RESULTS

Over a 24-month follow-up, eyes treated with DEX had approximately a fourfold higher incidence of ERM development compared to aflibercept [hazard ratio (HR) = 3.97, p = 0.02]. These eyes also showed worse BCVA (p = 0.059) and increased CMT (p = 0.004), despite requiring fewer total injections (p = 0.000) in the survival analysis model. The cumulative probability of ERM formation was 13.7%. Additionally, DME eyes exhibited poor functional and anatomical outcomes after developing ERM, while age, A1c level, DR severity, initial BCVA and CMT, lens status, and previous laser treatment were not associated with an elevated incidence of ERM formation.

CONCLUSION

Intravitreal DEX implantation in DME eyes resulted in a higher incidence of secondary ERM formation compared to aflibercept over a 2-year period. The therapeutic efficacy for DME was diminished following ERM development, leading to worse anatomical outcomes. New therapeutic approaches should be explored to prevent ERM formation while maintaining both anatomical and functional outcomes in DME treatment.

Maculopathies: A Systematic Literature Review on Pathophysiology, Public Health, and Treatment

Macular degeneration (MD) is a pathological condition affecting the macula, an area located near the center of the retina. This disease affects individuals of all ages, both children and adults, causing severe visual impairment. Age-related macular degeneration (AMD) is the leading cause of visual loss in the older population while Stargardt disease (SD) is the most common hereditary maculopathy with an autosomal dominant pattern of inheritance. Current management involves anti-vascular endothelial growth factor intravitreal injections, visual aids, and other conservative prevention mechanisms that can only delay the inevitable progress of the disease. Macular dystrophies have an impact on both individuals and societies with psychological and financial implications, respectively. It is evident that vision impairment has a significant impact on patients' physical and mental well-being, and therefore it is important to improve current treatment modalities, develop stem cell therapies, and further novel treatments in order to provide a better prognosis and overall quality of life.

High Intraocular Concentration of Fibrinogen Regulates Retinal Function Via the ICAM-1 Pathway

Purpose

Diabetic retinopathy (DR) is a significant complication of diabetes mellitus that can lead to progressive visual impairment. This study aimed to elucidate the role of fibrinogen, a protein whose serum and intraocular concentrations are elevated in patients with diabetes and DR, in the pathogenesis of DR.

Methods

The changes in the protein levels of the neuronal marker tubulin-β3 (TUBB3) and retinal response induced by the intravitreal injections of 1× phosphate-buffered saline, 40 mg/mL of fibrinogen, and 40 mg/mL of fibrinogen in combination with anti-intracellular adhesion molecule-1 (ICAM-1) antibody in normal mice were observed using immunofluorescence, western blotting, and electroretinography.

Results

High concentrations of fibrinogen led to a decrease in the expression of TUBB3 in immunofluorescence and western blotting. The amplitudes of the positive scotopic threshold response and b-wave were notably reduced after the injection of fibrinogen, indicating potential damage to the retinal ganglion cells. The co-administration of anti-ICAM-1 antibody effectively mitigated these fibrinogen-induced changes, indicating that fibrinogen-induced damage is mediated via the ICAM-1 pathway.

Conclusions

The present study underscores the significance of elevated intraocular fibrinogen levels as a pathogenic factor in DR. Involvement of the fibrinogen/ICAM-1 pathway presents new avenues for therapeutic intervention, especially in patients with treatment-resistant conditions.

Optical coherence tomography angiography of the retina and choroid in systemic diseases

Optical coherence tomography angiography (OCTA) has transformed ocular vascular imaging, revealing microvascular changes linked to various systemic diseases. This review explores its applications in diabetes, hypertension, cardiovascular diseases, and neurodegenerative diseases. While OCTA provides a valuable window into the body's microvasculature, interpreting the findings can be complex. Additionally, challenges exist due to the relative non-specificity of its findings where changes observed in OCTA might not be unique to a specific disease, variations between OCTA machines, the lack of a standardized normative database for comparison, and potential image artifacts. Despite these limitations, OCTA holds immense potential for the future. The review highlights promising advancements like quantitative analysis of OCTA images, integration of artificial intelligence for faster and more accurate interpretation, and multi-modal imaging combining OCTA with other techniques for a more comprehensive characterization of the ocular vasculature. Furthermore, OCTA's potential future role in personalized medicine, enabling tailored treatment plans based on individual OCTA findings, community screening programs for early disease detection, and longitudinal studies tracking disease progression over time is also discussed. In conclusion, OCTA presents a significant opportunity to improve our understanding and management of systemic diseases. Addressing current limitations and pursuing these exciting future directions can solidify OCTA as an indispensable tool for diagnosis, monitoring disease progression, and potentially guiding treatment decisions across various systemic health conditions.

Unlocking the potential of signature-based drug repurposing for anticancer drug discovery

Cancer is the leading cause of death worldwide and is often associated with tumor relapse even after chemotherapeutics. This reveals malignancy is a complex process, and high-throughput omics strategies in recent years have contributed significantly in decoding the molecular mechanisms of these complex events in cancer. Further, the omics studies yield a large volume of cancer-specific molecular signatures that promote the discovery of cancer therapy drugs by a method termed signature-based drug repurposing. The drug repurposing method identifies new uses for approved drugs beyond their intended initial therapeutic use, and there are several approaches to it. In this review, we discuss signature-based drug repurposing in cancer, how cancer omics have revolutionized this method of drug discovery, and how one can use the cancer signature data for repurposed drug identification by providing a step-by-step procedural handout. This modern approach maximizes the use of existing therapeutic agents for cancer therapy or combination therapy to overcome chemotherapeutics resistance, making it a pragmatic and efficient alternative to traditional resource-intensive and time-consuming methods.

[Aflibercept in the clinical routine: the AURIGA study : The 24-month results of the German cohort of treatment-naïve patients with diabetic macular edema receiving intravitreal aflibercept]

BACKGROUND

AURIGA is the largest prospective real-world study to evaluate intravitreal aflibercept (IVT-AFL) treatment of diabetic macular edema (DME) and macular edema secondary to retinal vein occlusion. This article presents 24-month data from the German cohort of treatment-naïve patients with DME.

METHODS

Treatment-naïve patients (≥ 18 years) with DME were treated with IVT-AFL at the discretion of the physician in clinical practice. The primary endpoint was mean change in visual acuity (early treatment diabetic retinopathy, ETDRS, letters) at month 12 compared to baseline. Statistical analyses were descriptive.

RESULTS

The analysis included data from 150 DME patients (54.7% male). At months 6, 12 and 24, mean (95% confidence interval) visual acuity gains of 4.6 (2.6; 6.5), 4.0 (2.1; 6.5) and 5.0 (3.0; 6.9) letters from baseline (mean ±SD: 65.0 ± 15.3 letters) and reductions in retinal thickness of 86µm (109; 64µm), 70µm (94; 43µm) and 75µm (103; 47µm) from baseline (mean ±SD: 391 ± 132 µm), respectively, were achieved. At month 24, 54% of patients gained ≥ 5 letters and 22% ≥ 15 letters. Patients received a mean number of 5.0 ± 1.6 injections until month 6, 7.1 ± 3.2 until month 12 and 9.0 ± 5.3 until month 24, 68% of patients received ≥ 5 injections until month 6 and 56% ≥ 7 injections within the first year. The safety profile was consistent with previous studies.

DISCUSSION

In the German AURIGA cohort, treatment-naïve DME patients achieved a clinically relevant gain in visual acuity as well as reduction in central retinal thickness following IVT-AFL treatment in clinical practice. From month 6 onwards, improvements were maintained despite a low injection frequency over 24 months. In comparison with previous real-world studies, care of DME patients in clinical practice seems to have improved; however, there is still room for further improvement.

Management of treatment-naïve diabetic macular edema patients: Review of real-world clinical data

The high prevalence of Diabetic macular edema (DME) is a real global health problem. Its complex pathophysiology involves different pathways. Over the last decade, the introduction of intravitreal treatments has dramatically changed the management and prognosis of DME. Among the different treatment options, inhibitors of vascular endothelial growth factor (anti-VEGF) and intravitreal steroids implants represent the first-line therapy of DME. We conducted a review of electronic databases to compile the available evidence about the clinical management of DME in a clinical setting, with a special focus on treatment-naïve patients. Anti-VEGF therapies represent a valuable option for treating DME patients. However, many patients do not respond properly to this treatment and, due to its administration regimen, many patients receive suboptimal treatment in real life. Current evidence demonstrated that in patients with DME, DEX-i improved significantly both anatomic and visual outcomes. Besides eyes with insufficient anti-VEGF respond or recalcitrant DME cases, DEX-i can be effectively and safely used in treatment-naïve DME patients as first line therapy. DEX-i may be considered first line therapy in different clinical scenarios, such as DME eyes with a greater inflammatory component, patients with cardiovascular events, vitrectomized eyes, or those requiring cataract surgery. In conclusion, there are still many points for improvement pending in the clinical management of the patient with DME. Since DME treatment must follow a patient-tailored approach, selecting the best therapeutic approach for each patient requires a good understanding of the pathophysiology of DME.

Diabetic retinopathy: New concepts of screening, monitoring, and interventions

The science of diabetes care has progressed to provide a better understanding of the oxidative and inflammatory lesions and pathophysiology of the neurovascular unit within the retina (and brain) that occur early in diabetes, even prediabetes. Screening for retinal structural abnormalities, has traditionally been performed by fundus examination or color fundus photography; however, these imaging techniques detect the disease only when there are sufficient lesions, predominantly hemorrhagic, that are recognized to occur late in the disease process after significant neuronal apoptosis and atrophy, as well as microvascular occlusion with alterations in vision. Thus, interventions have been primarily oriented toward the later-detected stages, and clinical trials, while demonstrating a slowing of the disease progression, demonstrate minimal visual improvement and modest reduction in the continued loss over prolonged periods. Similarly, vision measurement utilizing charts detects only problems of visual function late, as the process begins most often parafoveally with increasing number and progressive expansion, including into the fovea. While visual acuity has long been used to define endpoints of visual function for such trials, current methods reviewed herein are found to be imprecise. We review improved methods of testing visual function and newer imaging techniques with the recommendation that these must be utilized to discover and evaluate the injury earlier in the disease process, even in the prediabetic state. This would allow earlier therapy with ocular as well as systemic pharmacologic treatments that lower the and neuro-inflammatory processes within eye and brain. This also may include newer, micropulsed laser therapy that, if applied during the earlier cascade, should result in improved and often normalized retinal function without the adverse treatment effects of standard photocoagulation therapy.

Efficacy of Faricimab versus Aflibercept in Diabetic Macular Edema in the 20/50 or Worse Vision Subgroup in Phase III YOSEMITE and RHINE Trials

PURPOSE

Diabetic Retinopathy Clinical Research Network Protocol T suggests that the response to treatment among patients with diabetic macular edema (DME) may vary depending on baseline best-corrected visual acuity (BCVA). We evaluated the efficacy of faricimab 6 mg versus aflibercept 2 mg over 2 years in patients with DME and baseline BCVA of 20/50 or worse enrolled in faricimab phase III trials.

DESIGN

YOSEMITE and RHINE were identically designed, multicenter, randomized, double-masked, active comparator-controlled, noninferiority trials.

PARTICIPANTS

Adults ≥18 years of age with center-involving macular edema secondary to type 1 or 2 diabetes.

METHODS

Patients were randomized to faricimab every 8 weeks (Q8W), faricimab personalized treat-and-extend (T&E) regimen, or aflibercept Q8W. Post hoc subgroup analyses were conducted using the intention-to-treat population with baseline BCVA of 20/50 or worse.

MAIN OUTCOME MEASURES

Changes in ETDRS BCVA and central subfield thickness (CST) from baseline to years 1 and 2 were compared between treatment arms using mixed-model repeated measures analyses.

RESULTS

In YOSEMITE and RHINE, respectively, 220 and 217 patients in the faricimab Q8W arm, 220 and 219 patients in the faricimab T&E arm, and 219 and 214 patients in the aflibercept Q8W arm showed baseline BCVA of 20/50 or worse. In both trials, mean change in ETDRS BCVA was comparable between treatments across trials at years 1 and 2. In YOSEMITE, adjusted mean change from baseline in CST (μm) at year 1 was greater with faricimab Q8W (-232.8; P < 0.0001) and faricimab T&E (-217.4; P = 0.0004) ) versus aflibercept Q8W (-190.4). In RHINE, this was faricimab Q8W (-214.2; P = 0.0006) and faricimab T&E (-206.6; P = 0.0116) versus aflibercept Q8W (-186.6). In both trials, change from baseline in CST at year 2 was greater with faricimab Q8W versus aflibercept. The median time to first CST of <325 μm and first absence of intraretinal fluid was shorter in the faricimab arms versus the aflibercept arm, with fewer injections on average.

CONCLUSIONS

In patients with DME and baseline ETDRS BCVA of 20/50 or worse, faricimab treatment resulted in comparable visual acuity, greater reduction in retinal thickness, and fewer injections compared with aflibercept.

FINANCIAL DISCLOSURE(S)

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Diabetic macular edema (DME): dissecting pathogenesis, prognostication, diagnostic modalities along with current and futuristic therapeutic insights

One of the most common health concerns disturbing people within working years globally is diabetes mellitus (DM). One well-known consequence of DM is vascular damage, which can manifest as macro- and microangiopathy affecting the ocular retina. Therefore, Diabetic macular edema (DME) is a major sight-threatening complication of diabetic retinopathy (DR) worldwide. It is the most prevalent cause of significant vision impairment in diabetic patients. Long-term vision loss can be avoided by following early DME treatment guidelines in everyday life. Hence, there are various therapeutic approaches for DME management. Currently, the first-line treatment for DME is anti-VEGF family drugs, such as ranibizumab, brolucizumab, bevacizumab, and aflibercept. Nevertheless, relapses of the disease, inadequate response, and resistance during anti-VEGF therapy are still seen because of the intricate pathophysiological foundation of the disease. Consequently, there is an excellent requirement for therapeutic approaches to advance and become better at controlling diseases more satisfactorily and require fewer treatments overall. We conducted a thorough literature search in the current review to present a comprehensive overview of the primary data about the current DME therapeutic agents. We also covered the novel advances in DME management and probable future treatments being investigated and developed. This review recommended that Large clinical trials should afford sufficient evidence to support these innovative treatment modalities.

Ophthalmic Use of Targeted Biologics in the Management of Intraocular Diseases: Current and Emerging Therapies

BACKGROUND

Monoclonal antibodies (mAbs) have demonstrated substantial potential in the treatment of intraocular diseases. This review aimed to comprehensively evaluate the applications, efficacy, and safety of mAbs in the management of intraocular conditions.

METHODS

A comprehensive literature search was conducted in major medical databases through July 2024. Relevant studies on monoclonal antibodies for intraocular diseases were included. Two independent researchers screened the literature, extracted data, and assessed study quality. Cost-effectiveness analyses were also reviewed.

RESULTS

Anti-vascular endothelial growth factor (VEGF) antibodies, such as bevacizumab, ranibizumab, and aflibercept, showed significant therapeutic effects in neovascular age-related macular degeneration (NVAMD), diabetic macular edema (DME), and retinal vein occlusion (RVO). Tumor necrosis factor-alpha (TNF-α) inhibitors demonstrated promising results in treating noninfectious uveitis. Complement system-targeted therapies like pegcetacoplan offered new options for geographic atrophy. Anti-VEGF antibodies showed potential in managing retinopathy of prematurity (ROP). However, challenges persist, including high costs, potential drug resistance, and limited long-term safety data in certain scenarios.

CONCLUSIONS

Monoclonal antibodies are vital for treating intraocular diseases, but continuous innovation and rigorous clinical evaluation are essential. Future research should focus on developing novel delivery systems, exploring combination therapies, conducting long-term follow-up studies, and investigating personalized treatment strategies to provide safer, more effective, and cost-effective therapeutic solutions.

Bruton's tyrosine kinase inhibition suppresses pathological retinal angiogenesis

BACKGROUND AND PURPOSE

Pathological retinal angiogenesis is a typical manifestation of vision-threatening ocular diseases. Many patients exhibit poor response or resistance to anti-vascular endothelial growth factor (VEGF) agents. Bruton's tyrosine kinase (BTK) controls the proliferation and function of immune cells. Therefore, we examined the anti-inflammatory and anti-angiogenic effects of BTK inhibition on retinal angiogenesis.

EXPERIMENTAL APPROACH

Retinal neovascularisation and vascular leakage in oxygen-induced retinopathy in C57/BL6J mice were assessed by whole-mount retinal immunofluorescence. PLX5622 was used to deplete microglia and Rag1-knockout mice were used to test the contribution of lymphocytes to the effects of BTK inhibition. The cytokines, activation markers, inflammatory and immune-regulatory activities of retinal microglia/macrophages were detected using qRT-PCR and immunofluorescence. NLRP3 was detected by western blotting, and the effects of BTK inhibition on the co-culture of microglia and human retinal microvascular endothelial cells (HRMECs) were examined.

KEY RESULTS

BTK inhibition suppressed pathological angiogenesis and vascular leakage, and significantly reduced retinal inflammation, which involved microglia/macrophages but not lymphocytes. BTK inhibition increased anti-inflammatory factors and reduced pro-inflammatory cytokines that resulted from NLRP3 inflammasome activation. BTK inhibition suppressed the inflammatory activity of microglia/macrophages, and acted synergistically with anti-VEGF without retinal toxicity. Moreover, the supernatant of microglia incubated with BTK-inhibitor reduced the proliferation, tube formation and sprouting of HRMECs.

CONCLUSION AND IMPLICATIONS

BTK inhibition suppressed retinal neovascularisation and vascular leakage by modulating the inflammatory activity of microglia and macrophages. Our study suggests BTK inhibition as a novel and promising approach for alleviating pathological retinal angiogenesis.

Identification and Activity Study of an Impurity Band Observed in the nrSDS-PAGE of Aflibercept

BACKGROUND

Aflibercept is a biopharmaceutical targeting vascular endothelial growth factor (VEGF) that has shown promise in the treatment of neovascular age-related macular degeneration (nAMD) and diabetic macular edema (DME) in adults. Quality control studies of aflibercept employing non-reduced SDS-PAGE (nrSDS-PAGE) have shown that a significant variant band (IM1) is consistently present below the main band. Considering the quality control strategy of biopharmaceuticals, structural elucidation and functional studies are required.

METHODS

In this study, the variant bands in nrSDS-PAGE were collected through electroelution and identified by peptide mass fingerprinting based on liquid chromatography-tandem MS (LC-MS/MS). This variant was expressed using knob-into-hole (KIH) design transient transfection for the detection of ligand affinity, binding activity and biological activity.

RESULTS

The variant band was formed by C-terminal truncation at position N99 of one chain in the aflibercept homodimer. Then, this variant was successfully expressed using KIH design transient transfection. The ligand affinity of the IM1 truncated variant was reduced by 18-fold, and neither binding activity nor biological activity were detected.

CONCLUSIONS

The efficacy of aflibercept is influenced by the loss of biological activity of the variant. Therefore, this study supports the development of a quality control strategy for aflibercept.

Predictive value of optical coherence tomography angiography in management of diabetic macular edema

BACKGROUND

Optical coherence tomography angiography (OCTA) is a relatively new extension of Optical coherence tomography (OCT) that generates non-invasive, depth-resolved images of the retinal microvasculature which allows for the detection of various features of diabetic retinopathy.

OBJECTIVES

This study aimed to detect biomarkers that may predict an early anatomical response to the treatment of diabetic macular edema (DME) with intravitreal ranibizumab (IVR) by means of OCTA.

PATIENTS AND METHODS

This prospective interventional study was undertaken on 111 eyes of 102 naïve participants who had diabetic macular edema; enrolled patients were evaluated by taking a complete ophthalmologic history, examination and investigations by use of a pre-designed checklist involving Optical Coherence Tomography Angiography.

RESULTS

Regarding the best corrected visual acuity (BCVA) the Mean ± SD was 0.704 ± 0.158 preoperatively and 0.305 ± 0.131 postoperatively in good responder patients; and was 0.661 ± 0.164 preoperatively and 0.54 ± 0.178 postoperatively in poor responders. The central macular thickness (CMT) was 436.22 ± 54.66 μm preoperatively and 308.12 ± 33.09 μm postoperatively in good responder patients; and was 387.74 ± 44.05 μm preoperatively and 372.09 ± 52.86 μm postoperatively in poor responders. By comparing the pre injection size of the foveal avascular zone area (FAZ-A) in both groups, it found that the mean ± SD of FAZ-A was 0.297 ± 0.038 mm in good responder patients compared to 0.407 ± 0.05 mm in non-responder patients. The preoperative superficial capillary plexus (SCP) foveal vascular density (VD) was 24.02 ± 3.01% in good responder patients versus 17.89 ± 3.19% um in poor responders. The preoperative SCP parafoveal VD was 43.06 ± 2.67% in good responder patients versus 37.96 ± 1.82% um in poor responders. The preoperative deep capillary plexus (DCP) foveal VD was 30.58 ± 2.89% in good responder patients versus 25.45 ± 3.14% in poor responders. The preoperative DCP parafoveal VD was 45.66 ± 2.21% in good responder patients versus 43.26 ± 2.35% um in poor responders, this was statistically significant.

CONCLUSION

OCTA offers an accurate measurement for VD in the macula as well as the FAZ-A which could be used to predict an early anatomical response of anti-VEGF treatment in DME.

Aflibercept Biosimilar MYL-1701P vs Reference Aflibercept in Diabetic Macular Edema: The INSIGHT Randomized Clinical Trial

Importance

Biosimilars may be lower-cost alternatives to originator biologic products, potentially offering expanded access or reduced economic burden, but have not been evaluated with aflibercept in diabetic macular edema (DME).

Objective

To compare efficacy and safety of MYL-1701P, an aflibercept biosimilar, with reference aflibercept (Eylea [Regeneron]) in DME.

Design, Setting, and Participants

This was a double-masked, randomized clinical trial that included participants at 77 centers across the US, Europe, Japan, and India. Included in the analysis were individuals 18 years and older with type 1 or type 2 diabetes with central DME and best-corrected visual acuity (BCVA) letter score of 73 to 38 in the study eye using an Early Treatment Diabetic Retinopathy Study (ETDRS) chart. Study data were analyzed from October to December 2021.

Interventions

Formulations of MYL-1701P (0.5-mg vial) or reference aflibercept every 4 weeks for 5 consecutive intravitreal injections, followed by every 8 weeks through week 52.

Main Outcomes and Measures

The primary outcome was the adjusted difference in least squares mean (SE) change from baseline BCVA letter score at week 8 with an equivalence margin of -3 to +3 letters. Secondary outcomes included change in central subfield thickness (CST), BCVA, number of injections over 52 weeks, incidence of adverse events (AEs), and antidrug antibodies (ADAs).

Results

A total of 355 participants (mean [SD] age, 62.2 [9.2] years; 216 male [60.8%]) were randomized to MYL-1701P (179 participants [50.4%]) and aflibercept (176 participants [49.6%]). At week 8, mean (SE) change in BCVA was 6.60 (0.55) letters vs 6.56 (0.55) letters in the MYL-1701P vs aflibercept groups. The adjusted mean difference of 0.04 letters (90% CI, -1.16 to 1.24 letters) met the primary outcome. At week 8, mean (SE) change in CST was -112 (7) μm vs -124 (7) μm in the MYL-1701P vs aflibercept groups (adjusted mean difference, 12 μm; 90% CI, -3 to 26 μm). The incidence of treatment-emergent AEs in the MYL-1701P and aflibercept arms were ocular (30.9% [55 of 178] vs 29.5% [52 of 176]), serious ocular (0.6% [1 of 178] vs 1.1% [2 of 176]), nonocular (65.2% [116 of 178] vs 65.3% [115 of 176]), and serious nonocular (16.9% [30 of 178] vs 11.9% [21 of 176]). The mean (SD) total number of injections was 8.4 (2.1) vs 8.7 (1.8) in the MYL-1701P vs aflibercept groups. The incidence of treatment-induced or treatment-boosted ADAs was 2.8% (5 of 177) vs 5.7% (10 of 176) in the MYL-1701P vs aflibercept arms.

Conclusions and Relevance

MYL-1701P demonstrated clinical equivalence in regard to efficacy, with comparable safety and immunogenicity, to reference aflibercept. These findings support use of MLY-1701P as an alternative to reference aflibercept.

Trial Registration

ClinicalTrials.gov Identifier: NCT03610646.

VEGF-A165a and angiopoietin-2 differently affect the barrier formed by retinal endothelial cells

Exposure to VEGF-A165a over several days leads to a persistent dysfunction of the very tight barrier formed by immortalized endothelial cells of the bovine retina (iBREC). Elevated permeability of the barrier is indicated by low cell index values determined by electric cell-substrate impedance measurements, by lower amounts of claudin-1, and by disruption of the homogenous and continuous staining of vascular endothelial cadherin at the plasma membrane. Because of findings that suggest modulation of VEGF-A's detrimental effects on the inner blood-retina barrier by the angiogenic growth factor angiopoietin-2, we investigated in more detail in vitro whether this growth factor indeed changes the stability of the barrier formed by retinal endothelial cells or modulates effects of VEGF-A. In view of the clinical relevance of anti-VEGF therapy, we also studied whether blocking VEGF-A-driven signaling is sufficient to prevent barrier dysfunction induced by a combination of both growth factors. Although angiopoietin-2 stimulated proliferation of iBREC, the formed barrier was not weakened at a concentration of 3 nM: Cell index values remained high and expression or subcellular localization of claudin-1 and vascular endothelial cadherin, respectively, were not affected. Angiopoietin-2 enhanced the changes induced by VEGF-A165a and this was more pronounced at lower concentrations of VEGF-A165a. Specific inhibition of the VEGF receptors with tivozanib as well as interfering with binding of VEGF-A to its receptors with bevacizumab prevented the detrimental effects of the growth factors; dual binding of angiopoietin-2 and VEGF-A by faricimab was marginally more efficient. Uptake of extracellular angiopoietin-2 by iBREC can be efficiently prevented by addition of faricimab which is also internalized by the cells. Exposure of the cells to faricimab over several days stabilized their barrier, confirming that inhibition of VEGF-A signaling is not harmful to this cell type. Taken together, our results confirm the dominant role of VEGF-A165a in processes resulting in increased permeability of retinal endothelial cells in which angiopoietin-2 might play a minor modulating role.

Short pulse grid and subthreshold micropulse laser (the sandwich grid) plus intravitreal ranibizumab for the treatment of diabetic macular edema

OBJECTIVE

To investigate the effects of two laser treatment procedures combined, short pulse grid laser (SP) and subthreshold micropulse laser (MP) (the sandwich grid [SWG] technique), plus intravitreal ranibizumab (IVR) on central subfield thickness (CSFT), best-corrected visual acuity (BCVA) and macular sensitivity in patients with diabetic macular edema (DME).

METHODS

Forty-five eyes (of 33 patients) with center-involving DME were treated with the SWG laser technique plus IVR and followed for 12 months. Laser treatment was performed at baseline: SP laser spots were placed in a grid pattern in the macular area (500 µm from the fovea) according to the extension of DME; subsequently, MP laser was delivered up to the edge of the fovea. MP laser re-treatment sessions could be performed every 3 months if DME was present and CSFT was ≥ 300 μm on SD-OCT. IVR injection was performed at baseline and repeated monthly if CSFT > 300µm. Preoperatively and monthly, ophthalmological examination was performed including measurements of BCVA, CSFT, and macular sensitivity.

RESULTS

One-year follow-up data is available for 37 eyes of 27 patients. Mean ± SE CSFT (µm) was 509.36 ± 25.14 and 325.76 ± 15.34 at baseline and 12 months, respectively. A significant reduction in mean CSFT was observed at all study visits compared to baseline (p < 0.001). Mean ± SE BCVA (logMAR) was 0.62 ± 0.04 and 0.45 ± 0.04 at baseline and 12 months, respectively. A significant improvement in mean BCVA was observed at all study visits compared to baseline (p < 0.001). Mean ± SE macular sensitivity (dB) was 17.85 ± 0.80 and improved to 19.05 ± 0.59 after one year of follow-up (p = 0.006). The mean number of IVR injections was 8.29 ± 0.63. The mean number of MP laser procedures including the initial SWG laser session was 3.67 ± 0.22. No ocular or systemic adverse effects were observed.

CONCLUSION

The SWG laser technique plus IVR was associated with significant improvement in macular edema, BCVA, and macular sensitivity in patients with center-involving DME.

CLINICAL TRIAL NUMBER (CAAE)

22969019.4.0000.5440.