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Original Investigation
February 2016

Association of Baseline Visual Acuity and Retinal Thickness With 1-Year Efficacy of Aflibercept, Bevacizumab, and Ranibizumab for Diabetic Macular Edema

Author Affiliations
  • 1Palmetto Retina Center, West Columbia, South Carolina
  • 2Jaeb Center for Health Research, Tampa, Florida
  • 3Feinberg School of Medicine, Northwestern University, Chicago, Illinois
  • 4Beetham Eye Institute, Joslin Diabetes Center, Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts
  • 5Charlotte Eye, Ear, Nose and Throat Associates, PA, Charlotte, North Carolina
  • 6Paducah Retinal Center, Paducah, Kentucky
  • 7Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
  • 8Editor, JAMA Ophthalmology
  • 9Elman Retina Group, Baltimore, Maryland
  • 10National Eye Institute, National Institutes of Health, Bethesda, Maryland
  • 11Florida Retina Consultants, Winter Haven
  • 12California Retina Consultants, Santa Barbara
JAMA Ophthalmol. 2016;134(2):127-134. doi:10.1001/jamaophthalmol.2015.4599

Importance  Comparisons of the relative effect of 3 anti–vascular endothelial growth factor agents to treat diabetic macular edema warrant further assessment.

Objective  To provide additional outcomes from a randomized trial evaluating 3 anti–vascular endothelial growth factor agents for diabetic macular edema within subgroups based on baseline visual acuity (VA) and central subfield thickness (CST) as evaluated on optical coherence tomography.

Design, Setting, and Participants  Post hoc exploratory analyses were conducted of randomized trial data on 660 adults with diabetic macular edema and decreased VA (Snellen equivalent, approximately 20/32 to 20/320). The original study was conducted between August 22, 2012, and August 28, 2013. Analysis was conducted from January 7 to June 2, 2015.

Interventions  Repeated 0.05-mL intravitreous injections of 2.0 mg of aflibercept (224 eyes), 1.25 mg of bevacizumab (218 eyes), or 0.3 mg of ranibizumab (218 eyes) as needed per protocol.

Main Outcomes and Measures  One-year VA and CST outcomes within prespecified subgroups based on both baseline VA and CST thresholds, defined as worse (20/50 or worse) or better (20/32 to 20/40) VA and thicker (≥400 µm) or thinner (250 to 399 µm) CST.

Results  In the subgroup with worse baseline VA (n = 305), irrespective of baseline CST, aflibercept showed greater improvement than bevacizumab or ranibizumab for several VA outcomes. In the subgroup with better VA and thinner CST at baseline (61-73 eyes across 3 treatment groups), VA outcomes showed little difference between groups; mean change was +7.2, +8.4, and +7.6 letters in the aflibercept, bevacizumab, and ranibizumab groups, respectively. However, in the subgroup with better VA and thicker CST at baseline (31-43 eyes), there was a suggestion of worse VA outcomes in the bevacizumab group; mean change from baseline to 1 year was +9.5, +5.4, and +9.5 letters in the aflibercept, bevacizumab, and ranibizumab groups, respectively, and VA letter score was greater than 84 (approximately 20/20) in 21 of 33 (64%), 7 of 31 (23%), and 21 of 43 (49%) eyes, respectively. The adjusted differences and 95% CIs were 39% (17% to 60%) for aflibercept vs bevacizumab, 25% (5% to 46%) for ranibizumab vs bevacizumab, and 13% (–8% to 35%) for aflibercept vs ranibizumab.

Conclusions and Relevance  These post hoc secondary findings suggest that for eyes with better initial VA and thicker CST, some VA outcomes may be worse in the bevacizumab group than in the aflibercept and ranibizumab groups. Given the exploratory nature of these analyses and the small sample size within subgroups, caution is suggested when using the data to guide treatment considerations for patients.

Trial Registration  clinicaltrials.gov Identifier: NCT01627249.