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July 2017

Results of a Randomized Clinical Trial of Aflibercept vs Panretinal Photocoagulation for Proliferative Diabetic Retinopathy: Is It Time to Retire Your Laser?

Author Affiliations
  • 1Jaeb Center for Health Research, Tampa, Florida
JAMA Ophthalmol. 2017;135(7):685-686. doi:10.1001/jamaophthalmol.2017.1652

For decades, panretinal photocoagulation (PRP) treatment has been the standard treatment of proliferative diabetic retinopathy (PDR). In 2015, the Diabetic Retinopathy Clinical Research Network (DRCR.net) showed that a dosage of 0.5 mg of ranibizumab results in noninferior visual acuity at 2 years compared with PRP and also results in less visual field loss, better visual acuity over the course of 2 years, and fewer vitrectomies.1 Based on those findings, clinicians can choose antivascular endothelial growth factor (anti-VEGF) or PRP when treating PDR. On behalf of the CLARITY study group, Sivaprasad et al2 reported results from a randomized clinical trial of anti-VEGF compared with PRP. Study participants (n = 232) had PDR without diabetic macular edema and a visual acuity of 20/80 or better and were randomly allocated to receive treatment with 2.0-mg aflibercept or PRP. Approximately half of the eligible eyes had previous PRP at least 8 weeks before entering the study, but they had continued active neovascularization. Participants that received aflibercept were given a loading dose of 3 injections at 4-week increments. Starting at week 12, the injections were administered based on a clinician assessing neovascularization by a clinical examination and reviewing color photographs. Throughout 1 year, eyes received a mean (SD) of 4.4 (1.7) injections, meaning an average of 1.4 injections between weeks 12 and 52. Most of the eyes in the trial had a baseline visual acuity that was 20/40 or better (90%) and approximately 25% had high-risk PDR. At 1 year, visual acuity with aflibercept was not only noninferior to PRP at the prespecified noninferiority margin of 5 letters, but was also superior (mean difference, 3.9 letters; 95% CI, 2.3-5.6 letters; P  < .001). Fewer participants in the group treated with aflibercept (5%) lost 2 or more lines of vision compared with the group undergoing PRP (15%). Although outcomes were slightly worse for eyes with prior PRP, the treatment differences were similar to the full cohort. No eyes in the study developed endophtalmitis, retinal detachment, iris neovascularization, or neovascular glaucoma. The rates of Antiplatelet Trialists’ Collaboration events were 7% with aflibercept and 4% with PRP (P = .24)