Five-Year Outcomes of Panretinal Photocoagulation vs Intravitreous Ranibizumab for Proliferative Diabetic Retinopathy: A Randomized Clinical Trial | Diabetic Retinopathy | JAMA Ophthalmology | JAMA Network
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Original Investigation
July 24, 2018

Five-Year Outcomes of Panretinal Photocoagulation vs Intravitreous Ranibizumab for Proliferative Diabetic Retinopathy: A Randomized Clinical Trial

Author Affiliations
  • 1Carolina Retina Center PA, Columbia, South Carolina
  • 2Jaeb Center for Health Research, Tampa, Florida
  • 3Joslin Diabetes Center, Beetham Eye Institute, Harvard Department of Ophthalmology, Boston, Massachusetts
  • 4CME Editor, JAMA Ophthalmology
  • 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, PA, Baltimore, Maryland
  • 10Ophthalmic Research Consultants, LLC, Waxhaw, North Carolina
  • 11Deputy Editor, Opinion, JAMA Ophthalmology
  • 12Kellogg Eye Center, University of Michigan, Ann Arbor
  • 13Feinberg School of Medicine, Northwestern University, Chicago, Illinois
  • 14Cole Eye Institute, Cleveland Clinic, Cleveland, Ohio
  • 15Deputy Editor, JAMA Ophthalmology
JAMA Ophthalmol. 2018;136(10):1138-1148. doi:10.1001/jamaophthalmol.2018.3255
Key Points

Question  What is the comparative efficacy and safety of intravitreous ranibizumab vs panretinal photocoagulation over 5 years for treatment of patients with proliferative diabetic retinopathy?

Findings  In this randomized clinical trial of 305 participants, although loss to follow-up was relatively high, visual acuity in most study eyes that completed follow-up was very good at 5 years, consistent with 2-year results. Severe vision loss or serious proliferative diabetic retinopathy complications were uncommon in either group; the ranibizumab group had lower rates of developing vision-impairing diabetic macular edema.

Meaning  These findings support either ranibizumab or panretinal photocoagulation as viable treatments for proliferative diabetic retinopathy; patient-specific factors, including anticipated visit compliance, cost, and frequency of visits, should be considered when choosing a treatment for patients with proliferative diabetic retinopathy.

Abstract

Importance  Ranibizumab is a viable treatment option for eyes with proliferative diabetic retinopathy (PDR) through 2 years. However, longer-term results are needed.

Objective  To evaluate efficacy and safety of 0.5-mg intravitreous ranibizumab vs panretinal photocoagulation (PRP) over 5 years for PDR.

Design, Setting, and Participants  Diabetic Retinopathy Clinical Research Network multicenter randomized clinical trial evaluated 394 study eyes with PDR enrolled February through December 2012. Analysis began in January 2018.

Interventions  Eyes were randomly assigned to receive intravitreous ranibizumab (n = 191) or PRP (n = 203). Frequency of ranibizumab was based on a protocol-specified retreatment algorithm. Diabetic macular edema could be managed with ranibizumab in either group.

Main Outcomes and Measures  Mean change in visual acuity (intention-to-treat analysis) was the main outcome. Secondary outcomes included peripheral visual field loss, development of vision-impairing diabetic macular edema, and ocular and systemic safety.

Results  The 5-year visit was completed by 184 of 277 participants (66% excluding deaths). Of 305 enrolled participants, the mean (SD) age was 52 (12) years, 135 (44%) were women, and 160 (52%) were white. For the ranibizumab and PRP groups, the mean (SD) number of injections over 5 years was 19.2 (10.9) and 5.4 (7.9), respectively; the mean (SD) change in visual acuity letter score was 3.1 (14.3) and 3.0 (10.5) letters, respectively (adjusted difference, 0.6; 95% CI, −2.3 to 3.5; P = .68); the mean visual acuity was 20/25 (approximate Snellen equivalent) in both groups at 5 years. The mean (SD) change in cumulative visual field total point score was −330 (645) vs −527 (635) dB in the ranibizumab (n = 41) and PRP (n = 38) groups, respectively (adjusted difference, 208 dB; 95% CI, 9-408). Vision-impairing diabetic macular edema developed in 27 and 53 eyes in the ranibizumab and PRP groups, respectively (cumulative probabilities: 22% vs 38%; hazard ratio, 0.4; 95% CI, 0.3-0.7). No statistically significant differences between groups in major systemic adverse event rates were identified.

Conclusions and Relevance  Although loss to follow-up was relatively high, visual acuity in most study eyes that completed follow-up was very good at 5 years and was similar in both groups. Severe vision loss or serious PDR complications were uncommon with PRP or ranibizumab; however, the ranibizumab group had lower rates of developing vision-impairing diabetic macular edema and less visual field loss. Patient-specific factors, including anticipated visit compliance, cost, and frequency of visits, should be considered when choosing treatment for patients with PDR. These findings support either anti–vascular endothelial growth factor therapy or PRP as viable treatments for patients with PDR.

Trial Registration  ClinicalTrials.gov Identifier: NCT01489189

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