The results of DRCR Retina Network Protocol W study, published in this issue of JAMA Ophthalmology, show that aflibercept resulted in a more than 3-fold reduction in the incidence of center-involved diabetic macular edema (CI-DME) and a more than 2-fold reduction in the incidence of proliferative diabetic retinopathy (PDR) of eyes with moderate to severe nonproliferative diabetic retinopathy (NPDR), while showing no difference in visual acuity between aflibercept-treated and sham groups (with aflibercept administered in both groups if CI-DME or high-risk PDR developed) at 2 years.1 Therefore, should we offer prophylactic treatment with aflibercept to similar patients? Based on the Protocol W results, the natural history of NPDR progression to PDR and CI-DME, and the known risks and benefits of prophylactic aflibercept, my answer is yes. Patients with severe NPDR face the highest risk of progression to PDR, with or without DME. For this group, PDR develops in 14.6% of eyes at 1 year and 39.5% at 3 years.2 In eyes with very severe NPDR, the rates increase to 45% of eyes at 1 year and 64.9% at 3 years.2 Unfortunately, it is impossible to know specifically which of the eyes will progress and which will remain stable. Hence, preventive therapy entails unnecessary treatment of some eyes that would otherwise not progress. Thus, it is imperative to select the group of eyes with the highest risk for progression.
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Lim JI. Prevention of Severe Nonproliferative Diabetic Retinopathy Progression With More at Stake Than Visual Acuity. JAMA Ophthalmol. 2021;139(7):714–716. doi:10.1001/jamaophthalmol.2021.0625
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