Intravitreal ranibizumab for diabetic macular edema with prompt versus deferred laser treatment: three-year randomized trial results

Abstract

Objective: To report the 3-year follow-up results within a previously reported randomized trial evaluating prompt versus deferred (for ≥24 weeks) focal/grid laser treatment in eyes treated with intravitreal 0.5 mg ranibizumab for diabetic macular edema (DME).

Design: Multicenter, randomized clinical trial.

Participants: Three hundred sixty-one participants with visual acuity of 20/32 to 20/320 (approximate Snellen equivalent) and DME involving the fovea.

Methods: Ranibizumab every 4 weeks until no longer improving (with resumption if worsening) and random assignment to prompt or deferred (≥24 weeks) focal/grid laser treatment.

Main outcome measures: Best-corrected visual acuity and safety at the 156-week (3-year) visit.

Results: The estimated mean change in visual acuity letter score from baseline through the 3-year visit was 2.9 letters more (9.7 vs. 6.8 letters; mean difference, 2.9 letters; 95% confidence interval, 0.4-5.4 letters; P = 0.02) in the deferral group compared with the prompt laser treatment group. In the prompt laser treatment group and deferral group, respectively, the percentage of eyes with a ≥10-letter gain/loss was 42% and 56% (P = 0.02), whereas the respective percentage of eyes with a ≥10-letter gain/loss was 10% and 5% (P = 0.12). Up to the 3-year visit, the median numbers of injections were 12 and 15 in the prompt and deferral groups, respectively (P = 0.007), including 1 and 2 injections, respectively, from the 2-year up to the 3-year visit. At the 3-year visit, the percentages of eyes with central subfield thickness of 250 μm or more on time-domain optical coherence tomography were 36% in both groups (P = 0.90). In the deferral group, 54% did not receive laser treatment during the trial. Systemic adverse events seemed to be similar in the 2 groups.

Conclusions: These 3-year results suggest that focal/grid laser treatment at the initiation of intravitreal ranibizumab is no better, and possibly worse, for vision outcomes than deferring laser treatment for 24 weeks or more in eyes with DME involving the fovea and with vision impairment. Some of the observed differences in visual acuity at 3 years may be related to fewer cumulative ranibizumab injections during follow-up in the prompt laser treatment group. Follow-up through 5 years continues.

Figure 1. Mean Change in Visual Acuity at Follow-up Visits

Values that were ±30 letters were assigned a value of 30. Results were similar without truncation (data not shown). P value for difference in mean change in visual acuity from ranibizumab + prompt laser treatment (open triangle) at the 156-week study visit for ranibizumab + deferred laser treatment (closed square) = 0.02. Each visit week includes visits that are ±14 days, except the 52, 68, 84, 120, 136-week visits that are ±8 weeks, and the 104, 156-week visits that are ±16 weeks.

Figure 3. Mean Change in Optical Coherence Tomography Central Subfield Retinal Thickening at Follow-up Visits

P value for difference in mean change in optical coherence tomography (OCT) central subfield retinal thickness from ranibizumab + prompt laser treatment (open triangle) at the 156-week study visit for ranibizumab + deferred laser treatment (closed square) = 0.94. Each visit week includes visits that are ±14 days, except the 52, 68, 84, 120, 136-week visits that are ±8 weeks, and the 104, 156-week visits that are ±16 weeks.