Visual acuity outcomes and anti-VEGF therapy intensity in diabetic macular oedema: a real-world analysis of 28 658 patient eyes

Abstract

Background/aim: To assess visual acuity (VA) outcomes and antivascular endothelial growth factor (anti-VEGF) treatment intensity in diabetic macular oedema (DMO).

Methods: Retrospective analysis was performed in treatment-naïve patients with DMO from 2013 to 2018 using a database of aggregated de-identified electronic medical records (Vestrum Health).

Results: At 1 year, 28 658 patient eyes underwent a mean of 6.4 anti-VEGF injections, gaining a mean of +4.2 letters (95% confidence interval for mean gain: +4.0 to +4.5 letters, p<0.001). When stratified by anti-VEGF medication and by years 2013-2018, no clinically meaningful differences in injection frequency or 1-year VA change resulted. At 1 year, 50% of eyes received ≤6 injections, while <20% received 10-13 injections, representing monthly treatment. Mean letters gained at 1 year generally showed a linear relationship with mean number of anti-VEGF injections, beyond two injections. Eyes with good baseline VA (≥20/40) generally were at risk of VA loss at 1 year; those with moderately severe baseline impairment (20/70 to 20/200) who received ≥10 injections improved by a mean of +10.3 letters.

Conclusion: In clinical practice, patients with DMO undergo fewer anti-VEGF injections and exhibit worse visual gains compared with patients in randomised clinical trials. Visual outcomes correlate with treatment intensity at 1 year, with ceiling effects related to baseline VA.

Keywords: macula; retina; treatment medical.

Figure 1

(A) Histogram showing the distribution of diabetic macular oedema (DMO) patient eyes stratified by number of antivascular endothelial growth factor (anti-VEGF) injections received in the first year of treatment. The median number of injections/eye in the first year of treatment was 6. The distribution is skewed towards the lower range, with 50% of patient eyes receiving ≤6 injections and <20% of patient eyes receiving 10–13 injections, representing monthly treatment. (B) Graph showing change in visual acuity (VA) versus anti-VEGF injections administered to all DMO patient eyes in the first year of treatment. The 95% CIs are included. At 1 year, mean letters gained showed a linear relationship with number of anti-VEGF injections, beyond 2 injections. (C) Graph showing the mean VA change over 1 year, stratified by both anti-VEGF injection frequency and baseline VA. Mean 1-year VA change tended to increase in patient eyes with both increased anti-VEGF injection frequency and decreased baseline VA. There were ceiling effects related to baseline VA. Patient eyes with baseline VA of 20/40 or better generally were at risk of VA loss at 1 year, except for those who received ≥10 injections. However, these patient eyes also showed better final VA compared with those starting with worse baseline VA.