Anti-VEGF Treatment for PDR Did Not Increase Odds of Tractional Retinal Detachment

Brian L. VanderBeek, MD, MPH, MSCE

Intravitreal anti-vascular endothelial growth factor (VEGF) injection-only treatment in patients with proliferative diabetic retinopathy (PDR) was associated with a lower likelihood of tractional retinal detachment (TRD) compared with patients who received laser treatment only.

Meanwhile, research from the case-control analysis suggested a combined treatment of anti-VEGF injection and panretinal photocoagulation (PRP) were associated with a higher likelihood of TRD compared with only laser treatment.

“Thus, these findings resemble common practice patterns that use multiple treatment modalities to quell neovascularization and complications of proliferative disease and do not represent a clear increased risk from any single treatment type,” wrote study author Brian L. VanderBeek, MD, MPH, MSCE, Scheie Eye Institute, Department of Ophthalmology, University of Pennsylvania Perelman School of Medicine.

Current management options for PDR include intravitreal anti-VEGF medications and panretinal photocoagulation (PRP), but their association with TRD remains unclear, according to the investigator team. There is controversy on whether the use of anti-VEGFs as a singular treatment leads to adverse outcomes due to their time-limited effect. In fact, it is important to note when viewed within the context of the high percentage of patients with PDR who have prolonged periods of loss to follow-up (LTFU).

VanderBeek and colleagues examined whether different treatment types of a 6-month or longer LTFU is associated with TRD in a nested case-control study, including data of patients with PDR from January 2000 to June 2021 from a claims database. Individuals who progressed to TRD were matched to non-TRD controls up to a 5:1 ratio. Exclusion criteria included 2 or fewer years in the plan, age younger than 18 years, a history of nondiabetic retinopathy, and previous retinal detachment.

Two primary exposures of interest were identified by investigators. The first was PDR treatment history, categorized into anti-VEGF injection only, laser only, both or neither. The second exposure was individuals who had a prolonged period of LTFU, defined as having a 6-month or longer period in which they received no eye care.

Based on inclusion and exclusion criteria, the study included a total of 214 patients (mean age, 55.6 years; 115 female [53.7%]; 99 male [46.3%]) with PDR and TRD. This population was matched to 978 controls (mean age, 65.6 years; 507 female [51.8%]) with only PDR.

Of the population with TRD, 69 (32.2%) patients were treated with laser only, 17 (7.9%) were treated with injection only, 39 (18.2%) were treated for both, and 89 (41.6%) had no prior treatment. Moreover, among patients in the PDR-only group, 207 (21.2%) received laser only, 83 (8.5%) received injection only, 57 (5.8%) received both, and 631 (64.5%) received no treatment.

Following the adjusted analysis, investigators reported no differences in the odds of TRD for patients who received only injection, compared with patients who received only laser (adjusted odds ratio [aOR], 0.56; 95% CI, 0.27 - 1.14; P <.001 for treatment category).

Those who received both treatments had higher odds of TRD compared with laser only (aOR, 2.33; 95% CI, 1.21 - 4.48) and patients who had no treatment had lower odds of TRD (aOR, 0.46; 95% CI, 0.29 - 0.71).

In the cases of TRD, 107 (50.0%) had a period of LTFU for 6 months or longer compared with 602 patients (61.6%) in the PDR-only cohort. Investigators added that after adjustments for all covariates, no difference in the odds of TRD were seen between those being LTFU for 6 months or longer and those not LTFU (aOR, 0.72; 95% CI, 0.49 - 1.07; P <.11).

“As with other disease states, the association between LTFU and outcomes for PDR is likely nuanced with the truth of the importance of visit adherence in PDR falling somewhere between the 2 opposite ends of the spectrum: a prolonged period without care will definitely lead to a poor outcome vs visit adherence has no influence on PDR outcomes,” VanderBeek wrote. “Where reality falls between these extremes is still to be understood.”

The study, “Association of Treatment Type and Loss to Follow-up With Tractional Retinal Detachment in Proliferative Diabetic Retinopathy,” was published in JAMA Ophthalmology.