Macular oedema (MO) is a leading cause of visual impairment in patients with diabetic retinopathy. Whilst laser photocoagulation therapy has been the proven treatment for decades, studies over the last five years have also established a role for anti-VEGF agents in controlling this disease manifestation. Head-to-head studies are rare given the risk to market share companies face, and so this study is particularly illuminating as it pitted three anti-VEGF preparations directly against each other to evaluate their efficacy and safety in combating diabetic macular oedema. The authors recruited 660 adult patients in a large multicentre randomised, blinded trial and assigned them to have one of 2mg aflibercept, 1.25mg bevacizumab or 0.3mg ranibizumab as often as every four weeks based on a protocol. The outcome measure was visual acuity after one year. At the end of the study, the authors concluded that all three drugs were likely be equally safe though a post hoc analysis suggests that an observed higher rate of cardiovascular side-effects with ranibizumab (p=0.01) will need further evaluation. In terms of efficacy, the authors found that for patients with relatively little visual impairment all three drugs were about equally efficacious in improving vision. However, when the starting vision was worse (less than 6/18 or so) aflibercept treatment was significantly better (improving by 19 letters compared to 12 and 14 for its two rivals which were not 
statistically different from each other). So does this mean we should be treating all our CSMO patients with Eylea? Perhaps yes – for all patients required about an equal number of injections over the course of the year (around 10). However, the cost of aflibercept is much higher than for bevacizumab. So in an accompanying editorial the conclusion is drawn that bevacizumab should be recommended for those with better than about 6/18 vision, whilst aflibercept should be first line for those with a starting vision below this level. Given the lack of superiority over bevacizumab, as well as the potential safety concern raised, might we perhaps see a significant decrease in the cost of Lucentis in the near future? 

Aflibercept, bevacizumab or ranibizumab for diabetic macular edema.
The Diabetic Retinopathy Clinical Research Network.
2015; Epub ahead of print.
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Jonathan CP Roos

Harvard, Cambridge & Moorfields-trained Consultant Oculoplastic Surgeon and academic based in London at Publishes in the world’s leading medical journals and lectures internationally on aesthetics, eyelid diseases and thyroid eyes.

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