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  • Retina/Vitreous

    Review of: Progression to pars plana vitrectomy in patients with proliferative diabetic retinopathy

    Alsoudi A, Wai K, Koo E, et al. JAMA Ophthalmology, in press 2024

    A large-scale retrospective evaluation of patients with new-onset proliferative diabetic retinopathy (PDR) found greater risk of pars plana vitrectomy (PPV), vitreous hemorrhage (VH), and tractional retinal detachment (TRD) over 5 years of follow-up among those who underwent panretinal photocoagulation (PRP) monotherapy vs anti-VEGF monotherapy, though the incidences of each complication were relatively low overall.

    Study Design

    This retrospective cohort study used aggregated electronic health record (EHR) data of patients with new-onset PDR (January 2003–September 2023) to evaluate outcomes following treatment with either PRP monotherapy or anti-VEGF monotherapy. Patients were propensity-matched for age, gender, race, baseline hemoglobin A1c, body mass index, and use of systemic insulin or other injectable diabetic medications into 2 groups for comparison: a PRP monotherapy cohort and an anti-VEGF monotherapy cohort (N = 12,040). All patients had a minimum of 6 months of follow-up after treatment; patients treated with a combination of PRP and anti-VEGF injections were excluded. The main outcome measures were the incidences of VH, TRD, or PPV at 1, 3, and 5 years after initiating therapy.


    At 5 years, PRP monotherapy was associated with higher rates of TRD (relative risk [RR] 2.76), VH (RR 1.72), and PPV (RR 1.18) than anti-VEGF monotherapy. Overall, the incidence of PPV was relatively low in both cohorts, with 548 patients (9%) requiring PPV in the PRP monotherapy cohort vs 465 patients (8%) in the anti-VEGF monotherapy cohort. The mean number of injections given among the anti-VEGF monotherapy cohort was 3.8 injections at 1 year and 6.7 injections at 5 years.


    The study is limited by the retrospective nature of the report and reliance on accurate coding data from an EHR database. The study excluded patients who were lost to follow-up after initial treatment, a factor that may influence outcomes as prior studies have confirmed the importance of treatment compliance in patients treated with anti-VEGF monotherapy. Moreover, the study excluded patients who received a combination of PRP and anti-VEGF injections and cannot control for biases that may have influenced a physician's decision to proceed with PRP vs anti-VEGF monotherapy at the outset of treatment.

    Clinical Significance

    The current study identified a higher relative risk of VH, TRD, and need for PPV in patients treated with PRP monotherapy, mirroring the findings of the Diabetic Retinopathy Clinical Research Network ( Protocol S study, a prospective, randomized trial that first noted that patients treated with PRP monotherapy may be more likely to require PPV surgery than patients receiving anti-VEGF therapy.1 Additional studies will be helpful in further refining the risk of vision-threatening complications of PDR after PRP and anti-VEGF therapy, helping clinicians counsel patients and weigh the relative risk and benefits of each treatment modality.

    Financial Disclosures: Dr. M. Ali Khan discloses financial relationships with Allergan, Apellis Pharmaceuticals, Genentech (Consultant/Advisor); Regeneron Pharmaceuticals (Grant Support).


    1 Writing Committee for the Diabetic Retinopathy Clinical Research Network. JAMA. 2015;314:2137–2146.