Macaron Marie-Michele, Al Sabbakh Nader, Shami M Zaid, Akrobetu Dennis, Bourdakos Natalie E, Abdulsalam Fatma A M, Nakanishi Hayato, Than Christian A, Bakri Sophie J
St George's University of London, London, United Kingdom; University of Nicosia Medical School, University of Nicosia, 2417, Nicosia, Cyprus.
HCA Aventura Hospital and Medical Center of Miami, Miami, Florida.
Ophthalmol Retina. 2025 Feb;9(2):105-121. doi: 10.1016/j.oret.2024.08.004. Epub 2024 Aug 14.
To evaluate the efficacy and safety of anti-VEGF and panretinal photocoagulation (PRP) for the treatment of proliferative diabetic retinopathy (PDR). The outcomes examined are changes in best-corrected visual acuity (BCVA), neovascularization (NV), central macular thickness (CMT), and adverse outcomes.
Diabetic retinopathy is the leading cause of blindness in working-aged adults globally. At present, no consensus has been reached on the optimal choice for the treatment of PDR.
Cochrane, Embase, PubMed, Scopus, Web of Science, and CiNAHL were searched for articles from their inception to June 2023 according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis. The review was registered prospectively with PROSPERO (CRD42023437778). Tool data analysis was performed using RevMan software version 5.4 (Review Manager [RevMan] [computer program], The Cochrane Collaboration, 2020). Randomized control trials (RCTs) of PDR patients treated with anti-VEGF, PRP, or a combination were included. Risk of bias was assessed using the Rob2 assessment tool (revised tool for risk of bias in randomized trials), and certainty of evidence was assessed with the Grading Recommendations Assessment, Development and Evaluation (GRADE) approach.
Nineteen studies were included, with 1361 patients (n = 1788 eyes) treated for PDR with either anti-VEGF (n = 274), PRP (n = 482), or combination (n = 320). Our results show more favorable BCVA outcomes with anti-VEGF compared with PRP at 3 months (mean difference [MD] = 2.35 letters; 95% confidence interval [CI], 1.18-3.52; I = 0%) and 12 months follow-up (MD = 3.39 letters; 95% CI, 0.63-6.14; I = 26%). Combination treatment showed better BCVA outcomes compared with PRP at 12 months (MD = 4.06 letters; 95% CI, 0.26-7.86; I = 0%). Combination showed lower CMT at 3 months (MD = -33.10 μm; 95% CI, -40.12 to -26.08; I = 25%) and 6 months (MD = -34.28 μm; 95% CI, -55.59 to -12.97; I = 85%) compared with PRP, but CMT results were similar at 12 months. Complete regression of total NV (NVT) was more likely with anti-VEGF compared with PRP (odds ratio = 6.15; 95% CI, 1.39-27.15; I = 80%). Posttreatment vitreous hemorrhage, vitrectomy, and increased intraocular pressure events were similar between the anti-VEGF and combination groups compared with PRP; however, macular edema results favored the anti-VEGF over the PRP group. Using the GRADE assessment, BCVA evidence was rated to be of moderate certainty, whereas CMT and NVT evidence certainty was rated as very low.
Anti-VEGF and combination treatments could be regarded as alternative approaches to PRP alone in the management of PDR after engaging in a shared decision-making process based on patients' adherence, diabetic macular edema status, and preference. Limitations of this meta-analysis include the heterogeneity in participants' characteristics, treatment regimens, and outcome reporting between studies. Further RCTs should be conducted to compare the effectiveness of these treatments in the long term.
FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.
评估抗血管内皮生长因子（anti-VEGF）与全视网膜光凝（PRP）治疗增殖性糖尿病视网膜病变（PDR）的疗效和安全性。所检查的结果包括最佳矫正视力（BCVA）、新生血管形成（NV）、中心黄斑厚度（CMT）的变化以及不良结局。
糖尿病视网膜病变是全球劳动年龄成年人失明的主要原因。目前，对于PDR治疗的最佳选择尚未达成共识。
根据系统评价和Meta分析的首选报告项目，检索Cochrane、Embase、PubMed、Scopus、Web of Science和护理及健康领域累积索引数据库（CiNAHL）从建库至2023年6月的文章。该综述已在国际前瞻性系统综述注册库（PROSPERO，注册号CRD42023437778）进行前瞻性注册。使用RevMan软件5.4版（Review Manager [RevMan] [计算机程序]，Cochrane协作网，2020年）进行工具数据分析。纳入接受anti-VEGF、PRP或联合治疗的PDR患者的随机对照试验（RCT）。使用Rob2评估工具（随机试验偏倚风险修订工具）评估偏倚风险，并采用推荐分级的评估、制定与评价（GRADE）方法评估证据的确定性。
纳入19项研究，共1361例PDR患者（n = 1788只眼）接受了anti-VEGF治疗（n = 274）、PRP治疗（n = 482）或联合治疗（n = 320）。我们的结果显示，在3个月随访时（平均差值[MD] = 2.35字母；95%置信区间[CI]，1.18 - 3.52；I² = 0%）和12个月随访时（MD = 3.39字母；95% CI，0.63 - 6.14；I² = 26%），与PRP相比，anti-VEGF组的BCVA结果更优。在12个月时，联合治疗组的BCVA结果优于PRP组（MD = 4.06字母；95% CI，0.26 - 7.86；I² = 0%）。与PRP相比，联合治疗组在3个月时（MD = -33.10μm；95% CI，-40.12至-26.08；I² = 25%）和6个月时（MD = -34.28μm；95% CI，-55.59至-12.97；I² = 85%）的CMT更低，但在12个月时CMT结果相似。与PRP相比，anti-VEGF组总新生血管（NVT）完全消退的可能性更大（比值比 = 6.15；95% CI，1.39 - 27.15；I² = 80%）。与PRP相比，anti-VEGF组和联合治疗组治疗后玻璃体出血、玻璃体切除术和眼压升高事件相似；然而，黄斑水肿结果anti-VEGF组优于PRP组。使用GRADE评估，BCVA证据被评为中等确定性，而CMT和NVT证据确定性被评为非常低。
在基于患者依从性、糖尿病性黄斑水肿状态和偏好进行共同决策后，anti-VEGF和联合治疗可被视为单独PRP治疗PDR的替代方法。本Meta分析的局限性包括研究之间参与者特征、治疗方案和结局报告的异质性。应进行进一步的RCT以比较这些治疗的长期有效性。
专有或商业披露信息可在本文末尾的脚注和披露中找到。
