Effect of Intravitreal Aflibercept, Ranibizumab and Bevacizumab in Combination with Subthreshold Grid Laser on Diabetic Macular Edema

Abstract

Aims: To determine the efficacy of three Anti-Vascular Endothelial Growth Factors (Anti-VEGFs) with a combination of sub-threshold focal or modified grid laser.

Study Design: Observational study.

Duration and Settings of the Study: Eye Departments of Combined Military Hospital Multan and Bodla Eye Care Multan from July 2022 to June 2024.

Methods: The study was based on three different groups: group A (Bevacizumab), B (Ranibizumab), and C (Aflibercept) followed by sub- threshold focal or modified grid photocoagulation in 3-4 weeks. The sample size was 30, and patients were enrolled in the study by purposive convenient sampling. Intravitreal anti-VEGF was given after macular cube and raster Optical Coherence Tomography (OCT) (Optovue Avanti). Best Corrected Visual Acuity (BCVA) in LogMAR and Central Macular Thickness (CMT) were compared before and after the treatment.

Results: A total of 30 eyes of 30 participants were included in this study. The age range was 40 to 70 years. Bevacizumab did not result in a significant improvement in best-corrected visual acuity (mean change -0.04 LogMAR; p = 0.727). In contrast, significant visual acuity improvement was observed following ranibizumab (mean change -0.08 LogMAR; p = 0.002) and aflibercept therapy, with the greatest improvement seen in the aflibercept group (mean change -0.43 LogMAR; p < 0.001). All three anti-VEGF agents produced a significant reduction in central macular thickness, with mean decreases of 142 μm after bevacizumab (p < 0.001), 94 μm after ranibizumab (p = 0.001), and 170.8 μm following aflibercept treatment (p = 0.027).

Conclusion: Intravitreal anti-VEGF agents with subthreshold focal/grid laser therapy result in better outcomes in the treatment of DME. This combined approach may help reduce treatment burden while improving visual and anatomical results, highlighting laser as an effective adjunct to pharmacologic therapy.