Discussion
cataract, PDR, rheumatoid
CATARACT, PSORIATIC ARTHRITIS, RETINA, DIABETIC MACULAR EDEMA
In DRCR Retina Network Protocol AB, which compared initial treatment for VH due to PDR with intravitreal aflibercept versus vitrectomy with PRP, there was greater reduction in activity impairment over 24 weeks in the vitrectomy with PRP group compared with the aflibercept group. The mean change in work productivity loss from baseline over 24 weeks suggested a benefit favoring the vitrectomy group, but the difference was not statistically significant until after adjustment for baseline VA in the better-seeing eye. Vision-related quality of life is often sensitive to the VA of the better-seeing eye, which was also the case in Protocol AB.The mean baseline levels of activity impairment and work productivity loss among Protocol AB patients were similar to the levels seen in patients with rheumatoid or psoriatic arthritis and nearly twice as great as for patients that have PDR without visually-significant VH at baseline [In a post hoc analysis of Protocol AB, eyes with a baseline VA of 20/800 had greater VA improvement over 24 weeks when treated with vitrectomy compared with aflibercept, while there was no difference between groups among eyes with baseline VA of 20/32 to 20/160 [As discussed in prior publications, additional factors will affect the choice of treatment for VH from PDR. These include the cost of treatment, access to a surgical center, patient comorbidities, presence of concomitant diabetic macular edema, and the patient’s desire for rapid vision restoration, particularly for those whose affected eye is (or was) their better-seeing eye. Of note, these was no difference in the rate of cataract extraction between groups through 104 weeks [This study has limitations. First, the number of participants measured for work productivity loss was relatively small (87 vs 204 for activity impairment), which limits the power for detecting differences in these outcomes. Second, the Work Productivity and Activity Impairment Questionnaire does not measure whether the reason for not working (or no longer working if the participants was working at baseline) is vision related. Third, approximately 1 in 3 eyes from each group received the alternative treatment (aflibercept or vitrectomy with PRP) per protocol, which likely contributed to the similar outcomes at 104 weeks; however, this was per protocol, and the study was designed to mimic clinical care patterns to enhance applicability in practice. Fourth, because questionnaires were not administered between baseline and 4 weeks, the perioperative impacts of vitrectomy are not reflected in these data. Fifth, the clinical staff administering the questionnaire were not masked to the participant’s treatment assignment; however, staff were instructed to read the questions verbatim. Due to the randomized nature of the trial and high retention (95% through 24 weeks and 90% through 104 weeks) [In conclusion, participants with VH from PDR had less impairment when performing everyday activities over 24 weeks when treated initially with vitrectomy and PRP compared with intravitreal aflibercept. The trend was similar for work productivity loss but did not reach significance without further adjustment for VA in the better-seeing eye. By 104 weeks, the improvements were similar.