Vishal B. Swaminathan, MD
Mayo Clinic, Rochester, MN
Dr. Neil M. Bressler was invited to speak at this year’s ASRS 2025 meeting in Long Beach, CA. He discussed “Underappreciated or Overemphasized Management Techniques for Diabetic Retinopathy.”
Dr. Bressler highlighted four underappreciated management strategies and overemphasized metrics in diabetic retinopathy care.
- Anti-VEGF monotherapy without PRP in eyes with both proliferative DR and DME with vision loss.
- Durability of aflibercept 2 mg.
- Caution when overemphasizing OCT CST outcomes.
- Peripheral visual field loss in severe NPDR.
Anti-VEGF Monotherapy without PRP in PDR + DME
In Protocol S, 25% of participants had both proliferative diabetic retinopathy and center-involving DME with vision loss. Those treated with ranibizumab monotherapy maintained better visual acuity over 2 years (via area-under-the-curve analysis) and had less peripheral visual field loss than those receiving PRP in combination with ranibizumab, despite needing more injections. This suggests monotherapy can preserve both central and peripheral vision in these cases.
Durability of Aflibercept 2 mg
Dr. Bressler also reminded us that in the seminal DRCR Protocol T trial, eyes with baseline VA 20/50 or worse gained more vision with aflibercept than with other anti-VEGF agents ranibizumab and bevacizumab at the end of the first year. In year 2, 20% of aflibercept 2 mg patients required 1 or fewer injections and 36% needed ≤3 injections, showing meaningful durability. No identical-regimen head-to-head trials exist comparing 2 mg aflibercept with aflibercept 8 mg or faricimab, so relative durability at present remains unknown.
Overemphasis on OCT CST Changes
In the YOSEMITE and RHINE clinical trials, faricimab achieved greater early CST reductions than aflibercept 2 mg, but VA gains were the same. Similarly, in Protocol T, aflibercept sometimes reduced CST less than ranibizumab or bevacizumab, yet VA outcomes were equivalent. CST change is useful for guiding retreatment but is not inherently predictive of functional benefit.
Peripheral visual field loss in severe NPDR
In a multi-center study soon to be presented from Wilmer Eye Institute, severe NPDR patients had substantial visual field loss on 30-2 or 60-4 testing, even before developing PDR. Greater baseline field loss correlated with worse diabetic retinopathy outcomes across all measured endpoints, highlighting the potential value of incorporating formal visual field testing earlier in disease management.
Overall, Dr. Bressler emphasized how rethinking diabetic retinopathy management with evidence‑based insights with attention to what is relevant and important for the patient can help preserve both central and peripheral vision while reducing unnecessary treatment.