Determining the Superiority of Vitrectomy vs Aflibercept for Treating Dense Diabetic Vitreous Hemorrhage: A Systematic Review and Meta-Analysis of Randomized Clinical Trials

Abstract

This review aimed to systematically compare the efficacy and safety of intravitreal aflibercept (IVA) and vitrectomy for treating severe vitreous hemorrhage (VH) secondary to proliferative diabetic retinopathy (PDR). The review was conducted in accordance with PRISMA guidelines. A search strategy, including the MEDLINE, Embase, Cochrane Central Register of Controlled Trials, and US National Library of Medicine databases, was developed to identify randomized controlled trials (RCTs) that compared vitrectomy and IVA for managing VH due to PDR (participant age ≥ 18 years). The primary outcome measure was the difference in the mean visual acuity between the two treatment groups at 1, 6, and 24 months. Outcome measures included clearance of VH (in weeks), the incidence of recurrent VH, and the rate of complications. The studies were evaluated using the Cochrane Bias (ROB) tool. We identified 774 articles; six articles met the inclusion criteria, and two were ultimately included (n = 239 eyes). With or without PRP, IVA injections and vitrectomy were performed in 117 and 122 eyes, respectively. The mean BCVA at one month was significantly better in the vitrectomy group (MD=0.22, CI:0.10–0.34, p=0.0003), but no difference was found at six months (MD=0.04, CI: −0.04–0.12, p=0.356). The incidence of recurrent VH was significantly higher in the IVA group (OR=5.05, CI:2.71–9.42, p<0.0001). The probability of recurrent VH was five times greater in the IVA group than that in the vitrectomy group. There were no significant differences in the overall proportions of intra- or postoperative complications (OR=0.64, CI: 0.09–4.85, p=0.669). None of the studies had a low ROB in any of the seven domains. We conclude that IVA can be considered a viable treatment modality for diabetic VH in patients with a good follow-up. Vitrectomy initially provides better visual effect, faster VH recovery, and lower VH recurrence than IVA injections.

Keywords:

• aflibercept
• anti-VEGF
• intravitreal injection
• proliferative diabetic retinopathy
• vitrectomy

Abbreviations

AMD, age-related macular degeneration; BCVA, best-corrected visual acuity; CI, confidence interval; DME, diabetic macular edema; DR, diabetic retinopathy; DRCR, Diabetic Retinopathy Clinical Research; IVA, intravitreal aflibercept; LogMAR, logarithm of the minimum angle of resolution; MD, median deviation; PRP, panretinal photocoagulation; PDR, proliferative diabetic retinopathy; PICO, Population, Intervention, Comparator, Outcomes; OR, odds ratio; PPV, pars plana vitrectomy; PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analysis; RCTs, randomized controlled trials; RD, retinal detachment; ROB, Risk of Bias; VEGF, vascular endothelial growth factor; TRD, tractional retinal detachment; VH; vitreous hemorrhage.

Summary Statement

The management of vitreous hemorrhage in proliferative diabetic retinopathy is difficult because of its recurrence and poor visual outcomes. This systematic review compared the safety and efficacy of intravitreal aflibercept versus vitrectomy for the treatment of this condition by synthesizing evidence on the safety of the two different treatment modalities.

Data Sharing Statement

The datasets used in this study are included in the main article. Figures from this study may be released via a written application to the Photographic Laboratory and Clinical Archives at Oftalmologia Integral ABC, Medical and Surgical Assistance Institution (Nonprofit Organization), Av. Paseo de las Palmas 735 suite 303, Lomas de Chapultepec, Mexico City 11000, Mexico and the corresponding author upon request.

Ethics Approval and Consent to Participate

This study adhered to the tenets of the Declaration of Helsinki and received full approval from the appropriate research ethics committee, institutional review committee, and institutional teaching department (the institutions did not provide reference numbers for systematic reviews and meta-analyses).

Institutional Review Board Statement

This study was conducted in the Retina Department of the Oftalmologia Integral ABC Institution in Mexico City, Mexico. The Institutional Review Board approved the study’s institutional guidelines. No reference numbers were provided for the systematic review and meta-analysis.

Acknowledgments

We express our deep appreciation to the technical staff of the Retina Department of Oftalmologia Integral ABC (Nonprofit Medical and Surgical Organization) affiliated with The Postgraduate Division Studies at the National Autonomous University of Mexico. Mexico City, Mexico

Author Contributions

All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis, and interpretation, or in all these areas, took part in drafting, revising, or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

Disclosure

The authors declare no conflicts of interest.