TY - JOUR T1 - Frequency and timing of antivascular endothelial growth factor treatment for eyes with centre-involved diabetic macular oedema and good vision: Protocol V results in context JF - BMJ Open Ophthalmology JO - BMJ Open Ophth DO - 10.1136/bmjophth-2022-000983 VL - 7 IS - 1 SP - e000983 AU - Diana V Do AU - Hadi Moini AU - Charles C Wykoff Y1 - 2022/08/01 UR - http://bmjophth.bmj.com/content/7/1/e000983.abstract N2 - Limited prospective data exist to inform management of eyes with centre-involved diabetic macular oedema (CI-DMO) and good visual acuity (VA). Results of the randomised, single-masked, three-arm Diabetic Retinopathy Clinical Research Network Protocol V trial led some to conclude a management strategy of clinical observation with initiation of intravitreal antivascular endothelial growth factor (anti-VEGF) on visual deterioration is appropriate.1 This interpretation is primarily based on the absence of a statistically significant difference in the primary outcome of vision loss at 2 years between eyes that received prompt aflibercept versus those assigned to observation and treated with aflibercept when VA worsened by 5–9 letters at two consecutive visits or ≥10 letters at one visit.1The Protocol V findings, particularly the subsequent broad interpretation of observation as the preferred first-line management strategy, have kindled much debate.2 There is certainly a case for initial observation given the similar outcome for the proportion of patients with ≥5-letter loss at 2 years, which was 16% in the prompt aflibercept arm versus 19% in the observation arm. Furthermore, there was no significant difference between the prompt aflibercept and observation arms in the mean change from baseline VA (0.9 and −0.4 letters, respectively) or central subfield thickness (−48 and −42 µm, respectively) at 2 years.1 Retinal thickening can resolve spontaneously without treatment; indeed, in Protocol V, CI-DMO resolved without aflibercept treatment in 31% of eyes by 2 years in the observation arm.3 In addition, a first-line management strategy with observation can reduce the treatment burden, cost and inherent risk associated with intravitreal injections. However, this approach may not be appropriate for all patients with CI-DMO and good vision. Integral to achieving optimal efficacy with anti-VEGF treatment in general is the concept of delivering the right amount of treatment at the optimal time.4 To … ER -