The Diabetic Retinopathy Clinical Research Network Dedicated to multicenter clinical research of diabetic retinopathy, macular edema and associated conditions Supported through a cooperative agreement from the National Eye Institute and the National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Department of Health and Human Services EY14231, EY018817 DRCR.net Overview Objective: • The development of a collaborative network to facilitate multicenter clinical research on diabetic retinopathy, DME and associated conditions. Funding: • National Eye Institute (NEI) and The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)-sponsored cooperative agreement initiated September 2002. o Current award 2014-2018 2 Priority Initiatives Involvement of community-based practices, as well as “academic” or university-based centers. Collaborate with industry to facilitate investigations and pursue opportunities otherwise not possible and to do so in a manner consistent with the Network’s dedication to academic integrity and optimal clinical trial performance. 3 DRCR.net Status (as of 1/6/14) Active Total 119 179 80 (67%) 120 (67%) Investigators Other Personnel 363 979 786 2746 States 37 41 Sites (Community & Academic Centers) Community Sites 4 How to Join the Network All retina specialists are welcome to apply E-mail drcrnet@jaeb.org Your request will be reviewed and if approved the necessary paperwork will be sent to you 5 How to Submit a Protocol Idea Go to the public* website: drcr.net Click on Information for Investigators. Scroll down to Protocol Idea Form. E-mail form to drcrnet@jaeb.org It will be reviewed by the Operations Group at the next in-person meeting. * Forms also available on the study website 6 DRCR Network Completed Protocols (as of 2/12/14) Protocol # of Subjects I: Laser-Ranibizumab-Triamcinolone Study for DME 691 J: Laser-Ranibizumab-Triamcinolone Study for DME + PRP 333 K: The Course of Response to Focal Photocoagulation for DME 128 L: Autorefraction and E-ETDRS Measurements in DME 490 N: Intravitreal Ranibizumab for Vitreous Hemorrhage from PDR Study 261 O: Comparison of Time Domain OCT & Spectral Domain OCT in DME 1183 P: Pilot Study of Individuals with DME Undergoing Cataract Surgery 68 Q: Individuals with Diabetes without DME Undergoing Cataract Surgery 317 R: NSAIDs in Eyes with Non Central Involved DME 125 7 DRCR Network Ongoing Protocols (as of 2/12/14) Protocol # of Subjects M: Diabetes Education Study* 1875 S: Prompt PRP vs. Ranibizumab + Deferred PRP for DPR* 305 T: Anti-VEGF comparison* 660 U: Phase II Persistent DME Study** V: Very Good Visual Acuity** 39 Genetics Ancillary Study: Genes in Diabetic Retinopathy** 855 DRCR Network Participant Total Since 2003 8807 8 * Enrollment done/in active follow-up; **Recruiting What Has Been Learned? Diabetic Macular Edema Treatment Protocol B: Over 2 years, focal/grid photocoagulation is more effective and has fewer side effects than 1 mg or 4 mg doses of preservative-free intravitreal triamcinolone. Protocol E: In cases of DME with good visual acuity, peribulbar triamcinolone, with or without focal photocoagulation, is unlikely to be of substantial benefit. Protocol H: The results demonstrated that intravitreal bevacizumab can reduce DME in some eyes, but the study was not designed to determine whether the treatment was beneficial. 9 What Has Been Learned? Diabetic Macular Edema Treatment Protocol I: Intravitreal ranibizumab with prompt or deferred (≥24 weeks) focal/grid laser is more effective through 2 years in increasing visual acuity compared with focal/grid laser treatment alone for the treatment of DME involving the central macula. Ranibizumab should be considered for patients with DME and decreased visual acuity. Protocol K: Sixteen weeks after focal/grid laser for DME in eyes with a definite reduction, but not resolution, of central edema, 23% to 63% likely will continue to improve without additional treatment. 10 What Has Been Learned? Diabetic Retinopathy Treatment Protocol F: Results suggest that clinically meaningful differences are unlikely in OCT thickness or visual acuity following application of PRP in 1 sitting compared with 4 sittings. These results suggest PRP costs to some patients in terms of travel and lost productivity as well as to eye care providers could be reduced. Protocol J: The addition of 1 intravitreal triamcinolone injection or 2 intravitreal ranibizumab injections in eyes receiving focal/grid laser for DME and PRP is associated with better visual acuity and decreased macular edema by 14 weeks. Whether continued long-term intravitreal treatment is beneficial cannot be determined from this study. 11 What Has Been Learned? OCT and Retinal Thickening Protocol C: Although on average there are slight decreases in retinal thickening during the day, most eyes with diabetic macular edema have little meaningful change in OCT central subfield thickening or visual acuity between 8 AM and 4 PM. Protocol C: Reproducibility of retinal thickness in DME was better for central subfield thickness measurements than for center point measurements. A change in central subfield thickness exceeding 11% is likely to be real. Protocol G (Secondary Outcomes): While subclinical DME may be uncommon, this study suggests that between approximately one-quarter and one-half of eyes with subclinical DME will progress to more definite thickening or be judged to need treatment for DME within 2 years after its identification. 12 What Has Been Learned? Optical Coherence Tomography Protocol G (Primary Outcomes): CSF thickness on Stratus OCT™ in people with diabetes and minimal or no retinopathy are similar to thicknesses reported from a normative database of people without diabetes. CSF thickness is greater in men than in women. Studies involving comparisons of retinal thickness to expected norms should consider different mean values for women and men. Protocol O: Mean CSF thickness is ~70 µm thicker when measured with Heidelberg Spectralis OCT as compared with Stratus OCT among individuals with diabetes in the absence of retinopathy or with minimal non-proliferative retinopathy and a normal macular architecture. CSF thickness values ≥320 µm for men and 305 µm for women are proposed as gender-specific thickness levels. 13 What Has Been Learned? Optical Coherence Tomography Protocol O: Conversion equations may be used to transform CSF values obtained on a SD-OCT to a TD scale for group comparisons. However, the CSF conversion equations do not appear to predict TD values for an individual accurately enough to warrant use of these conversion equations confidently in clinical decision-making at the patient level. 14 Recently Completed Protocols 15 Protocol I: Intravitreal Ranibizumab or Triamcinolone Acetonide in Combination with Laser Photocoagulation for Diabetic Macular Edema 16 Objective • To evaluate the safety and efficacy of intravitreal antiVEGF treatment in combination with immediate or deferred focal/grid laser photocoagulation and intravitreal corticosteroids in combination with focal/grid laser compared with focal/grid laser alone in eyes with center-involved DME Major Eligibility Criteria • Diabetic macular edema involving the center of the macula (OCT central subfield thickness ≥ 250 microns) responsible for visual acuity of 20/32 or worse Protocol Status • Total enrolled (3/07-12/08): 691 subjects/854 eyes at 52 sites • Final 5 year visit December 2013 Diabetic Retinopathy Clinical Research Network. Randomized trial evaluating ranibizumab plus prompt or deferred laser or triamcinolone plus prompt laser for diabetic macular edema. Ophthalmology. 2010 17 June;117(6):1064-1077.e35. Change in Visual Acuity from Baseline (letter score) Mean Change in Visual Acuity* at Follow-up Visits Sham+Prompt Laser Ranibizumab+Prompt Laser Ranibizumab+Deferred Laser Triamcinolone+Prompt Laser 11 10 9 8 7 N = 626 (52 weeks) N = 600 (68 weeks) N = 600 (84 weeks) N = 628 (104 weeks) 6 5 4 3 2 1 0 0 4 8 12 16 20 24 28 32 36 40 44 48 52 56 60 64 68 72 76 80 84 88 92 96 100104 Visit Week *Truncated to ± 30 letters P-values for difference in mean change in VA from sham+prompt laser at the 104 week visit: ranibizumab+prompt laser =0.03; ranibizumab+deferred laser <0.001; and triamcinolone+prompt laser=0.35. 18 Injections Prior to 3 Year* Maximal number of injections prior to 3- year visit Ranibizumab + Prompt Laser N=144 Ranibizumab + Deferred Laser N=147 39 39 *Only eyes that completed 3 year visit 19 Injections Prior to 3 Year* Ranibizumab + Prompt Laser N=144 Ranibizumab + Deferred Laser N=147 Maximal number of injections prior to 3- year visit 39 39 Median number of injections in year one (1st / 2nd 6 months) 8 (6/3) 9 (6/3) *Only eyes that completed 3 year visit 20 Injections Prior to 3 Year* Ranibizumab + Prompt Laser N=144 Ranibizumab + Deferred Laser N=147 Maximal number of injections prior to 3- year visit 39 39 Median number of injections in year one (1st / 2nd 6 months) 8 (6/3) 9 (6/3) 2 3 Median number of injections in year two *Only eyes that completed 3 year visit 21 Injections Prior to 3 Year* Ranibizumab + Prompt Laser N=144 Ranibizumab + Deferred Laser N=147 Maximal number of injections prior to 3- year visit 39 39 Median number of injections in year one (1st / 2nd 6 months) 8 (6/3) 9 (6/3) Median number of injections in year two 2 3 Median number of injections in year three 1 2 Median number of injections prior to 3 year visit 12 15 *Only eyes that completed 3 year visit 22 Focal/Grid Laser Prior to 3 Years* Ranibizumab + Prompt Laser N = 144 Ranibizumab + Deferred Laser N = 147 Maximal possible number of focal/grid laser treatments prior to 3-year visit 12 10 Median number of focal/grid laser treatments from baseline to (prior to) 3-year visit 3 0 100% 46% % of eyes that received focal/grid laser treatments from baseline to (prior to) 3year visit * Only eyes that completed 3-year visit 23 Mean Change in Visual Acuity* at Follow-up Visits Change in Visual Acuity from Baseline (Letter Score) 12 Ranibizumab + Prompt Laser N = 338 (52 weeks) 10 Ranibizumab + Deferred Laser N = 317 (104 weeks) N = 291 (156 weeks) 8 6 4 2 0 Visit Week *Truncated to ± 30 letters 52 156 104 24 Change in Visual Acuity* Change in Visual Acuity (letters)** 2-years (Estimated Means) 3- Years (Estimated Means) Ranibizumab + Prompt Laser N = 144 +7.2 +6.8 Ranibizumab + Deferred Laser N = 147 Estimated Difference (B vs. C) (95% CI) [P-Value] +9.0 -1.8 (-3.6 to +0.1) [P = 0.06] +9.7 -2.9 (-5.4 to -0.4) [P = 0.02] *Visits occurring between 980 and 1204 days from randomization were included as 3 year visits **truncated to ± 30 letters, based on longitudinal analyses adjusting for baseline VA 25 Visual Acuity Gain at 3 Years Proportion of Visual Acuity Change 100% 90% 80% ≥15 letter loss 10-14 letter loss 5-9 letter loss within ±4 9-5 letter gain 14-10 letter gain 70% 60% 50% 40% 30% ≥15 letter gain 20% 10% 0% Ranibizumab + Prompt Laser N = 144 Ranibizumab + Deferred Laser N = 147 26 Conclusions Intravitreal ranibizumab with prompt or deferred (≥24 weeks) focal/grid laser is more effective through 2 years in increasing visual acuity compared with focal/grid laser treatment alone for the treatment of DME involving the central macula. Ranibizumab should be considered for patients with DME and decreased visual acuity. 27 Conclusions: Ranibizumab + prompt laser vs. deferred laser Results suggest that focal/grid laser treatment at the initiation of intravitreal ranibizumab is no better, and possibly worse, for vision outcomes than deferring laser treatment for 24 weeks or more in eyes with DME involving the fovea and with vision impairment. Some of the observed differences in visual acuity at 3 years may be related to the fewer number of ranibizumab injections during follow-up in the prompt laser treatment group. Despite the decreasing number of injections given in the 2nd and 3rd year of management, the ranibizumab + deferred laser treatment group showed no decline in visual acuity, and the ranibizumab + prompt laser treatment group showed only a slight decline from the 28 1-year to 3-year visit. Protocol M: Effect of Diabetes Education During Retinal Ophthalmology Visits on Diabetes Control 29 Objective • Determine if glycemic control in individuals with type 1 or type 2 diabetes can be improved with subject-specific diabetes education and risk assessment during office visits to a retina specialist Major Eligibility Criteria • Diagnosis of diabetes mellitus (type 1 or type 2) • Patient is not eligible if patient has a known HbA1c <7.5% within prior 6 months Protocol Status • Recruitment: 1,875; original goal: 2,000 • Final visits currently being completed 30 Protocol R: A Phase II Evaluation of Topical NSAIDs in Eyes with Non Central Involved DME 31 Objective • To assess the effects of topical NSAIDs on macular retina volume compared with placebo in eyes with non-central DME • To assess the effects of topical NSAIDs on central subfield thickness and to compare the progression of non-central DME to central DME as determined by OCT and stereoscopic fundus photographs Major Eligibility Criteria • Best corrected E-ETDRS VA letter score ≥74 (20/25 or better) • Definite retinal thickening due to DME within 3000 µm of the center of the macula but not involving the central subfield • No focal/grid laser within the last 6 months or other treatment for DME within the last 4 months Protocol Status • Total enrolled: 125subjects randomized • All follow-up visits completed. 32 Active Studies 33 Image: National Eye Institute, National Institutes of Health Protocols in Follow-up 34 Protocol S: Prompt PRP versus Intravitreal Ranibizumab with Deferred PRP for PDR Objective • To determine if visual acuity outcomes at 2 years in eyes with PDR that receive antiVEGF therapy with deferred PRP are noninferior to those in eyes that receive standard prompt PRP therapy. 35 Image: National Eye Institute, National Institutes of Health Protocol S: Prompt PRP versus Intravitreal Ranibizumab with Deferred PRP for PDR Major Eligibility Criteria • Study eye with o o o PDR for which PRP can be safely deferred for at least 4 weeks in the investigator’s judgment. No prior PRP Visual acuity letter score in the study eye > 24 (~ Snellen equivalent of 20/320 or better) Enrollment (Completed) • Total enrolled: 305 participants and 394 study eyes at 56 sites 36 Protocol T: A Comparative Effectiveness Study of Intravitreal Aflibercept, Bevacizumab and Ranibizumab for DME 37 Image: National Eye Institute, National Institutes of Health Study Objective and Treatment Arms (N = 660) To compare the efficacy and safety of (1) intravitreal aflibercept, (2) intravitreal bevacizumab, and (3) intravitreal ranibizumab when given to treat central-involved DME in eyes with visual acuity of 20/32 to 20/320. 2.0 mg intravitreal aflibercept 1.25 mg intravitreal bevacizumab 0.3 mg intravitreal ranibizumab Major Inclusion Criteria Age ≥18 years Type 1 or 2 diabetes Study eye: • • • Visual acuity (~Snellen equivalent) 20/32 or worse and 20/320 or better Definite retinal thickening due to central-involved DME on clinical exam OCT CSF ≥ OCT-machine gender specific cut-off for definite central involved DME Follow-up Schedule Baseline to 1 Year Optional Visit 2-3 Days after 1st 2nd or 3rd visit 1 Year to 2 Years • Visits every 4 weeks • Primary outcome at 1 year • Urine sample • Blood pressure (another BP measurement will be taken at the first 4 week visit after the optional visit) • Visits every 4 to 16 weeks • Depends on disease status and treatment Protocols Currently Enrolling 41 Protocol V Very Good Visual Acuity 42 Protocol V - Treatment for Centralinvolved DME in Eyes with Very Good Visual Acuity Objective: compare the safety and efficacy of 1) prompt laser with deferred anti-VEGF, 2) observation with deferred anti-VEGF, and 3) prompt anti-VEGF in eyes with center involved DME and good vision (defined as visual acuity 20/25). Primary Outcome: proportion of eyes with a visual loss of at least 5 letters at 1 year, confirmed at 2 consecutive 4-week visits 43 Study Design Randomized, multi-center clinical trial At least one eye meeting all of the following criteria: • Central-involved DME on OCT (Cirrus/Spectralis only)* • VA letter score 20/25 or better* • No prior treatment for DME Prompt anti-VEGF Prompt laser + deferred anti-VEGF Observation + deferred anti-VEGF Primary outcome: Proportion of eyes that have lost ≥5 letters of VA at 2 years *Confirmed at 2 visits (screening and randomization 1-28 days apart) 44 Outcome Measures Primary Outcome % with VA loss of ≥ 5 letters at 2 years Secondary Outcomes Mean change in VA letter score % with at least 10 and 15 letter VA gain/loss Visual acuity area under the curve Mean change in OCT CSF thickness % with 1 or 2 log step gain or loss on OCT Number of injections/lasers performed Worsening/improvement of DR severity level Low contrast visual acuity Safety outcomes 45 Major Eligibility Criteria Type 1 or 2 diabetes Study Eye: • • • • Central-involved DME on clinical exam, confirmed on OCT at two consecutive visits (1-28 days apart) VA letter score >79 (~20/25 or better) at two consecutive visits (1-28 days apart) The investigator is comfortable with the eye being randomized to any of the three treatment groups No history of prior DME treatment Non-study eye: • Investigator must be willing to use (or switch to using) study aflibercept on the non-study eye if needed 46 Major Exclusion Criteria Systemic • • • History of chronic renal failure requiring dialysis or kidney transplant Initiation of intensive insulin treatment (a pump or multiple daily injections) within 4 months prior to randomization or plans to do so in the next 4 months BP > 180/110 Study eye • • • Macular edema not due to DME (eyes with thickening due to ERM, prior cataract surgery or other non-DME reason should not be enrolled) PRP in last 4 months or anticipated in next 6 months History of or anticipated need for intravitreal anti-VEGF for an ocular condition other than DME 47 Follow-Up Schedule Total follow-up through 2 years Visit schedule will vary by treatment group and disease progression • • Prompt anti-VEGF group: visits every 4 weeks through 24 weeks, then every 4 to 16 weeks depending on whether injections are being given Deferred groups (observation and laser groups): visits at 8 and 16 weeks, then every 16 weeks unless vision and/or OCT are worsening or anti-VEGF is initiated (visits every 4, 8 or 16 weeks depending on disease progression and treatment) All participants will have visits at 1 and 2 years 48 Protocol U Short-term Evaluation of Combination Corticosteroid+Anti-VEGF Treatment for Persistent CI-DME Following AntiVEGF Therapy in Pseudophakic Eyes 49 Objectives To assess short-term effects of combination steroid+anti-VEGF therapy on OCT retinal thickness and visual acuity in comparison with that of continued anti-VEGF therapy alone in pseudophakic eyes with persistent DME and visual acuity impairment despite previous anti-VEGF treatment. To provide more information needed for future conduct of a definitive phase III clinical trial. 50 Study Design Phase II, multicenter, controlled, participant-masked, clinical trial Duration of Follow-up Run-in Phase 12 Weeks Purpose To ensure that enrolled eyes truly have “persistent DME” with decreased visual acuity despite prior anti-VEGF therapy. Randomized Phase 24 Weeks 51 Study Overview SHM SHM VGF VGF Week 0 VGF Week 4 VGF Week 8 VGF Week 12 VGF Week 16 Week 20 Week 24 Group A: Sham + Ranibizumab VGF VGF Week 0 Week 4 VGF Week 8 Week 12 Group B: Dexamethasone+ Ranibizumab Enrollment Week 0 VGF Dex Run-In Phase (3 months) Assess Eligibility For Randomization Week 4 VGF Week 8 VGF Week 12 VGF Week 16 VGF Week 20 Week 24 VGF Dex Randomization Phase (6 months) 52 Major Eligibility Criteria Age ≥18 years Type 1 or type 2 diabetes At least 1 eye meeting study eye eligibility criteria No history of chronic renal failure requiring dialysis or kidney transplant BP <180/110 No history of cardiac event or stroke within 1 month prior to enrollment 53 Major Study Eye Eligibility Criteria Pseudophakic At least 6 injections of anti-VEGF drugs (aflibercept, bevacizumab, or ranibizumab) within the prior 36 weeks (9 months) Visual acuity letter score ≤78 and ≥24 (20/32 to 20/320) Central-involved DME on clinical exam OCT CSF thickness within 8 days of enrollment ≥340 on Zeiss Cirrus ≥360 on Zeiss Stratus No macular laser or PRP within 4 months or anticipated need for PRP in next 6 months No previous history of glaucoma or steroid intraocular pressure response in either eye 54 Efficacy Outcomes at 24 Weeks Primary: • Mean change in visual acuity letter score adjusted for baseline (randomization) Secondary: • Visual Acuity o o • OCT o o o o • % of eyes with ≥10 and ≥15 letter increase or decrease Area under the curve (AUC) from baseline Change in CSF thickness adjusted for baseline % ≥2 logOCT step gain or loss in CSF CSF thickness < spectral-domain value equivalent to 250 microns on Zeiss Stratus AUC from baseline Diabetic Retinopathy worsening or improvement on clinical exam 55 Genetics Genes in Diabetic Retinopathy Project 56 Genes in Diabetic Retinopathy Project Objective • To create a repository of genetic material and clinical phenotype information as a resource for the research community • The database may provide the opportunity to assess genetic susceptibility and resistance to DR and also variants impacting visually-important biomarkers for ME and neovascularization. Major Eligibility Criteria • Previous or current participant in a DRCR.net study Enrollment (Ongoing) 57 • Total enrolled: 855 subjects (as of 2/13/14) Protocols In Development 58 Protocol AA: Peripheral Diabetic Retinopathy (DR) Lesions on Ultrawide-field Fundus Images and Risk of DR Worsening Over Time 59 Objectives Primary objective • • In general to assess whether there are factors in the retinal periphery that are associated with rate of DR worsening over time. Specifically, the primary factor of interest is to assess whether predominance versus non-predominance of DR lesions in the retinal periphery is associated with rates of DR worsening over time 60 Study Design & Eligibility Criteria Prospective, observational longitudinal study Follow-up: Annually for 4 years Enrollment Criteria • Adults with Type 1 or type 2 diabetes NPDR (ETDRS level 35 - 57) based on modified 7 field ETDRS grading. No history of PRP or Vitrectomy Eyes not previously treated with intravitreal agents over prior 12 months and treatment not anticipated for next 6 months o Enrollment will be limited to only 50% of the cohort with any prior intravitreal anti-VEGF or steroid for DME. • No DME in the central subfield • • • 61 Outcomes Longitudinal Analysis • • Relative risk of 2 or more step worsening of DR severity over 4 years in the groups with and without predominantly peripheral lesions on UWF images at baseline. Secondary analysis - additional risk factors including: o o o • Type of peripheral lesions Location of peripheral lesions Extent of peripheral non-perfusion on FA Secondary outcomes include the evaluation of risk factors for the progression to PDR, improvement of DR, improvement, worsening, or development of DME, and development of VH. 62 Outcomes Cross Sectional Analysis at Baseline • Level of agreement between DR or DME severity as graded on UWF vs DRCR.net protocol images • % and type of peripheral lesions identified on UWF images not seen on DRCR.net protocol images • % of time peripheral lesions seen on UWF images outside the 7 std fields could change level of ETDRS DR severity 63 Sample Size Projected to Begin Q2 2014 Estimated 40 sites will participate Within each primary cohort, o o o ~40% w/ mild NPDR (ETDRS levels 35) ~40% w/ moderate or moderately severe NPDR (ETDRS levels 43-47) ~20% w/ severe NPDR (ETDRS level 53) Predominantly Peripheral Lesions NOT Predominantly Peripheral Lesions 64 The Diabetic Retinopathy Clinical Research Network Thank you 65