Comparative efficacy of aflibercept, bevacizumab, and ranibizumab on hard exudate resolution in diabetic macular edema.

Objective: To compare the efficacy of aflibercept, bevacizumab, and ranibizumab for resolution of diabetic macular edema-associated hard exudates (HEs).

Design: Post hoc analysis of the Diabetic Retinopathy Clinical Research Network Protocol T trial.

Participants: Two hundred and forty-eight subjects with 84 eyes were treated with aflibercept, 71 eyes were treated with bevacizumab, and 93 eyes were treated with ranibizumab.

Methods: The volume of HEs was measured by automatically quantifying hyperreflective foci on optical coherence tomography volume scans using a deep-learning algorithm. HEs were quantified within the total macula (6 × 6 mm scan area), as well as separately within the central subfield (CSF), inner ring (IR), and outer ring (OR) of the Early Treatment Diabetic Retinopathy Study grid at baseline, 4, 12, 24, and 52 weeks (w) after treatment. The extent of HEs at baseline and the change over time were compared among the groups.

Results: Baseline HEs in the total macula were 0.0211 ± 0.0275, 0.0215 ± 0.0266, and 0.0223 ± 0.0272 mm³ for the aflibercept, bevacizumab, and ranibizumab groups, respectively. At 1 year, HEs significantly decreased with aflibercept and ranibizumab in the total macula and in all subregions (CSF, OR, and IR), but they only decreased with evacizumab in the CSF. Over 1 year, the reduction in HEs was greater for aflibercept and ranibizumab than for bevacizumab within the total macular region, and anibizumab was superior to bevacizumab for the IR as well.

Conclusions: HEs decreased significantly with aflibercept and ranibizumab treatment over 1 year in all regions, but not with bevacizumab, highlighting the differential efficacy among agents in resolving HEs.