Intravitreal anti-vascular endothelial growth factor agents as an adjunct for proliferative diabetic retinopathy: a systematic review and meta-analysis.

Objective: To evaluate the efficacy and safety of intravitreal anti-vascular endothelial growth factor (anti-VEGF) agents adjunct prior to pars plana vitrectomy (PPV) for patients with proliferative diabetic retinopathy (PDR).

Methods: A systematically comprehensive literature search was performed in PubMed, Embase, Cochrane Library, ClinicalTrials.gov, China National Knowledge Infrastructure (CNKI), Wanfang, VIP Database for Chinese Technical Periodicals, and Chinese Biomedical Literature Database to identify relevant randomized controlled trials (RCTs) up to October 31, 2024. The Peferred Reporting Items for Systematic Reviews and Meta Analysis guidelines were followed. Review Manager 5.4 software was used to conduct statistical analyses.

Results: 91 RCTs involving 8721 eyes were included. The intraoperative indices revealed that the amount, grade and incidence of intraoperative bleeding, duration of surgery, the frequency of endodiathermy, the incidences of iatrogenic retinal breaks, endodiathermy, retinotomy, and silicone oil tamponade were significantly less in the PPV + anti-VEGF group than in the PPV group (P < 0.05). Moreover, the postoperative indices showed that anti-VEGF agents adjunct before PPV could achieve better postoperative best corrected visual acuity (BCVA) at different time points, higher postoperative retinal anatomical reattachment, lower postoperative macular retinal thickness (MRT) at different time points and intraocular pressure (IOP) at < 1 month, ≥ 3 months but < 6 months, and shorter clearing time of postoperative vitreous hemorrhage (POVH) (P < 0.05). Furthermore, the incidences of postoperative complications such as early POVH, late POVH at different time points, retinal detachment, re-proliferation, aseptic and infective endophthalmitis, iris rubeosis, neovascular glaucoma, hyphema, and elevated IOP were significantly lower in the PPV + anti-VEGF group than in the PPV group (P < 0.05). Besides, anti-VEGF agents adjunct before PPV could achieve lower re-PPV probability (P < 0.0001).

Conclusions: Intravitreal anti-VEGF agents adjunct prior to PPV for PDR patients might facilitate much easier surgery, shorter surgical time, better postoperative BCVA, and lower postoperative MRT; meanwhile reduce the incidence of intraoperative and postoperative complications, and the risk of re-PPV. In addition, more RCTs with better design, larger sample sizes and longer follow-up time are needed to provide more reliable evidence.

Prospero registration number: CRD42024604615 (22 October 2024).