ImportanceWhile combined treatment of anti–vascular endothelial growth factor (VEGF) injections plus panretinal photocoagulation (PRP) is a common approach for treating proliferative diabetic retinopathy (PDR) in the clinical practice setting, large randomized clinical trials typically use monotherapy. Subsequently, information is limited as to whether the order of treatment when combining PRP and anti-VEGF injections for PDR affects outcomes.ObjectiveTo compare outcomes of patients with PDR treated with PRP and subsequent anti-VEGF injections with outcomes of matched patients treated with anti-VEGF injections and subsequent PRP.Design, Setting, and ParticipantsThis retrospective cohort study used data from January 2003 to January 2024 in the TriNetX aggregated electronic health records network, with data analysis performed in January 2024. Patients with PDR treated with PRP and anti-VEGF injections were eligible for inclusion.ExposuresPatients with new PDR diagnoses stratified by therapy with PRP and subsequent anti-VEGF injections or anti-VEGF injections and subsequent PRP.Main Outcomes and MeasuresThe primary outcome was the need for pars plana vitrectomy (PPV), defined by Current Procedural Terminology codes 67040 or 67113. The secondary outcome included incidence of PPV, vitreous hemorrhage (VH), or tractional retinal detachment (TRD). Relative risk ratios, relative risk differences, and 95% CIs were all calculated for univariate comparison of the cohorts and the development of primary outcomes after matching.ResultsBefore propensity score matching (PSM), which controlled for baseline demographic characteristics and medical comorbidities, 2167 patients with PDR treated with PRP first and subsequent anti-VEGF injections and 1549 patients with PDR treated with anti-VEGF injections and subsequent PRP were included. Post-PSM, mean (SD) participant age was 63.0 (13.1) years in cohort 1 (PRP and subsequent anti-VEGF injection) and 63.0 (12.4) years in cohort 2 (anti-VEGF injection and subsequent PRP). Of 1377 total participants in each cohort, 641 patients (46.6%) and 663 patients (48.1%) in cohorts 1 and 2 were female, respectively. Treatment with PRP first and subsequent anti-VEGF injection was associated with higher rates of PPV at 5 years compared with patients treated with anti-VEGF injection and subsequent PRP (relative risk [RR], 1.88; 95% CI, 1.55-2.27; risk difference [RD], 8.93%; 95% CI, 6.31%-11.55%; P < .001), with similar associations at 6 months, 1 year, and 3 years. Treatment with PRP and subsequent anti-VEGF injection was associated with higher rates of VH at 5 years (RR, 1.40; 95% CI, 1.09-1.80; RD, 6.47%; 95% CI, 1.66%-11.29%; P < .001) and TRD at 5 years (RR, 1.85; 95% CI, 1.35-2.53; RD, 4.31%; 95% CI, 2.10%-6.52%; P < .001), with similar findings at 6 months, 1 year, and 3 years compared with patients treated with anti-VEGF injection and subsequent PRP.Conclusions and RelevanceIn this retrospective cohort study, findings suggest that patients with PDR treated with PRP first then subsequent anti-VEGF injection are more likely to undergo PPV for VH and TRD compared with matched patients treated with anti-VEGF agents first, then PRP. These findings support the need for further investigations to determine if the order of PRP and anti-VEGF injections should be considered when treating patients with PDR.

中文翻译：

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全视网膜光凝术与抗 VEGF 注射治疗增殖性糖尿病视网膜病变的初始治疗


重要性虽然抗血管内皮生长因子 （VEGF） 注射加全视网膜光凝术 （PRP） 的联合治疗是临床实践环境中治疗增殖性糖尿病视网膜病变 （PDR） 的常用方法，但大型随机临床试验通常使用单一疗法。随后，关于联合 PRP 和抗 VEGF 注射治疗 PDR 的治疗顺序是否影响结局的信息有限。目的比较接受 PRP 和随后的抗 VEGF 注射的 PDR 患者的结局与接受抗 VEGF 注射治疗的匹配患者和后续 PRP.Design 的结果、环境和参与者这项回顾性队列研究使用了 2003 年 1 月至 2024 年 1 月在 TriNetX 聚合电子健康记录网络中的数据，并于 2024 年 1 月进行了数据分析。接受 PRP 和抗 VEGF 注射治疗的 PDR 患者符合纳入条件。暴露新诊断为 PDR 的患者按 PRP 治疗和随后的抗 VEGF 注射或抗 VEGF 注射和随后的 PRP 进行分层。主要结局和措施主要结局是需要睫状体玻璃体切除术 （PPV），由当前手术术语代码 67040 或 67113 定义。次要结局包括 PPV 、玻璃体出血 （VH） 或牵拉性视网膜脱离 （TRD） 的发生率。计算相对风险比、相对风险差和 95% CIs，用于队列的单变量比较和匹配后主要结局的发展。结果在控制基线人口学特征和躯体合并症的倾向评分匹配 （PSM） 之前，包括 2167 例 PDR 患者首次和随后接受 PRP 注射和 1549 例 PDR 患者接受抗 VEGF 注射和随后的 PRP。PSM 后，队列 1 （PRP 和随后的抗 VEGF 注射） 参与者的平均 （SD） 年龄为 63.0 （13.1） 岁，队列 2 （抗 VEGF 注射和随后的 PRP）为 63.0 （12.4） 岁。在每个队列的 1377 名参与者中，第 1 组和第 2 组分别为 641 名患者 （46.6%） 和 663 名患者 （48.1%） 为女性。与接受抗 VEGF 注射和随后的 PRP 治疗的患者相比，首次和随后的抗 VEGF 注射治疗与 5 年 PPV 发生率较高相关（相对风险 [RR]，1.88;95% CI，1.55-2.27;风险差 [RD]，8.93%;95% CI，6.31%-11.55%;P < .001），在 6 个月、 1 年和 3 年时具有相似的关联。PRP 治疗和随后的抗 VEGF 注射与 5 年时较高的 VH 发生率相关 （RR， 1.40;95% CI， 1.09-1.80;RD，6.47%;95% CI，1.66%-11.29%;P < .001） 和 5 年 TRD （RR， 1.85;95% CI， 1.35-2.53;RD，4.31%;95% CI，2.10%-6.52%;P < .001），与接受抗 VEGF 注射和后续 PRP 治疗的患者相比，在 6 个月、 1 年和 3 年时有相似的发现。结论和相关性在这项回顾性队列研究中，研究结果表明，与先接受抗 VEGF 药物治疗，然后接受 PRP 治疗的匹配患者相比，先接受 PRP 治疗后接受抗 VEGF 注射的 PDR 患者更有可能接受 VH 和 TRD 的 PPV。 这些发现支持需要进一步调查，以确定在治疗 PDR 患者时是否应考虑 PRP 和抗 VEGF 注射的顺序。