Which treatment modality offers the best outcomes for diabetic retinopathy? A systematic review and network...

Diabetic retinopathy (DR) is a leading cause of preventable blindness globally, with proliferative diabetic retinopathy (PDR) and diabetic macular edema (DME) being the most vision-threatening complications. While panretinal photocoagulation (PRP) has been the traditional treatment for PDR, anti-vascular endothelial growth factor (anti-VEGF) therapies have emerged as effective alternatives. However, the comparative efficacy and safety of these interventions remain unclear. This network meta-analysis aimed to evaluate and compare the effectiveness of anti-VEGF agents, PRP, and combination therapies in improving visual and anatomical outcomes in patients with DR.

A systematic search of PubMed, Embase, Cochrane Library, and clinical trial registries was conducted up to February 2025. Randomized controlled trials (RCTs) comparing anti-VEGF agents (Ranibizumab, Aflibercept, Bevacizumab), PRP, or their combination in patients with DR were included. Primary outcomes included best-corrected visual acuity (BCVA) and central retinal thickness (CRT). Secondary outcomes included neovascularization regression, rates of vision-threatening complications, and adverse events. A Bayesian network meta-analysis was performed to synthesize direct and indirect evidence.

A total of 28 RCTs involving 6,450 patients were included. Anti-VEGF therapies demonstrated superior BCVA improvement compared to PRP at 12 months (mean difference: +3.39 letters; 95 % CI: +1.85 to +4.93). Anti-VEGF agents also achieved greater CRT reduction (-24.50 µm; 95 % CI: -39.03 to -9.97) and higher rates of neovascularization regression (odds ratio: 6.15). Combination therapy provided additional benefits for CRT reduction (-33.10 µm at 3 months). Anti-VEGF agents had fewer adverse events compared to PRP, including lower rates of visual field loss and raised intraocular pressure.

Anti-VEGF therapies are more effective than PRP in improving visual acuity, reducing macular thickness, and controlling neovascularization in DR patients while exhibiting superior safety profiles. Combination therapy may offer added benefits in specific scenarios. These findings support anti-VEGF agents as first-line treatments for vision-threatening DR.