Study Quantifies Link Between Poor Adherence and Subpar Outcomes in DME

Only 14% of baseline DME patients followed through with proper management course for the condition, as per DRCR.net Protocol S. Photo:  Erik Hanson, MD. Click image to enlarge. For some patients, adhering to their physician’s prescribed regimen can be difficult, leading to future complications and undesirable outcomes. One of the leading causes of blindness, proliferative diabetic retinopathy (PDR), can worsen with such a transgression toward crucial follow-up and treatment.Researchers from Johns Hopkins University in Maryland and Vestrum Health in Massachusetts analyzed records from a retina database to understand practice patterns and long-term complications of PDR treatment. They used the regimen outlined by the Diabetic Retinopathy Clinical Research Network's Protocol S. This trial measured the efficacy of ranibizumab for managing PDR. Subjects received anti-VEGF injections at baseline and four, eight and 12 weeks during the trial. If vitreous hemorrhage was present,  subjects were prescribed subsequent injections.This study analyzed adherence and efficacy for 26,632 eyes, with 74.2% presenting with baseline diabetic macular edema (DME) and approximately 82.6% presenting with bilateral PDR at first injection. The researchers measured changes to visual acuity in accordance with adherence as well as rates of vitrectomy, retinal detachment and neovascular glaucoma in accordance with adherence.Results showed that patients who followed their treatment regimen were more likely to receive positive results and fewer complications compared to patients who did not adhere. Only 14% of baseline DME patients and 10% of remaining patients followed through with proper protocol. Those who complied throughout the entire trial had a visual acuity change of +3.0 letters compared to -0.6 from other patients.The lower the rate of adherence, the higher the rate of complications. Patients who adhered to their regimen presented with a retinal detachment rate of 3.2%, compared to 3.4% from other patients. Those same compliant patients presented with a vitrectomy rate of 7.2%, compared to 7.7% from other patients. This trend continued for rates of neovascular glaucoma, with compliant patients presenting with a rate of 0.6% compared to 1% from other patients.“Diabetic macular edema is characterized by central vision losses, which may result in increased patient adherence to follow-up appointments relative to those without DME, given the vision improvements after initiation of anti-VEGF therapy,” wrote the authors in their paper. “We find that follow-up rates for ophthalmic care are lower when the disease pathology has an imperceptible effect on vision, as is the case in glaucoma management.”Due to the selection bias of the analyzed trial, this study has its limitations. Clinical trials are meant to simulate the real world, but the researchers suggest that oftentimes this data can exclude advanced diseases, unique cases, and several patients who were not compliant with the follow-up plan. Additionally, there was a lack of demographic data in this study, so these results could not be highlighted.“Poor adherence to the regimented strategy of anti-VEGF care may result in poor real-world efficacy of anti-VEGF monotherapy,” concluded the authors. “Consideration of a patient’s personal circumstances and social determinants of health that influence likelihood of follow-up is important when determining the optimal therapy for treating PDR, a lifetime disease.”Click here for the journal source. Maturi JR, Boucher N, Fernando R, et al. Visual outcomes and adherence challenges in proliferative diabetic retinopathy anti-vascular endothelial growth factor monotherapy in the clinical practice setting. Retina 2025;45:7:1303-1312.