Effects of Intravitreal Ranibizumab for Macular Edema With Nonproliferative Diabetic Retinopathy

• Sponsor: Wonkwang University Hospital (Other)
• Overall Status: Completed
• CT.gov ID: NCT02834663
• Collaborator: Novartis Korea Ltd. (Industry)
• Enrollment: 25
• Arm: 1
• Actual Duration (Months): 40

Study Details

Study Description

Brief Summary

Title of study:

Effects of Ranibizumab to delay or regression non-proliferative diabetic retinopathy(NPDR) with DME assessed by microaneurysm changes: A pilot study Objectives Diabetic retinopathy (DR) is a major cause of visual impairment. Anti-vascular endothelial growth factors have demonstrated therapeutic benefits in diabetic macular edema (DME). We aimed to prospectively analyze the effects of early intensive treatment using intravitreal ranibizumab (IVR) injections in nonproliferative diabetic retinopathy patients with macular edema.

Primary objective:

To investigate other efficacy endpoints including other visual acuity, anatomical change in mild-to-moderate NPDR with DME after intravitreal Ranibizumab injection from baseline through 6 months after treatment.

Secondary objectives:

To compare microvascular changes assessed by microaneurysm counts and perifoveal non-perfusion area changes and safty in eyes of mild-to-moderate NPDR with DME after intravitreal Ranibizumab injection from baseline through 6 months after treatment.

Condition or Disease	Intervention/Treatment	Phase
Nonproliferative Diabetic Retinopathy	Drug: Lucentis	Phase 4

Detailed Description

Title of study:

Effects of Ranibizumab to delay or regression non-proliferative diabetic retinopathy(NPDR) with DME assessed by microaneurysm changes: A pilot study

Study Rationale:

Diabetic retinopathy is the leading disease that causes acquired vision loss after 20 by making diabetic macular edema and neovascularization. In recent young generation, as prevalence of type 2 diabetes is growing, the burden of sight-threatening retinopathy is increasing on trend.1 Pathologically, angiogenesis is a main cause that destroys the structure of the eye and induces the visual function disorder as VEGF playing an important role in increasing the migration and proliferation of endothelial cells and increasing the permeability of the blood vessels.2,3 VEGF is made from the endothelial cells of retinal tissue, perivascular cells, pigment endothelial cells by hypoxia. And hypoxic condition of intraocular tissues is a key regulator of intra ocular angiogenesis by VEGF, the balance between VEGF and angiogenesis inhibitors determines the neovascular proliferation in diabetic retinopathy.4 VEGF is also inducing the expression of cell-to-cell contact molecule (intracellular adhesion molecule-1, ICM-1) and the adhesion of leukocytes to help the inflammatory response5, as mediator which destroys the blood retinal barrier, affecting the protein of tight junctions, making a microaneurysm and increasing permeability of capillary, that makes the liquid leakage and macular edema.5,6 Microanuerysm is the earliest clinical manifestations, the saccular local lesion that perivascular cells protruding in damaged areas on the capillary wall. According to Stitt AW et al9, diabetic microaneurysm is non-functioning extrusion of the vascular system from the deep part of inner retinal capillary plexus.

It is sometimes disappeared by being blocked with blood clots, on the other hand, new microanerysm is occurred in the other vascular bed structure.

Through these changes, the investigators know the course of a diabetic retinopathy and it is known that the generation rate of microaneurysm is associated with the clinically significant progression of macular edema (CSME) in mild-to-moderate nonproliferative diabetic retinopathy .10,11 In addition, the number of microanerysm is an important prognostic indicator which can estimate the progression or regression of diabetic retinopathy, as predicting whether becoming better or worse in diabetic retinopathy.12 Kohner and Sleightholm13 describe this concept at first time in 1986, its association with the number of microvascular flow and the severity of diabetic retinopathy. In recent years it is reported that measuring the number of microaneurysm and the turnover rate associated with the appearance or disappearance of microaneurysm, are predictors in progression of diabetic retinopathy and macular edema.14 To delay the progression of diabetic retinopathy and to improve macular edema, the laser photocoagulation have been the important role.15 Although the laser photocoagulation have had treatment effect in the diabetic retinopathy by reducing the amount of VEGF in micraneurysm and by degenerating the neovascularization after laser therapy, there was a problem that has many limitations - peripheral visual field defects, night blindness, progression of macular edema etc., and that the disease does not cured in a good time because of limits of laser therapy due to cataract, vitreous hemorrhage and turbidity. As an alternative method to solve these limitations, there is an anti-VEGF therapy.6 According to a previous study result, intraocular injection of Bevacizumab inhibits occurring of neovascularization by blocking the VEGF receptor .17 Recently, several studies have been reported that when injected intravitreal anti-VEGF, macular edema is improved and neovascularization is inhibited, by reducing the leakage of neovascularization.3 Especially, Leicht SF et al18 reported the number of microaneurysms and turnover rate in NPDR(non-proliferative diabetic retinopathy) patients injected with Ranibizumab. And the result showed entire number of the microaneurysms and turnover rate are decreased, which could be mean the regression of diabetic retinopathy and it could decide the therapeutic effect.

On this study, through the fluorescein fundus angiography, the average number of microaneurysms was significantly decreased after intravitreal injection of anti-VEGF therapy (p<0.05). The decrease of 35.70±24.79% in the treatment group was statistically higher than 13.95±38.21% in the control group of the fellow eye (p<0.05).

The result is found because decreased concentration of intravitreal VEGF inhibits the progression of diabetic retinopathy, such as endothelial cell proliferation and endothelial cell damage on retinal capillary and perivascular cells.

Sjølie AK et al12 reported up-regulation of VEGF occuring microaneurysms causes endothelial cell proliferation and inflammation and effusion reaction, so anti-VEGF is effective in early diabetic retinopathy. But there is less effectiveness in late diabetic retinopathy as it reaches the non-changing point. Also Kohner EM et al19 reported diabetic retinopathy lesions are reversible and could be delayed in early diabetic retinopathy.

So far, changes of microaneurysms in late diabetic retinopathy is uncertain, and if there would be a finding according to anti-VEGF therapy, the investigators could get a clue of surrogate marker which represents treatment results in diabetic retinopathy.

This study was designed to find the clinical evaluation and reduction rate through fluorescein angiography as microaneurysm examination tools to research NPDR with DME treatment results assessed by microaneurysm counts, timely monitored with anti-VEGF therapy.

Objectives To evaluate the effects of intravitreal Ranibizumab injection on microvascular changes in eyes of mild-to-moderate NPDR with DME.

Primary objective:

To investigate other efficacy endpoints including other visual acuity, anatomical change in mild-to-moderate NPDR with DME after intravitreal Ranibizumab injection from baseline through 6 months after treatment.

Secondary objectives:

To compare microvascular changes assessed by microaneurysm counts and perifoveal non-perfusion area changes and safty in eyes of mild-to-moderate NPDR with DME after intravitreal Ranibizumab injection from baseline through 6 months after treatment.

Primary and secondary endpoints:

Primary endpoint:

To compare other visual acuity, anatomical changes after intravitreal Ranibizumab injection from baseline through 6 months after treatment.

1. The changes in best corrected visual acuity (BCVA) using ETDRS chart. ii) The central macular thickness - Circle Diameters : 1 mm ETDRS by spectralis OCT ; Heidelberg Engineering.

Secondary endpoints:

To compare microaneurysmal changes and perifoveal non-perfusion area and safty after intravitreal Ranibizumab injection from baseline through 6 months after treatment.

1. The total number of microaneurysm by fundus photo using Retmarker DR(version 1.0.2) software.

2. The microaneurysm formation rate : Number of new MAs detected/month. iii) The microaneurysm disappearance rate : Number of MAs that resolved/month. iv)The microaneurysm turnover. v) Perifoveal non-perfusion area in FAG (mm²) using ImageJ software (version 1.52a) by FAG image.

3. Safety parameters : Systemic adverse events (MI, CVA, etc), Ocular adverse events (retinal detachment, RPE tear, endophthalmitis, uveitis, vitreous hemorrhage, subretinal hemorrhage, cataract , IOP elevation, etc).

Methodology:

single center, prospective, interventional, one arm, pilot study

Evaluation Participants will be evaluated with a full ocular examination at each visit (VA measurement, tonometry, slit lamp exam). Fluorescein angiography (FA) will be performed at baseline, at 3 months after baseline and at the last visit(6 months after baseline), and OCT will be performed monthly (baseline and 1, 2, 3, 4, 5, 6 months from baseline).

The MAs and perifoveal non-perfused areas in individual retinas were evaluated at 6 months using fundus photography and FA imaging. The Retmarker (version 1.0.2 by Retmarker Ltd, Coimbra, Portugal) software was used for automatic measurement and analysis of changes in number and extent of MAs on fundus photographs and to calculate the total number and turnover of MAs.

Perifoveal non-perfused area was estimated using the early FA image (from each of the three examinations) in which both the vascular arch and the non-perfused area were clearly visualized. Subsequently, the ImageJ software (version 1.25a 23/04/2018 by ImageJ, USA) was used for scaling each image to 200 µm and for equalizing the contrast and sensitivity of each picture to the maximum possible extent, by auto-adjustment of brightness and contrast. The raw red-green-blue (RGB) images were then converted to 8-bit images, with the threshold set for optimal visualization of the non-perfused area. The same threshold was applied to all images of the same patient.

Result analysis The investigators compare the differences between at baseline, at 3 month, and at 6 month. Statistical analyses will be performed using SPSS ver.18.0 (SPSS Inc., Chicago, Il, USA). Kolmogorov-Smirnov test was applied to test for normality of sample group data. the paired T-test was used for comparative statistical analysis of these parameters. (BCVA, CRT, total number of MAs, MA formation rate, MA disappearance rate, MA turnover, and perifoveal non-perfused area)

Study Design

• Study Type: Interventional
• Actual Enrollment: 25 participants
• Allocation: N/A
• Intervention Model: Single Group Assignment
• Masking: None (Open Label)
• Primary Purpose: Other
• Official Title: Prospective, Single-center, Six-month Study of Intravitreal Ranibizumab for Macular Edema With Nonproliferative Diabetic Retinopathy: Effects on Microaneurysm Turnover and Non-perfused Retinal Area
• Actual Study Start Date: Aug 1, 2016
• Actual Primary Completion Date: Feb 1, 2019
• Actual Study Completion Date: Dec 1, 2019

Arms and Interventions

Arm	Intervention/Treatment
Experimental: Lucentis Patients were administered 0.5-mg IVR injections monthly for 6 months.	Drug: Lucentis; Local anesthesia with T-caine with Saline irrigation. Routine eye drap was done by potadine-cotton ball. Lucentis injected to vitreous cavity, finally dressing.; Other Names: Intravitreal Lucentis injection

Outcome Measures

Primary Outcome Measures

1. The Best Corrected Visual Acuity (BCVA) [6 months]

   BCVA was performed using the Early Treatment Diabetic Retinopathy Study (ETDRS) chart at baseline and 6 months. The BCVA compare the degree of improvement or worsening of vision at baseline and 6 months. (value at 6 months minus value at baseline)

2. Central Macular Thickness(CMT) [6 months]

   CRT was performed using OCT at each visit. The OCT measured at each visit was analyzed statistically. the CMT compare the degree of improvement or worsening of vision at baseline and 6 months. (value at 6 months minus value at baseline)

Secondary Outcome Measures

1. The Total Number of Microaneurysm [6 months]

   The number of MAs in individual retinas were evaluated during 6 months using fundus photography and FA imaging. The Retmarker software was used for automatic measurement and analysis of changes in number and extent of MAs on fundus photographs and to calculate the total number and turnover of MAs. Changes in MAs were analyzed statistically. the total number of MAs compare the degree of improvement or worsening of vision at baseline and 6 months. (value at 6 months minus value at baseline)

2. The Microaneurysm Formation Rate [6 months]

   number of new MAs detected/month The MAs in individual retinas were evaluated at 6 months using fundus photography. The Retmarker (version 1.0.2 by Retmarker Ltd, Coimbra, Portugal) software was used for automatic measurement and analysis of changes in number and extent of MAs on fundus photographs and to calculate the total number and turnover of MAs. MA turnover was calculated by adding the MA formation rate (number of new MAs detected/month) to the MA disappearance rate (number of MAs that resolved/month). The microaneurysm formation rate compare the degree of improvement or worsening of vision at baseline and 6 months. (value at 6 months minus value at baseline)

3. The Microaneurysm Disappearance Rate [6 months]

   Number of MAs that resolved/month The MAs in individual retinas were evaluated at 6 months using fundus photography. The Retmarker (version 1.0.2 by Retmarker Ltd, Coimbra, Portugal) software was used for automatic measurement and analysis of changes in number and extent of MAs on fundus photographs and to calculate the total number and turnover of MAs. MA turnover was calculated by adding the MA formation rate (number of new MAs detected/month) to the MA disappearance rate (number of MAs that resolved/month). The microaneurysm disappearance rate compare the degree of improvement or worsening of vision at baseline and 6 months. (value at 6 months minus value at baseline)

4. The Microaneurysm Turnover [6 months]

   The microaneurysm formation rate + The microaneurysm disappearance rate The MAs in individual retinas were evaluated at 6 months using fundus photography. The Retmarker (version 1.0.2 by Retmarker Ltd, Coimbra, Portugal) software was used for automatic measurement and analysis of changes in number and extent of MAs on fundus photographs and to calculate the total number and turnover of MAs. MA turnover was calculated by adding the MA formation rate (number of new MAs detected/month) to the MA disappearance rate (number of MAs that resolved/month). The microaneurysm turnover compare the degree of improvement or worsening of vision at baseline and 6 months. (value at 6 months minus value at baseline)

5. Perifoveal Non-perfusion Area in FAG (mm²) [6 months]

   Using ImageJ software (version 1.52a) by FAG image. The Perifoveal non-perfusion area in FAG compare the degree of improvement or worsening of vision at baseline and 6 months. (value at 6 months minus value at baseline)

6. Safety Parameters [6 months]

   Systemic adverse events (MI, CVA, etc), Ocular adverse events (retinal detachment, RPE tear, endophthalmitis, uveitis, vitreous hemorrhage, subretinal hemorrhage, cataract , IOP elevation, etc) at baseline and each visit.

Eligibility Criteria

Criteria

• Ages Eligible for Study: 40 Years and Older
• Sexes Eligible for Study: All
• Accepts Healthy Volunteers: No

Inclusion Criteria:

• Patients (Male & female) ≥40 years of age

• Type 2 DM

• Best corrected visual acuity ≥ 20/200 (Snellen equivalent using Early Treatment Diabetic Retinopathy Study chart)

• central retinal thickness of ≥300 µm on optical coherence tomography

• nonproliferative diabetic retinopathy (NPDR) with diabetic macular edema

Exclusion Criteria:

• proliferative diabetic retinopathy

• Vitreous hemorrhage

• previous history of vitreoretinal surgery, post-cataract operation status (≤4 months before participation in this study)

• prior treatment with anti-VEGF drugs, intraocular corticosteroids, and/or retinal laser application

• Uncontrolled hypertension.

• Uncontrolled glaucoma.

• If both eyes met the study inclusion criteria, the more severely affected eye was selected

Contacts and Locations

Locations

No locations specified.

Sponsors and Collaborators

• Wonkwang University Hospital
• Novartis Korea Ltd.

Investigators

• Study Chair: Yunsik Yang, MD, Ph D, Department of Ophthalmology, Wonkwang University School of Medicine
• Principal Investigator: Seungjoon Lee, MD, Ph D, Study Official Affiliation should have no more than 80 characters.

Study Documents (Full-Text)

• Study Protocol and Statistical Analysis Plan - Jan 18, 2017
• Informed Consent Form - Jan 18, 2017

More Information

Publications

• Crawford TN, Alfaro DV 3rd, Kerrison JB, Jablon EP. Diabetic retinopathy and angiogenesis. Curr Diabetes Rev. 2009 Feb;5(1):8-13. Review.
• Ferrara N, Hillan KJ, Gerber HP, Novotny W. Discovery and development of bevacizumab, an anti-VEGF antibody for treating cancer. Nat Rev Drug Discov. 2004 May;3(5):391-400. Review.
• Hammes HP. Pericytes and the pathogenesis of diabetic retinopathy. Horm Metab Res. 2005 Apr;37 Suppl 1:39-43. Review.
• Han XX, Guo CM, Li Y, Hui YN. Effects of bevacizumab on the neovascular membrane of proliferative diabetic retinopathy: reduction of endothelial cells and expressions of VEGF and HIF-1α. Mol Vis. 2012;18:1-9. Epub 2012 Jan 1.
• Haritoglou C, Kernt M, Neubauer A, Gerss J, Oliveira CM, Kampik A, Ulbig M. Microaneurysm formation rate as a predictive marker for progression to clinically significant macular edema in nonproliferative diabetic retinopathy. Retina. 2014 Jan;34(1):157-64. doi: 10.1097/IAE.0b013e318295f6de.
• Hoeben A, Landuyt B, Highley MS, Wildiers H, Van Oosterom AT, De Bruijn EA. Vascular endothelial growth factor and angiogenesis. Pharmacol Rev. 2004 Dec;56(4):549-80. Review.
• Horii T, Murakami T, Nishijima K, Sakamoto A, Ota M, Yoshimura N. Optical coherence tomographic characteristics of microaneurysms in diabetic retinopathy. Am J Ophthalmol. 2010 Dec;150(6):840-8. doi: 10.1016/j.ajo.2010.06.015. Epub 2010 Sep 19.
• Kohner EM, Sleightholm M. Does microaneurysm count reflect severity of early diabetic retinopathy? Ophthalmology. 1986 May;93(5):586-9.
• Kohner EM, Stratton IM, Aldington SJ, Turner RC, Matthews DR. Microaneurysms in the development of diabetic retinopathy (UKPDS 42). UK Prospective Diabetes Study Group. Diabetologia. 1999 Sep;42(9):1107-12.
• Leicht SF, Kernt M, Neubauer A, Wolf A, Oliveira CM, Ulbig M, Haritoglou C. Microaneurysm turnover in diabetic retinopathy assessed by automated RetmarkerDR image analysis--potential role as biomarker of response to ranibizumab treatment. Ophthalmologica. 2014;231(4):198-203. doi: 10.1159/000357505. Epub 2014 Mar 19.
• Liinamaa MJ, Savolainen MJ. High vitreous concentration of vascular endothelial growth factor in diabetic patients with proliferative retinopathy using statins. Ann Med. 2008;40(3):209-14. doi: 10.1080/07853890701749209.
• Noma H, Funatsu H, Yamasaki M, Tsukamoto H, Mimura T, Sone T, Hirayama T, Tamura H, Yamashita H, Minamoto A, Mishima HK. Aqueous humour levels of cytokines are correlated to vitreous levels and severity of macular oedema in branch retinal vein occlusion. Eye (Lond). 2008 Jan;22(1):42-8. Epub 2006 Jul 7.
• Nunes S, Pires I, Rosa A, Duarte L, Bernardes R, Cunha-Vaz J. Microaneurysm turnover is a biomarker for diabetic retinopathy progression to clinically significant macular edema: findings for type 2 diabetics with nonproliferative retinopathy. Ophthalmologica. 2009;223(5):292-7. doi: 10.1159/000213639. Epub 2009 Apr 16.
• Photocoagulation treatment of proliferative diabetic retinopathy. Clinical application of Diabetic Retinopathy Study (DRS) findings, DRS Report Number 8. The Diabetic Retinopathy Study Research Group. Ophthalmology. 1981 Jul;88(7):583-600.
• Ribeiro ML, Nunes SG, Cunha-Vaz JG. Microaneurysm turnover at the macula predicts risk of development of clinically significant macular edema in persons with mild nonproliferative diabetic retinopathy. Diabetes Care. 2013 May;36(5):1254-9. doi: 10.2337/dc12-1491. Epub 2012 Nov 30.
• Roy S, Ha J, Trudeau K, Beglova E. Vascular basement membrane thickening in diabetic retinopathy. Curr Eye Res. 2010 Dec;35(12):1045-56. doi: 10.3109/02713683.2010.514659. Epub 2010 Oct 7. Review.
• Sjølie AK, Klein R, Porta M, Orchard T, Fuller J, Parving HH, Bilous R, Aldington S, Chaturvedi N. Retinal microaneurysm count predicts progression and regression of diabetic retinopathy. Post-hoc results from the DIRECT Programme. Diabet Med. 2011 Mar;28(3):345-51. doi: 10.1111/j.1464-5491.2010.03210.x.
• Stitt AW, Gardiner TA, Archer DB. Histological and ultrastructural investigation of retinal microaneurysm development in diabetic patients. Br J Ophthalmol. 1995 Apr;79(4):362-7.
• Usui T, Ishida S, Yamashiro K, Kaji Y, Poulaki V, Moore J, Moore T, Amano S, Horikawa Y, Dartt D, Golding M, Shima DT, Adamis AP. VEGF164(165) as the pathological isoform: differential leukocyte and endothelial responses through VEGFR1 and VEGFR2. Invest Ophthalmol Vis Sci. 2004 Feb;45(2):368-74.

• Responsible Party: Yun-Sik Yang, MD, PhD, Wonkwang University Hospital
• ClinicalTrials.gov Identifier: NCT02834663
• Other Study ID Numbers: CRFB002DKR03T
• First Posted: Jul 15, 2016
• Last Update Posted: May 22, 2020
• Last Verified: May 1, 2020

• Individual Participant Data (IPD) Sharing Statement: No
• Plan to Share IPD: No
• Keywords provided by Yun-Sik Yang, MD, PhD, Wonkwang University Hospital: Nonproliferative diabetic retinopathy, Microaneurysms
• Additional relevant MeSH terms: Macular Edema; Retinal Diseases; Diabetic Retinopathy; Ranibizumab

Study Results

Participant Flow

Recruitment Details	This was an interventional, prospective, single-center study conducted at Wonkwang University Hospital from August 2016 to February 2019. All patients included in the study provided signed, informed consent prior to enrollment.
Pre-assignment Detail	previous history of vitreoretinal surgery, post-cataract operation status (≤4 months before participation in this study), uncontrolled hypertension, or glaucoma were excluded from the study.

Arm/Group Title	Lucentis(Ranivizumab)
Arm/Group Description	25 eyes of 25 type 2 diabetes mellitus patients with macular edema were included between August 2016 and February 2019. For 6 months, patients were administered 0.5-mg intra-vitreal Lucentis(Ranibizumab) injections monthly.
Period Title: Overall Study
STARTED	25
COMPLETED	25
NOT COMPLETED	0

Baseline Characteristics

Arm/Group Title	Baseline Characteristics
Arm/Group Description	Totally, 25 eyes of 25 patients (13 males, 12 females, mean age 63.80±11.45 years; range: 41-80 years) were included in the study
Overall Participants	25
Age (years) [Mean (Standard Deviation) ]
Mean (Standard Deviation) [years]	63.80 (11.45)
Sex: Female, Male (Count of Participants)
Female	12 48%
Male	13 52%
Race (NIH/OMB) (Count of Participants)
American Indian or Alaska Native	0 0%
Asian	25 100%
Native Hawaiian or Other Pacific Islander	0 0%
Black or African American	0 0%
White	0 0%
More than one race	0 0%
Unknown or Not Reported	0 0%
Duration of Diabetes Mellitus(DM) (year) (years) [Mean (Standard Deviation) ]
Mean (Standard Deviation) [years]	12.04 (7.475)
HbA1c(%) (%) [Mean (Standard Deviation) ]
Mean (Standard Deviation) [%]	8.27 (2.11)
BCVA (ETDRS letters) (ETDRS letters) [Mean (Standard Deviation) ]
Mean (Standard Deviation) [ETDRS letters]	67.60 (3.29)
CRT (um) (um) [Mean (Standard Deviation) ]
Mean (Standard Deviation) [um]	479.12 (16.66)
Total microaneurysms (number) (microaneurysms) [Mean (Standard Deviation) ]
Mean (Standard Deviation) [microaneurysms]	5.68 (3.41)
Microaneurysm-turnover (microaneurysms/month) [Mean (Standard Deviation) ]
Mean (Standard Deviation) [microaneurysms/month]	6.88 (3.83)
Perifoveal non-perfused area (mm^2) (mm^2) [Mean (Standard Deviation) ]
Mean (Standard Deviation) [mm^2]	2.517 (0.456)

Outcome Measures

1. Primary Outcome

Title	The Best Corrected Visual Acuity (BCVA)
Description	BCVA was performed using the Early Treatment Diabetic Retinopathy Study (ETDRS) chart at baseline and 6 months. The BCVA compare the degree of improvement or worsening of vision at baseline and 6 months. (value at 6 months minus value at baseline)
Time Frame	6 months

Outcome Measure Data

Analysis Population Description

Totally, 25 eyes of 25 patients (13 males, 12 females, mean age 63.80±11.45 years; range: 41-80 years) were included in the study.

Arm/Group Title	BCVA Baseline	BCVA Resulte
Arm/Group Description	Before the treatment regimen, assessment of BCVA using the ETDRS charts.	After completion of the treatment regimen during 6 months, assessment of BCVA using the ETDRS charts.
Measure Participants	25	25
Mean (Standard Deviation) [letters]	67.6 (3.29)	76.36 (1.61)

Statistical Analysis 1

Statistical Analysis Overview	Comparison Group Selection	BCVA Baseline, BCVA Resulte
	Comments	Patients were evaluated for changes in BCVA of the treated eye, from the start of the study till 6 months, until trial completion. After administration of each injection, measurements of BCVA were compared to their respective baseline results. The paired t-test and repeated measures ANOVA was performed for comparative analysis, as all showed normality.
	Type of Statistical Test	Superiority
	Comments
Statistical Test of Hypothesis	p-Value	<0.0001
	Comments	The threshold for statistical significance was p < 0.05
	Method	t-test, 2 sided
	Comments
Method of Estimation	Estimation Parameter	Mean Difference (Final Values)
	Estimated Value	-8.760
	Confidence Interval	(2-Sided) 95%; -13.928 to -3.592
	Parameter Dispersion	Type: Standard Deviation; Value: 12.521
	Estimation Comments

2. Primary Outcome

Title	Central Macular Thickness(CMT)
Description	CRT was performed using OCT at each visit. The OCT measured at each visit was analyzed statistically. the CMT compare the degree of improvement or worsening of vision at baseline and 6 months. (value at 6 months minus value at baseline)
Time Frame	6 months

Outcome Measure Data

Analysis Population Description

Totally, 25 eyes of 25 patients (13 males, 12 females, mean age 63.80±11.45 years; range: 41-80 years) were included in the study.

Arm/Group Title	CRT Baseline	CRT Resulte
Arm/Group Description	Before the treatment regimen, assessment of CRT using the OCT.	After the treatment regimen during 6 months, assessment of CRT using the OCT.
Measure Participants	25	25
Mean (Standard Deviation) [um]	479.12 (16.66)	369.12 (13.02)

Statistical Analysis 1

Statistical Analysis Overview	Comparison Group Selection	BCVA Baseline, BCVA Resulte
	Comments
	Type of Statistical Test	Superiority
	Comments
Statistical Test of Hypothesis	p-Value	0.0001
	Comments	The threshold for statistical significance was p < 0.05
	Method	t-test, 2 sided
	Comments
Method of Estimation	Estimation Parameter	Mean Difference (Final Values)
	Estimated Value	110
	Confidence Interval	(2-Sided) 95%; 82.790 to 137.210
	Parameter Dispersion	Type: Standard Deviation; Value: 65.919
	Estimation Comments

3. Secondary Outcome

Title	The Total Number of Microaneurysm
Description	The number of MAs in individual retinas were evaluated during 6 months using fundus photography and FA imaging. The Retmarker software was used for automatic measurement and analysis of changes in number and extent of MAs on fundus photographs and to calculate the total number and turnover of MAs. Changes in MAs were analyzed statistically. the total number of MAs compare the degree of improvement or worsening of vision at baseline and 6 months. (value at 6 months minus value at baseline)
Time Frame	6 months

Outcome Measure Data

Analysis Population Description

Totally, 25 eyes of 25 patients (13 males, 12 females, mean age 63.80±11.45 years; range: 41-80 years) were included in the study.

Arm/Group Title	Total MA Baseline	Total MA Resulte
Arm/Group Description	The number of MAs in individual retinas were evaluated at first visit using fundus photography and FA imaging. The Retmarker software was used for automatic measurement and analysis of changes in number and extent of MAs on fundus photographs and to calculate the total number and turnover of MAs.	The number of MAs in individual retinas were evaluated during 6 months using fundus photography and FA imaging. The Retmarker software was used for automatic measurement and analysis of changes in number and extent of MAs on fundus photographs and to calculate the total number and turnover of MAs.
Measure Participants	25	25
Mean (Standard Deviation) [microaneurysms]	5.68 (3.41)	1.60 (1.73)

Statistical Analysis 1

Statistical Analysis Overview	Comparison Group Selection	BCVA Baseline, BCVA Resulte
	Comments
	Type of Statistical Test	Superiority
	Comments
Statistical Test of Hypothesis	p-Value	0.001
	Comments	The threshold for statistical significance was p < 0.05
	Method	t-test, 2 sided
	Comments
Method of Estimation	Estimation Parameter	Mean Difference (Final Values)
	Estimated Value	3.920
	Confidence Interval	(2-Sided) 95%; 1.884 to 5.956
	Parameter Dispersion	Type: Standard Deviation; Value: 4.932
	Estimation Comments

4. Secondary Outcome

Title	The Microaneurysm Formation Rate
Description	number of new MAs detected/month The MAs in individual retinas were evaluated at 6 months using fundus photography. The Retmarker (version 1.0.2 by Retmarker Ltd, Coimbra, Portugal) software was used for automatic measurement and analysis of changes in number and extent of MAs on fundus photographs and to calculate the total number and turnover of MAs. MA turnover was calculated by adding the MA formation rate (number of new MAs detected/month) to the MA disappearance rate (number of MAs that resolved/month). The microaneurysm formation rate compare the degree of improvement or worsening of vision at baseline and 6 months. (value at 6 months minus value at baseline)
Time Frame	6 months

Outcome Measure Data

Analysis Population Description

Totally, 25 eyes of 25 patients (13 males, 12 females, mean age 63.80±11.45 years; range: 41-80 years) were included in the study.

Arm/Group Title	The MA Formation Rate Baseline	The MA Formation Rate Resulte
Arm/Group Description	The Retmarker software was used for automatic measurement and analysis of MA formation at first visit.	The Retmarker software was used for automatic measurement and analysis of MA formation during monthly 6 months
Measure Participants	25	25
Mean (Standard Deviation) [microaneurysms/month]	2.48 (1.98)	0.96 (1.02)

Statistical Analysis 1

Statistical Analysis Overview	Comparison Group Selection	BCVA Baseline, BCVA Resulte
	Comments
	Type of Statistical Test	Superiority
	Comments
Statistical Test of Hypothesis	p-Value	0.0001
	Comments	The threshold for statistical significance was p < 0.05
	Method	t-test, 2 sided
	Comments
Method of Estimation	Estimation Parameter	Mean Difference (Final Values)
	Estimated Value	2.23
	Confidence Interval	(2-Sided) 95%; 1.30 to 3.15
	Parameter Dispersion	Type: Standard Deviation; Value: 2.24
	Estimation Comments

5. Secondary Outcome

Title	The Microaneurysm Disappearance Rate
Description	Number of MAs that resolved/month The MAs in individual retinas were evaluated at 6 months using fundus photography. The Retmarker (version 1.0.2 by Retmarker Ltd, Coimbra, Portugal) software was used for automatic measurement and analysis of changes in number and extent of MAs on fundus photographs and to calculate the total number and turnover of MAs. MA turnover was calculated by adding the MA formation rate (number of new MAs detected/month) to the MA disappearance rate (number of MAs that resolved/month). The microaneurysm disappearance rate compare the degree of improvement or worsening of vision at baseline and 6 months. (value at 6 months minus value at baseline)
Time Frame	6 months

Outcome Measure Data

Analysis Population Description

Totally, 25 eyes of 25 patients (13 males, 12 females, mean age 63.80±11.45 years; range: 41-80 years) were included in the study.

Arm/Group Title	The MA Disappearance Rate Baseline	The MA Disappearance Rate Resulte
Arm/Group Description	The Retmarker software was used for automatic measurement and analysis of MA disappearance at first visit.	The Retmarker software was used for automatic measurement and analysis of MA disappearance during monthly 6 months.
Measure Participants	25	25
Mean (Standard Deviation) [microaneurysms/month]	4.40 (2.66)	0.96 (1.09)

Statistical Analysis 1

Statistical Analysis Overview	Comparison Group Selection	BCVA Baseline, BCVA Resulte
	Comments
	Type of Statistical Test	Superiority
	Comments
Statistical Test of Hypothesis	p-Value	0.0001
	Comments	The threshold for statistical significance was p < 0.05
	Method	t-test, 2 sided
	Comments
Method of Estimation	Estimation Parameter	Mean Difference (Final Values)
	Estimated Value	5.64
	Confidence Interval	(2-Sided) 95%; 2.67 to 8.62
	Parameter Dispersion	Type: Standard Deviation; Value: 7.21
	Estimation Comments

6. Secondary Outcome

Title	The Microaneurysm Turnover
Description	The microaneurysm formation rate + The microaneurysm disappearance rate The MAs in individual retinas were evaluated at 6 months using fundus photography. The Retmarker (version 1.0.2 by Retmarker Ltd, Coimbra, Portugal) software was used for automatic measurement and analysis of changes in number and extent of MAs on fundus photographs and to calculate the total number and turnover of MAs. MA turnover was calculated by adding the MA formation rate (number of new MAs detected/month) to the MA disappearance rate (number of MAs that resolved/month). The microaneurysm turnover compare the degree of improvement or worsening of vision at baseline and 6 months. (value at 6 months minus value at baseline)
Time Frame	6 months

Outcome Measure Data

Analysis Population Description

Totally, 25 eyes of 25 patients (13 males, 12 females, mean age 63.80±11.45 years; range: 41-80 years) were included in the study.

Arm/Group Title	The Microaneurysm Turnover Baseline	The Microaneurysm Turnover Results
Arm/Group Description	The Retmarker software was used for automatic measurement and analysis of MA turnover at first visit.	The Retmarker software was used for automatic measurement and analysis of MA turnover during monthly 6 months.
Measure Participants	25	25
Mean (Standard Deviation) [microaneurysms/month]	6.88 (3.83)	1.92 (1.75)

Statistical Analysis 1

Statistical Analysis Overview	Comparison Group Selection	BCVA Baseline, BCVA Resulte
	Comments
	Type of Statistical Test	Superiority
	Comments
Statistical Test of Hypothesis	p-Value	0.0001
	Comments	The threshold for statistical significance was p < 0.05
	Method	t-test, 2 sided
	Comments
Method of Estimation	Estimation Parameter	Mean Difference (Final Values)
	Estimated Value	5.64
	Confidence Interval	(2-Sided) 95%; 2.67 to 8.62
	Parameter Dispersion	Type: Standard Deviation; Value: 7.21
	Estimation Comments

7. Secondary Outcome

Title	Perifoveal Non-perfusion Area in FAG (mm²)
Description	Using ImageJ software (version 1.52a) by FAG image. The Perifoveal non-perfusion area in FAG compare the degree of improvement or worsening of vision at baseline and 6 months. (value at 6 months minus value at baseline)
Time Frame	6 months

Outcome Measure Data

Analysis Population Description

Totally, 25 eyes of 25 patients (13 males, 12 females, mean age 63.80±11.45 years; range: 41-80 years) were included in the study.

Arm/Group Title	Perifoveal Non-perfusion Area Baseline	Perifoveal Non-perfusion Area Results
Arm/Group Description	The perifoveal non-perfused areas in individual retinas were evaluated at first visit using fundus photography and FA imaging. The Retmarker software was used for automatic measurement and analysis of changes in number and extent of MAs on fundus photographs and to calculate the total number and turnover of MAs	The perifoveal non-perfused areas in individual retinas were evaluated during monthly 6 months using fundus photography and FA imaging. The Retmarker software was used for automatic measurement and analysis of changes in number and extent of MAs on fundus photographs and to calculate the total number and turnover of MAs
Measure Participants	25	25
Mean (Standard Deviation) [mm2]	2.517 (0.456)	2.495 (0.293)

Statistical Analysis 1

Statistical Analysis Overview	Comparison Group Selection	BCVA Baseline, BCVA Resulte
	Comments
	Type of Statistical Test	Superiority
	Comments
Statistical Test of Hypothesis	p-Value	0.221
	Comments	The threshold for statistical significance was p < 0.05
	Method	t-test, 2 sided
	Comments
Method of Estimation	Estimation Parameter	Mean Difference (Final Values)
	Estimated Value	0.021
	Confidence Interval	(2-Sided) 95%; -0.751 to 0.795
	Parameter Dispersion	Type: Standard Deviation; Value: 1.87
	Estimation Comments

8. Secondary Outcome

Title	Safety Parameters
Description	Systemic adverse events (MI, CVA, etc), Ocular adverse events (retinal detachment, RPE tear, endophthalmitis, uveitis, vitreous hemorrhage, subretinal hemorrhage, cataract , IOP elevation, etc) at baseline and each visit.
Time Frame	6 months

Outcome Measure Data

Analysis Population Description

Totally, 25 eyes of 25 patients (13 males, 12 females, mean age 63.80±11.45 years; range: 41-80 years) were included in the study.

Arm/Group Title	Safety Parameters Results
Arm/Group Description	Complications and adverse events on patients were evaluated.
Measure Participants	25
Count of Participants [Participants]	0 0%

Adverse Events

Time Frame	Twenty-five eyes of 25 type 2 diabetes mellitus patients with DME were included between August 2016 and February 2019. For 6 months, patients were administered 0.5-mg IVR injections monthly.
Adverse Event Reporting Description	Ocular evaluation, including best-corrected visual acuity (BCVA; using the Early Treatment Diabetic Retinopathy Study chart), central retinal thickness (CRT; using optical coherence tomography), fundus photography, and fluorescein angiography, was performed for all participants. Results obtained at baseline were compared to those observed after 6 months.
Arm/Group Title	Adverse Event
Arm/Group Description	Systemic adverse events (MI, CVA, etc), Ocular adverse events (retinal detachment, RPE tear, endophthalmitis, uveitis, vitreous hemorrhage, subretinal hemorrhage, cataract , IOP elevation, etc) on patients were evaluated.
All Cause Mortality
	Adverse Event
	Affected / at Risk (%)	# Events
Total	0/25 (0%)
Serious Adverse Events
	Adverse Event
	Affected / at Risk (%)	# Events
Total	0/25 (0%)
Other (Not Including Serious) Adverse Events
	Adverse Event
	Affected / at Risk (%)	# Events
Total	0/25 (0%)

Limitations/Caveats

[Not Specified]

More Information

Certain Agreements

Principal Investigators are NOT employed by the organization sponsoring the study.

There is NOT an agreement between Principal Investigators and the Sponsor (or its agents) that restricts the PI's rights to discuss or publish trial results after the trial is completed.