Risk of excessive macular thinning in diabetic macular edema with ellipsoid zone disruption treated with anti-VEGF: 2-year real-world evidence

This study investigates whether different morphological features affect the best-corrected visual acuity (BCVA) and central macular thickness (CMT) in patients with diabetic macular edema (DME) undergoing anti–vascular endothelial growth factor (anti-VEGF) therapy. We retrospectively collected data from 727 eyes of 464 patients with DME who received either ranibizumab or aflibercept. We constructed mixed-effects regression models to determine if different morphological features shown on optical coherence tomography would affect post-treatment BCVA and CMT after controlling for clinical variables. In eyes with ellipsoid zone disruption (EZD), the relationship between baseline BCVA and achieving a final CMT < 200 μm was further examined. After 24 months of anti-VEGF treatment, patients demonstrated improvements in BCVA and reductions in CMT. Poorer post-treatment BCVA was associated with older age, longer treatment duration, EZD (p = 0.017) and disorganization of the retinal inner layers (DRIL) (p = 0.001). Excessive macular thinning (final CMT < 200 μm) was more frequently observed in eyes with EZD, particularly among those with a baseline BCVA < 15 ETDRS letters, in exploratory subgroup analyses. The association appeared more pronounced among individuals with increased hyperreflective foci (HRF) in the outer retina. In DME eyes with EZD, a poorer baseline BCVA and increased HRF appear to be statistically associated with excessive macular thinning following anti-VEGF treatment.