1. The Diabetic Retinopathy Clinical Research Network Comparison of Visual and OCT Outcomes in Eyes with and without Prior Vitrectomy Receiving Anti- Vascular Endothelial Growth Factor Treatment in a Randomized Trial Evaluating Ranibizumab Prompt or Deferred Laser for Diabetic Macular Edema 1

2. Background  Results from DRCR Network showed intravitreous ranibizumab with prompt or deferred laser is more effective than prompt laser alone through at least 2 years for the treatment of center-involved DME, and the vision benefits attained at year 1 appear to be sustained thru at least 3 years of follow-up  It has been suggested that the duration of action of anti-VEGF agents in eyes with prior vitrectomy would be shorter compared with eyes without prior vitrectomy due to more rapid drug clearance  Lack of supporting data that confirms this hypothesis in a clinical setting, with the exception of 2 small and short term series of DME eyes treated with bevacizumab *† 2 Kondo M, Ito Y, Terasaki H. Intravitreal Bevacizumab (Avastin) for Treatment of Persistent Macular Edema in Vitrectomized Eyes. RETINAL CASES & BRIEF REPORTS 1:195–197, 2007 † Yanyali A, Aytug B, Horozoglu F, et al. Bevacizumab (Avastin) for Diabetic Macular Edema in Previously Vitrectomized Eyes. Am J Ophthalmol 2007;144:124–126.

3. Primary Objective To compare functional and anatomic outcomes in eyes treated with ranibizumab, with or without prior vitrectomy, from the Laser-Ranibizumab-Triamcinolone (LRT) Trial for Diabetic Macular Edema (Protocol I) within the DRCR Network 3

4. Methods  Exploratory analysis of study eyes with and without vitrectomy prior to enrollment assigned to intravitreous ranibizumab with prompt or deferred laser.  Visual acuity (VA), OCT central subfield thickness (CST), OCT volume and the number of injections from baseline thru 3 years* evaluated by pre-enrollment vitrectomy status.  Follow-up data censored from day of vitrectomy for eyes undergoing initial vitrectomy during study follow-up 4 *156 weeks

5. Results 5

6. Baseline Characteristics Baseline characteristics were balanced between vitrectomy status groups with respect to subject-level demographic, medical history, and diabetes-related factors, including: age diabetes type pre-existing cardiovascular conditions HbA1c However, imbalances were present for a number of eye-level factors related to DR and DME severity and prior treatment 6

7. Baseline Characteristics Ocular CharacteristicsVitrectomy Status Yes (N = 25, 7%) No (N = 335, 93%) Visual Acuity Mean letter score (Snellen Equivalent) 59 (20/63) 63 (20/63) OCT CSF Thickness (Stratus) Mean (25 th, 75 th percentile)368 (290, 471)408 (311, 484) OCT Volume (mm 3 ) Mean (25 th, 75 th percentile)8.3 (7.5, 8.8)8.9 (7.5, 9.7) 7

8. Baseline Characteristics Ocular CharacteristicsVitrectomy Status Yes (N = 25) No (N = 336) Prior PRP 64%20% Prior DME Treatment96%61% Prior Treatment with Anti-VEGF for DME 20%12% Lens Status Phakic36%72% Pseudophakic64%28% 8

9. Baseline Characteristics Ocular CharacteristicsVitrectomy Status Yes (N = 25) No (N = 336) DR Severity on clinical exam None/Microaneurysms only 8%3% Mild/moderate NPDR16%55% Severe NPDR4%21% PDR and/or prior scatter72%21% Randomized treatment assignment Ranibizumab + prompt laser64%49% Ranibizumab + deferred laser36%51% 9 7 variables identified as imbalanced, which may affect outcomes: VA, OCT CSF thickness and volume, Prior PRP, Prior DME treatment, Prior anti-VEGF for DME, Lens status, DR severity, and randomized assignment to specific ranibizumab group.

10. Adjusted Mean Change in Visual Acuity by Pre-Enrollment Vitrectomy Status Means were adjusted for 6 of 7 imbalanced baseline covariates (exception was OCT volume). No difference was identified between groups 10 N = 306 N = 19 N = 24 N = 20 N = 255 N = 312 N = 283

11. Adjusted Mean Change in CSF Thickness by Pre-Enrollment Vitrectomy Status Means were adjusted for imbalanced baseline covariates. N = 19 11 P = 0.009 P = 0.035 N = 23 P =0.24 N = 24 P =0.33 P =0.11 N = 19 N = 305 N = 310 N = 278 N = 251

12. Adjusted Mean Differences Between Non-vitrectomized and Vitrectomized Eyes Visit - Week52 Week Visit104 Week Visit156 Week Visit Mean Change in Visual Acuity Letter Score Vitrectomized8.910.87.6 Non-vitrectomized9.08.98.7 Difference (99%CIs)-0.1 (-5.1, 4.8)2.0 (-3.0, 6.9)-1.1 (-6.3, 4.1) Mean Change in Central Subfield Thickness (μm) Vitrectomized-115-131-124 Non-vitrectomized-138-150-157 Difference (99%CIs)22 (-27, 71)18 (-30, 67)33 (-19, 85) Mean Change in OCT Volume (mm 3 ) Vitrectomized-1.3-1.6 Non-vitrectomized-1.5-1.6-1.7 Difference (99%CIs)0.2 (-0.4 0.8)0.0 (-0.5, 0.6)-0.1 (-0.5, +0.7) Mean differences in VA and CSF were adjusted for imbalanced baseline covariates. OCT CST and volume converted to Zeiss Stratus equivalent values. 12

13. Treatment 13

14. Number of anti-VEGF Injections During Follow-up Visits by Vitrectomy Status Vitrectomy Status Median (25 th, 75 th percentile) NVitrectomizedNNon-vitrectomized Baseline to 24 week visit 256 (5, 6)3176 (5, 6) >24 to 52 week visit 245 (2, 6)3123 (1, 5) >52 to 104 week visit242 (0, 8)284 2 (0, 5) >104 to 156 week visit201 (0, 2) 2581 (0, 4) 14

15. Number of anti-VEGF Injections During Follow-up Visits by Vitrectomy Status Vitrectomy Status Median (25 th, 75 th percentile) NVitrectomizedNNon-vitrectomized Baseline to 24 week visit 256 (5, 6)3176 (5, 6) >24 to 52 week visit 245 (2, 6)3123 (1, 5) >52 to 104 week visit242 (0, 8)284 2 (0, 5) >104 to 156 week visit201 (0, 2) 2581 (0, 4) Baseline to 156 week visit2013 (9, 22) 25813 (8, 19) 15

16. Laser Treatment by Pre-Enrollment Vitrectomy Status and Treatment Arm TreatmentRanibizumab + Laser Group Ranibizumab + Deferred Laser Group Follow-Up Time Vitrectomy Status YesNoYesNo Baseline up to 52 weeks N = 15N = 150N = 9N = 162 Median (q1, q3) 2 (1, 3) 1 (0, 1)0 (0, 1) Baseline up to 156 weeks N = 13N = 126N = 7N = 132 Median (q1, q3) 2 (1, 3)3 (2, 4)1 (1, 2)0 (0, 2) 16 Ranibizumab + Deferred laser: Vitrectomy Gp: 1 of 7 eyes (14%) no laser Non-vitrectomy Gp: 75 of 132 eyes (57%) no laser; p=0.05

17. Limitations of this Analysis  Post-hoc nature of study  Limited number of cases with prior vitrectomy  Potential differences (confounding factors) other than vitrectomy between the eyes in the vitrectomy and no prior vitrectomy groups that might account for differences noted 17

18. Conclusions  Among the small group of eyes with vitrectomy prior to enrollment, change in VA and OCT thickness from baseline and number of injections and lasers, appears similar to eyes without prior vitrectomy, after adjustment for baseline differences in ocular and prior treatment characteristics* Note: during the 1 st year of treatment, eyes without prior vitrectomy appeared to have more rapid reduction in retinal thickness.  This exploratory analysis showed little evidence that eyes similar to those enrolled and treated in this trial with DME and a history of prior vitrectomy would have a clinically different result, particularly in the long run, from those without vitrectomy. * VA, OCT CSF thickness (and volume for volume outcome), DR severity, Prior PRP, Prior DME treatment, Prior anti-VEGF for DME, lens status, and randomized treatment assignment 18