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To the Editor:
We thank Drs. Khodifad and Baskaran1 for their letter to the editor regarding our publication titled “Intravitreal Bevacizumab for Proliferative diabetic retinopathy: Results from the Pan-American Collaborative Retina Study Group (PACORES) at 24 months of Follow-up” (Retina 2017;37:334–343).2
Drs. Khodifad and Baskaran1 point out that the number of patients on insulin, oral hypoglycemic agents, or both were 30, 23, and 44, respectively, which sums up to 97 “patients,” and that the total number of patients included in the study was only 81. However, in the footnotes to Table 1, we state that the item “Systemic Glycemic Control (n/%)” that “n” refers to number of eyes.
Drs. Khodifad and Baskaran1 state correctly that of the 37 treatment naive eyes, 18 eyes received “immediate panretinal photocoagulation (PRP).” In the “Methods,” we clarified that our patients were examined at 1 week, 2 weeks, and 1 month after the first injection and monthly thereafter. An assessment for retreatment with intravitreal bevacizumab (IVB), retreatment with laser, or initiation of laser treatment, occurred at each visit. Patients received reinjections if ophthalmic examination or fluorescein angiography indicated that retinal neovascularization was not completely resolved. We used the term “immediate PRP” when a patient with proliferative diabetic retinopathy (PDR) treated with primary IVB was subsequently treated with PRP within 3 months after the first IVB therapy. Therefore, “immediate PRP” implies no response to IVB after at least two injections.
A separate subgroup analysis of patients who required immediate PRP may have significant limitations of subgroup analysis especially in the setting of a small retrospective study. In addition, data on the results of PRP compared with anti–vascular endothelial growth factor therapy are published from a multicenter randomized clinical trial.3
Drs. Khodifad and Baskaran1 also comment on our three treatment naive eyes (without previous PRP) that avoided vitreoretinal surgery. These patients were treated with only IVB as stated in the article.
We encourage the readers to keep in mind that we have reported real world data and that strict follow-up of PDR patients is required for treatment with IVB. The rate of IVB injections delivered in our study (4 ± 2.5 injections [range, 1–8 injections]) over 2 years resulted in marked regression of retinal neovascularization in patients with PDR and previous PRP. However, in naive-eyes, only a minority of patients achieved control or regression of PDR with IVB injections and most patients required PRP or vitrectomy at the end of follow-up.
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