Diabetic Retinopathy Clinical Research Network

Diabetic Retinopathy Clinical Research Network Intravitreal Ranibizumab or Triamcinolone Acetonide as Adjunctive Treatment to Panretinal Photocoagulation for Proliferative Diabetic Retinopathy Version 5.0 March 24, 2008 J- LRT for PDR Protocol 3-24-08 V5.0.doc

Contact Information Coordinating Center Jaeb Center for Health Research 15310 Amberly Drive, Suite 350 Tampa, FL 33647 Phone: 813-975-8690 Fax: 800-816-7601 Director: Roy W. Beck, M.D., Ph.D. Email: rbeck@jaeb.org Network Chair Neil M. Bressler, MD Wilmer Eye Institute Johns Hopkins 600 North Wolfe Street Baltimore, MD 21287-9226 Phone: (410) 955-8342 Fax: (410) 955-0845 Email: nbressler@jhmi.edu Protocol Chair Alexander J. Brucker, MD Scheie Eye Institute 51 North 39th Street Philadelphia, PA 19104 Phone: (215) 662-8675 Fax: (215) 243-4696 Email: ajbrucke@mail.med.upenn.edu J- LRT for PDR Protocol 3-24-08 V5.0.doc

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 Table of Contents Chapter 1. Background Information and Study Synopsis...1-3 1.1 Background and Rationale...1-3 1.1.1 Public Health Impact of Diabetic Retinopathy...1-3 1.1.2 Proliferative Diabetic Retinopathy: Impact on Vision Loss, Treatment, and Complications from Treatment...1-3 1.1.3 Rationale for Adjunctive Therapy to Scatter (Panretinal) Photocoagulation...1-5 1.2 Study Objectives and Hypothesis...1-7 1.3 Study Design and Synopsis of Protocol...1-8 1.4 General Considerations...1-11 Chapter 2. Subject Eligibility and Enrollment...2-1 2.1 Identifying Eligible Subjects and Obtaining Informed Consent...2-1 2.2 Subject Eligibility Criteria...2-1 2.2.1 Subject-level Criteria...2-1 2.2.2 Study Eye Criteria...2-2 2.2.3 Fellow Eye Criteria...2-4 2.3 Screening Evaluation and Baseline Testing...2-5 2.3.1 Historical Information...2-5 2.3.2 Baseline Testing Procedures...2-5 2.4 Enrollment/Randomization of Eligible Subjects...2-6 Chapter 3. Treatment Regimens...3-1 3.1 Introduction...3-1 3.2 Panretinal Photocoagulation Regimen...3-1 3.2.1 Additional Scatter Photocoagulation for Proliferative Diabetic Retinopathy...3-2 3.2.2 Deferral of Additional Scatter Photocoagulation for Decreased Visual Acuity from Exacerbation of Macular Edema...3-2 3.3 Focal Photocoagulation Technique...3-3 3.4 Ranibizumab (Lucentis )...3-4 3.5 Triamcinolone Acetonide...3-4 3.6 Intravitreal Injection Technique...3-4 3.6.1 Sham Injection Technique...3-4 3.7 Miscellaneous Considerations...3-4 Chapter 4. Follow-up Visits...4-1 4.1 Visit Schedule...4-1 4.2 Testing Procedures...4-1 Chapter 5. Miscellaneous Considerations in Follow-up...5-1 5.1 Endophthalmitis...5-1 5.2 Surgery for Vitreous Hemorrhage and Other Complications of Diabetic Retinopathy...5-1 5.3 Treatment of Macular Edema in Nonstudy Eye...5-1 5.4 Diabetes Management...5-1 5.5 Subject Withdrawal and Losses to Follow-up...5-1 5.6 Discontinuation of Study...5-1 5.7 Contact Information Provided to the Coordinating Center...5-1 5.8 Subject Reimbursement...5-2 J- LRT for PDR Protocol 3-24-08 V5.0.doc 1-1

45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 Chapter 6. Adverse Events...6-1 6.1 Definition...6-1 6.2 Recording of Adverse Events...6-1 6.3 Reporting Serious or Unexpected Adverse Events...6-1 6.4 Data and Safety Monitoring Committee Review of Adverse Events...6-2 6.5 Risks...6-2 6.5.1 Potential Adverse Effects of the Study Drugs...6-2 6.5.2 Potential Adverse Effects of Intravitreal Injection...6-3 6.5.3 Risks of Focal Photocoagulation Treatment...6-4 6.5.4 Risks of Panretinal Photocoagulation Treatment...6-4 6.5.5 Risks of Eye Examination and Tests...6-2 Chapter 7. Statistical Methods...7-1 7.1 Sample Size...7-1 7.1.1 Projected Proportions...7-1 7.1.2 Sample Size Estimation...7-1 7.1.3 Power for Secondary Analysis...7-3 7.2 Efficacy Analysis Plan...7-3 7.2.1 Principles for Analysis...7-3 7.2.2 Visual Acuity...7-4 7.2.3 OCT Outcome...7-4 7.2.4 Fundus Photographs...7-5 7.2.5 Additional Outcomes...7-5 7.2.6 Formal Interim Efficacy Analyses...7-5 7.3 Safety Analysis Plan...7-5 7.4 Additional Tabulations and Analyses...7-6 References...8-1 J- LRT for PDR Protocol 3-24-08 V5.0.doc 1-2

72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 CHAPTER 1. BACKGROUND INFORMATION AND STUDY SYNOPSIS 1.1 Background and Rationale 1.1.1 Public Health Impact of Diabetic Retinopathy It is estimated that diabetes mellitus affects 4 percent of the world s population, almost half of whom have some degree of diabetic retinopathy at any given time. Diabetic retinopathy (DR) remains the leading cause of visual loss and new-onset blindness in the United States for those 20 through 74 years of age. 1 The prevalence of DR in diabetic patients older than 40 years of age exceeds 40%, with 5%-10% developing vision-threatening complications, including proliferative diabetic retinopathy (PDR), severe non-proliferative diabetic retinopathy, or macular edema. 1 Given the aging US population and the concomitant increasing age-specific prevalence of diabetes, the public health impact of DR is enormous. 2 Visual loss from DR is not restricted to patients with type 2 diabetes, nor to middle-age or older individuals. Amongst 209 million Americans 18 years of age or older, an estimated 889,000 have type 1 diabetes diagnosed before the age of 30. 1 Of those with type 1 diabetes, DR prevalence has been estimated between 75 % for blacks, and 82 % in whites. Moreover, 30% of blacks and 32% of whites have DR that has progressed to a vision-threatening disease. 1 While the incidence of retinopathy can be reduced by aggressive intervention to control hyperglycemia and hypertension, the vast majority of patients with diabetes of either type eventually develop some degree of DR. 1.1.2 Proliferative Diabetic Retinopathy: Impact on Vision Loss, Treatment, and Complications from Treatment The pathophysiology of diabetic retinopathy is characterized by manifestations of both retinal ischemia and increased retinal vascular permeability. Manifestations of ischemia include the formation of microaneurysms, retinal hemorrhages, nerve fiber layer infarcts, venous anomalies, and retinal neovascularization. The mechanisms of DR-related vision loss include vitreous hemorrhage from PDR, tractional retinal detachment from PDR, retinal capillary nonperfusion, and macular edema. The initial manifestation of proliferate diabetic retinopathy (PDR) is retinal neovascularization at the disc (NVD) or elsewhere (NVE). Vitreous hemorrhage or traction detachment from PDR is a leading cause of severe visual loss and new onset blindness in developed countries worldwide. Without intervention, 60 percent of diabetic individuals will eventually develop proliferative retinopathy, resulting in profound visual loss (<5/200; acuity worse than that used to define legal blindness) in nearly half. 3 Despite advances in the treatment of both diabetes and diabetic retinopathy, in the United States alone there are approximately 700,000 persons with proliferative diabetic retinopathy, with 63,000 new cases of proliferative retinopathy and 5,000 new cases of diabetes-induced legal blindness each year. The annual US economic impact of retinopathy-associated morbidity is estimated to exceed $620 million. Proliferative diabetic retinopathy is currently treated with scatter (panretinal) laser photocoagulation (PRP) which destroys areas of retina but preserves central vision. Multicentered clinical trials have demonstrated the effectiveness of PRP in preserving vision and J- LRT for PDR Protocol 3-24-08 V5.0.doc 1-3

119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 151 152 153 154 155 156 157 158 159 160 161 162 163 164 165 166 167 reducing the risk of vision loss. 4, 5 The ETDRS demonstrated that PRP applied when an eye 6 approaches or just reaches high risk PDR reduces the risk of severe vision loss to less than 4%. Although remarkably effective at reducing visual loss if applied in a timely and appropriate manner, the treatment is inherently destructive and is associated with unavoidable side effects (including macular edema with transient or permanent central vision loss, diminished peripheral vision loss, and night vision loss), potential complications from misdirected or excessive burns, and progression of visual loss in nearly 5 percent of individuals despite appropriate treatment. 7 In PRP, typically 1200 to 1800 laser burns are applied to the peripheral retinal tissue, actually focally destroying outer photoreceptors and retinal pigment epithelium of the retina. Large vessels are avoided, as are areas of pre-retinal hemorrhage. The treatment is thought to exert its effect by increasing oxygen delivery to the inner retina and decreasing viable hypoxic cells which are producing growth factors such as VEGF. The total treatment is usually applied over two or three sessions, spaced one to two weeks apart; although a single session is sometimes used. Follow-up evaluation usually occurs at three to four months after the initiation of treatment. The response to PRP varies. The most desirable effect is to see a regression of the new vessels, although stabilization of the neovascularization with no further growth may result. Occasionally significant macular edema may develop or existing edema worsen following laser panretinal photocoagulation. This is thought to be most common following more extensive treatment. The development or worsening of macular edema following full scatter photocoagulation is a well recognized occurrence. However, there is limited literature in this regard. Most of the literature consists of case reports and case series. 5, 7-9 Shimura et al 10 conducted a randomized trial of 36 patients with type 2 diabetes who had bilateral symmetric severe nonproliferative or early proliferative retinopathy but did not have clinically significant macular edema. Visual acuity was 20/20 or better in each eye. Patients were randomized to receive scatter photocoagulation weekly in one eye and biweekly in the other eye. Macular thickness was measured with OCT weekly for 8 weeks and then after 12 weeks and 16 weeks. Seven eyes of four patients were excluded because the eyes developed macular edema with a more rapid and progressive course than did the remaining eyes. Ninety percent of eyes maintained their visual acuity level and did not develop clinically significant macular edema, although many eyes had a transient increase in retinal thickness from the acute insult of the PRP. Among the eyes maintaining their level of visual acuity, central retinal thickness increased by 42%, and among eyes that had a reduction in visual acuity, central retinal thickness increased by 150%. There was a greater increase in central retinal thickening in the eyes treated weekly than in the eyes treated biweekly, and the resolution of the edema was slower in the eyes treated weekly. The Early Treatment Diabetic Retinopathy Study (ETDRS), which was performed prior to OCT availability, found that among eyes with no central retinal thickening at baseline in graded fundus photographs, retinal thickening was present at 4 months in 16% of eyes that underwent full scatter photocoagulation compared with 12% in eyes for which scatter photocoagulation was not performed, indicative of an acute insult of the PRP which increases the chance of macular edema. 11 Unpublished data from the ETDRS shows that 14% of eyes with some PDR (level 61 or worse) and macular edema with center involvement at onset of PRP lose at least 10 letters of vision from baseline to 4 months, while 14% also lose at least 15 letters at 4 months (unpublished data from the ETDRS analyzed by Jaeb). From a public health point of view, it would be desirable to avoid this acute vision loss when PRP is judged indicated in the presence of macular edema (high risk PDR and some cases of less than high risk PDR), even if the J- LRT for PDR Protocol 3-24-08 V5.0.doc 1-4

168 169 170 171 172 173 174 175 176 177 178 179 180 181 182 183 184 185 186 187 188 189 190 191 192 193 194 195 196 197 198 199 200 201 202 203 204 205 206 207 208 209 210 211 212 213 214 215 benefits on visual acuity loss are only relevant through 4 months after the onset of PRP. This is because, among other problems, this acute vision loss can represent a considerable time of lost work, wages, ability to care for diabetes, or ability to drive safely. 1.1.3 Rationale for Adjunctive Therapy to Scatter (Panretinal) Photocoagulation Adjunctive therapy to prevent or reduce the magnitude of acute vision loss following PRP, presumably from at least transient exacerbation of macular edema, could have several important ramifications. Obviously, it might prevent the onset of new edema or reduce the magnitude of the increase in existing edema and thus diminish subsequent short term vision loss that may occur especially if the edema, even if transient, involves the center of the macula. Reducing the frequency of this short term complication can reduce the morbidity associated with it, including temporary loss of work or other activities of daily living dependent on central vision. Since exacerbation of edema after PRP occurs more commonly with extensive PRP, use of adjunctive therapy may permit more extensive PRP if judged necessary at any given session. This would be of benefit in eyes with severe PDR or anterior segment neovascularization (neovascularization of the iris or angle) where rapid stabilization and regression is desired. In addition, it might allow more treatment per session and thus reduce the number of required sessions, being more convenient for the patient and more cost effective. 1.1.3.1 Rationale for Anti-VEGF Therapy as Adjunctive Therapy to Scatter (Panretinal) Photocoagulation Given the limitations and side effects of photocoagulation, there has been increased effort to understand the molecular mechanisms that underlie at least transient vision loss, presumably from macular edema, in diabetes. Studies have implicated vascular endothelial growth factor (VEGF) as a major causative factor in human eye diseases characterized by neovascularization and/or increased vascular permeability, including PDR and DME, 12-22 and it is reasonable to hypothesize that development or exacerbation of edema following PRP is due to inflammation which contributes to transient increased levels of VEGF following the acute insult of PRP to the retina. Thus, inhibition of VEGF would be expected to reduce both PDR and the transient vision loss presumably from exacerbation of macular edema. Any anti-vegf agent might be expected to have an effect on reducing at least transient macular edema following PRP. Several different anti-vegf drugs exist, including pegaptanib (Macugen, Eyetech Pharmaceuticals), ranibizumab (Lucentis, Genentech, Inc.), bevacizumab (Avastin, Genentech, Inc.), and VEGF Trap (Regeneron, Inc.). Pegaptanib and ranibizumab have had more extensive testing for age-related macular degeneration (AMD) than for diabetic macular edema. Pegaptanib has been studied in a phase 2 trial for diabetic macular edema 23, and results were promising with respect to decreasing edema compared with no treatment. Bevacizumab has been used widely in clinical practice for AMD and DME but has not been well studied. DRCRnet is currently conducting a phase 2 trial of bevacizumab in DME. Johns Hopkins University is conducting a trial of ranibizumab in DME. VEGF Trap is being evaluated in a Phase 1 trial for DME, but results are not available at this time. Pegaptanib is an aptamer consisting of a pegylated modified oligonucleotide which binds to extracellular VEGF isoform 165 (the predominant isoform). Pegaptanib is approved for the treatment of neovascular age-related macular degeneration. In a 172-patient phase 2 trial of pegaptanib for the treatment of diabetic macular edema, intravitreal pegaptanib (0.3mg, 1mg, or 3mg) or sham injection was administered every 6 weeks for 12 weeks with the option of J- LRT for PDR Protocol 3-24-08 V5.0.doc 1-5

216 217 218 219 220 221 222 223 224 225 226 227 228 229 230 231 232 233 234 235 236 237 238 239 240 241 242 243 244 245 246 247 248 249 250 251 252 253 254 255 256 257 258 259 260 261 262 263 subsequent doses and/or focal laser photocoagulation thereafter. At week 36, 73% of those treated with pegaptanib gained >0 lines of vision compared with 51% of the sham group (p=0.02); 18% of treated patients gained >3 lines of vision compared with 7% of the sham group (p=.12). Central retinal thickness decreased 68µm in the 0.3mg group compared with 3.7µm in the sham group (p=0.021); a decrease in CRT of >100µm was demonstrated in 42% of patients in the 0.3mg group compared with 16% in the sham group (p=0.02). Twenty-five percent of patients in the 0.3mg group underwent laser photocoagulation compared with 48% in the sham group. One case of endophthalmitis (not associated with severe vision loss) was observed DRCRnet is conducting a short-term 100-subject phase 2 trial of intravitreal bevacizumab for DME to assess the proportion of eyes that have a positive response and the short-term duration of efficacy. Results will be available prior to the initiation of this phase 3 trial. Ranibizumab is the drug to be evaluated in this trial. It is a humanized monoclonal antibody fragment which, like pegaptanib, competitively inhibits VEGF in the extracellular space. Unlike pegaptanib, however, ranibizumab is designed to block all isoforms of VEGF-A. It has been approved by the FDA as treatment for neovascular AMD and had far greater effects on reducing vision loss and causing vision gain in patients with neovascular AMD than was reported with pegaptanib. In one trial of ranibizumab on DME (in publication), ten patients with chronic DME received intraocular injections of 0.5 mg of ranibizumab at baseline, 1, 2, 4, and 6 months. The primary outcome was change in foveal thickness between baseline and 7 months and secondary outcome measures were changes from baseline in visual acuity and macular volume. Mean values at baseline were 503 µm for foveal thickness, 9.22 mm 3 for macular volume, and 28.1 letters (20/80) read on an ETDRS visual acuity chart. At 7 months (1 month after the fifth injection), the mean foveal thickness was 257 µm, a reduction of 246 µm (85% of the excess foveal thickness present at baseline; p=0.005 by Wilcoxon signed-rank test for likelihood that this change is due to ranibizumab rather than chance). The macular volume was 7.47 mm 3, a reduction of 1.75 mm 3 (77% of the excess macular volume at baseline; p=0.009). Mean visual acuity was a letter score of 40.4 letters (approximate Snellen equivalent of 20/40), an improvement of 12.3 letters (p=0.005). The injections were well-tolerated with no ocular or systemic adverse events. Since intraocular injections of ranibizumab significantly reduced foveal thickness and improved visual acuity in 10 patients with DME, there is a strong rationale to consider this drug as adjunctive therapy to PRP in an attempt to reduce the acute, transient edema that may occur with PRP. 1.1.3.2 Rationale for Corticosteroids as Adjunctive Therapy to PRP Corticosteroids, a class of substances with anti-inflammatory properties, have been demonstrated to inhibit the expression of the VEGF gene. 33 In a study by Nauck et al, the platelet-derived growth-factor (PDGF) induced expression of the VEGF gene in cultures of human aortic vascular smooth muscle cells, which was abolished by corticosteroids in a dose-dependent manner. 33 A separate study by Nauck et al demonstrated that corticosteroids abolished the induction of VEGF by the pro-inflammatory mediators PDGF and platelet-activating factor (PAF) in a time and dose-dependent manner. 34 This study was performed using primary cultures of human pulmonary fibroblasts and pulmonary vascular smooth muscle cells. Intravitreal injection has been proposed as a way to deliver corticosteroid (triamcinolone acetonide) to the posterior segment. Triamcinolone acetonide is a readily available pharmacologic agent (Kenalog 40, Bristol-Myers-Squibb, Princeton NJ). However, it is not 24. J- LRT for PDR Protocol 3-24-08 V5.0.doc 1-6

264 265 266 267 268 269 270 271 272 273 274 275 276 277 278 279 280 281 282 283 284 285 286 287 288 289 290 291 292 293 294 295 296 297 298 299 300 301 302 303 304 305 306 307 308 309 310 311 specifically formulated for intraocular use. The most common dose of triamcinolone acetonide used to treat eyes with diabetic macular edema is 4mg. 35 This dose is typically used because at a shelf dosage of 40mg/cc, it is easily aliquoted to a 4mg/0.1cc dose. A volume of 0.1cc is readily injected into the vitreous cavity. Other than the convenience of this dose, there are no data that support the use of 4mg over any other alternative dose. The use of 25mg of triamcinolone acetonide has less commonly been used to treat eyes with diabetic macular edema. 36 However, there are no data that compare the efficacy and safety of the 4mg vs. the 25mg dose. As discussed above, corticosteroids have been experimentally shown to down regulate VEGF production and possibly reduce breakdown of the blood-retinal barrier. Similarly, steroids have 37, 38 anti-angiogenic properties, possibly due to attenuation of the effects of VEGF. Both of these steroid effects have been utilized. For example, triamcinolone acetonide is often used clinically as a periocular injection for the treatment of cystoid macular edema (CME) secondary to uveitis 39, 40 or as a result of intraocular surgery. In animal studies, intravitreal triamcinolone acetonide has been used in the prevention of proliferative vitreoretinopathy 41, 42 and retinal neovascularization. 43, 44 In addition, intravitreal triamcinolone acetonide has been used clinically in the treatment of proliferative vitreoretinopathy 45 and choroidal neovascularization. 46-48 There is some literature on the use of corticosteroids as adjunctive therapy to PRP. Bandello et al 49 evaluated the effect of intravitreal triamcinolone as adjunctive treatment to scatter photocoagulation for proliferative diabetic retinopathy. In nine patients with bilateral PDR, one eye was randomly assigned to receive an intravitreal injection of 4 mg triamcinolone 10 to 15 days prior to initiating the scatter photocoagulation treatment. Most eyes (15/18) had clinically significant macular edema at baseline and most had a slight reduction in visual acuity (20/25-20/32). Scatter photocoagulation was administered to both eyes in three sittings consisting of 400 to 600 spots in each. The mean (SD) total number of burns was 1293 (257) in injected eyes and 1465 (587) in the control eyes. All patients completed nine months of follow up and five patients completed 12 months. At nine and 12 months, reduction in central macular thickening and fluorescein leakage was greater in the injection group than in the control group. Mean visual acuity improved by one line in the injection group and worsened by two lines in the control group. Zacks and Johnson described four cases with proliferative retinopathy and macular edema in which intravitreal triamcinolone administered at the time of PRP stabilized or improved the macular edema. 50 1.1.4. Summary of Rationale In summary, acute visual acuity loss following PRP for PDR in the setting of diabetic macular edema is a major public health problem. Even if this acute visual acuity loss is transient, reducing its frequency through at least 4 months would have a considerable benefit on the quality of life of individuals undergoing this therapy. There is a strong rationale that using either intravitreal ranibizumab or intravitreal triamcinolone acetonide as an adjunct to PRP in these individuals could reduce the magnitude of this loss. The DRCR Network is uniquely poised to investigate this problem with the study outlined below. 1.2 Study Objectives and Hypothesis This study is being conducted to determine whether intravitreal injection of an anti-vegf drug or an intravitreal injection of a corticosteroid can reduce the risk of visual acuity impairment that can occur following PRP and increase the chances of at least short-term visual acuity J- LRT for PDR Protocol 3-24-08 V5.0.doc 1-7

312 313 314 315 316 317 318 319 320 321 322 323 324 325 326 327 328 329 330 331 332 333 334 335 336 337 338 339 340 341 342 343 344 345 346 347 348 349 350 351 352 353 354 355 356 357 improvement in eyes with evidence of center-involved macular edema that are undergoing PRP for severe NPDR or PDR. 1.3 Study Design and Synopsis of Protocol A. Study Design Prospective, multi-center randomized clinical trial B. Major Eligibility Criteria Age >=18 years Type 1 or type 2 diabetes Study eye with o Severe nonproliferative or proliferative diabetic retinopathy for which the investigator intends to perform full scatter photocoagulation o diabetic macular edema involving the center of the macula (OCT central subfield thickness >250 microns) C. Intervention and Follow-up Visits Approximately 364 study eyes will be randomly assigned to one of the following three injection groups: Intravitreal injection of 0.5 mg ranibizumab (Lucentis ) at baseline and 4 weeks Intravitreal injection of 4 mg triamcinolone acetonide at baseline and sham injection at 4 weeks Sham injection at baseline and 4 weeks Subjects may have one or two study eyes. Subjects with two study eyes will be randomly assigned to receive sham injection at baseline and 4 weeks in one eye and either ranibizumab or triamcinolone in the other eye. Further details on randomization are located in section 2.4. The initial injection (or sham) is given on the day of randomization. Focal (macular) photocoagulation is given 3 to 10 days following the injection. Panretinal (scatter) photocoagulation can be initiated either on the same day as the focal photocoagulation (immediately following the focal photocoagulation) or on a subsequent day but must be initiated within 14 days of the baseline injection. Panretinal photocoagulation will consist of 1200 to 1600 burns given over 1 to 3 sittings, with completion of the regimen within 49 days of randomization. To avoid bias, the investigator will need to declare prior to randomization the number of sittings planned to complete the PRP relative to the initial injection (or sham), and the approximate number of burns planned for each sitting. Required follow-up visits occur at 4 weeks and 14 weeks (primary outcome). A second injection (or sham) is given at the 4-week visit (intravitreal injection for the ranibizumab group and a sham injection for the other two groups). After the 14-week visit, additional treatment can be given at investigator discretion during the safety phase of the study. J- LRT for PDR Protocol 3-24-08 V5.0.doc 1-8

358 359 360 361 362 363 364 365 366 367 368 369 370 371 Additional safety visits will be performed at 34 weeks after randomization and at 56 weeks (which is 52 weeks after the last study injection). D. Main Efficacy Outcomes Primary: visual acuity at 14 weeks adjusted for the baseline acuity. Secondary Outcomes at 14 Weeks Change in retinal thickening from baseline (OCT central subfield and retinal volume) Presence and extent of new vessels on fundus photographs Vitreous hemorrhage Additional sessions of scatter photocoagulation due to worsening PDR before 14 week visit after completion of initial session E. Main Safety Outcomes 372 Injected-related: endophthalmitis, retinal detachment 373 Ocular drug-related: inflammation, cataract/cataract surgery, IOP/glaucoma 374 375 Systemic drug-related: cardiovascular events J- LRT for PDR Protocol 3-24-08 V5.0.doc 1-9

376 377 378 379 F. Schedule of Study Visits and Procedures Study Visits Study Time 0 Randomization 1 st injection 3-10 days Safety visit Focal (macular) photocoagulation 3-14 days Initial sitting of panretinal photocoagulation (following focal photocoagulation) 28 (24-32) days Follow-up exam 2 nd injection 49 days Last day to complete panretinal photocoagulation 98 (91-105) days Primary outcome exam 34 (32-36) weeks Safety follow-up visit 56 (54-58) weeks Safety follow-up visit 380 381 382 383 Examination Procedures 0 1w 4w 14w 34w 56w Visit window - 3 to 10 d + 4d +1w +2w +2w E-ETDRS best corrected visual acuity a X X X X X X Fundus photos b X X X OCT c X X X X X X Eye exam d X X X X X X Blood pressure X 384 385 386 387 388 389 390 391 392 HbA1c e X a=both eyes at each visit; includes protocol refraction in study eye at each visit except 1-week visit when baseline refraction is used. Protocol refraction in nonstudy eye is only required at baseline, 14 weeks, and 56 weeks. E-ETDRS refers to electronic ETDRS testing using the Electronic Visual Acuity Tester that has been validated against 4-meter chart ETDRS testing. b=both eyes at baseline, study eye only at 14 wks and 56 wks c=study eye only d=both eyes at baseline and at follow-up visits. Includes slit lamp exam (including assessment of lens), measurement of intraocular pressure, and dilated ophthalmoscopy e=can be obtained up to 3 weeks after randomization; does not need to be repeated if HbA1c is available from within the prior 3 months J- LRT for PDR Protocol 3-24-08 V5.0.doc 1-10

393 394 395 396 397 398 399 400 401 402 403 404 405 406 407 408 409 1.4 General Considerations The study is being conducted in compliance with the policies described in the DRCRnet Policies document, with the ethical principles that have their origin in the Declaration of Helsinki, with the protocol described herein, and with the standards of Good Clinical Practice. The DRCRnet Procedures Manuals (Visual Acuity-Refraction Testing Procedures Manual, Photography Testing Procedures Manual, and Study Procedures Manual) provide details of the examination procedures and intravitreal injection procedure. Study subjects will be masked to treatment group throughout the study. The visual acuity examiner and OCT technician at the primary outcome visit (14 weeks) will be masked to treatment group. Data will be directly collected in electronic case report forms, which will be considered the source data. There is no restriction on the number of subjects to be enrolled by a site. J- LRT for PDR Protocol 3-24-08 V5.0.doc 1-11

410 411 412 413 414 415 416 417 418 419 420 421 422 423 424 425 426 427 428 429 430 431 432 433 434 435 436 437 438 439 440 441 442 443 444 445 446 447 448 449 450 451 452 453 454 455 CHAPTER 2. SUBJECT ELIGIBILITY AND ENROLLMENT 2.1 Identifying Eligible Subjects and Obtaining Informed Consent A minimum of 364 eyes are expected to be enrolled. Assuming that 20% of the subjects randomized under version 5.0 or later of the protocol have two study eyes, this equates with an enrollment of about 325 subjects, with a goal to enroll an appropriate representation of minorities. As the enrollment goal approaches, sites will be notified of the end date for recruitment. Subjects who have signed an informed consent form can be randomized up until the end date, which means the recruitment goal might be exceeded. Potential eligibility will be assessed as part of a routine-care examination. Prior to completing any procedures or collecting any data that are not part of usual care, written informed consent will be obtained. For subjects who are considered potentially eligible for the study based on a routine-care exam, the study protocol will be discussed with the subject by a study investigator and clinic coordinator. The subject will be given the Informed Consent Form to read. Subjects will be encouraged to discuss the study with family members and their personal physician(s) before deciding whether to participate in the study. Consent may be given in two stages (if approved by the IRB). The initial stage will provide consent to complete any of the screening procedures needed to assess eligibility that have not already been performed as part of a usual-care exam. The second stage will be obtained prior to randomization and will be for participation in the study. A single consent form will have two signature/date lines for the subject: one for the subject to give consent for the completion of the screening procedures and one for the subject to give consent for the randomized trial. Subjects will be provided with a copy of the signed Informed Consent Form. Once a subject is randomized, that subject will be counted regardless of whether the assigned treatment is received or not. Thus, the investigator must not proceed to randomize a subject until he/she is convinced that the subject is eligible and will accept assignment to any one of the 3 treatment groups. 2.2 Subject Eligibility Criteria 2.2.1 Subject-level Criteria Inclusion To be eligible, the following inclusion criteria (1-5) must be met: 1. Age >= 18 years Subjects <18 years old are not being included because DME is so rare in this age group that the diagnosis of DME may be questionable. 2. Diagnosis of diabetes mellitus (type 1 or type 2) Any one of the following will be considered to be sufficient evidence that diabetes is present: Current regular use of insulin for the treatment of diabetes Current regular use of oral anti-hyperglycemia agents for the treatment of diabetes Documented diabetes by ADA and/or WHO criteria (see Procedures Manual for definitions) J- LRT for PDR Protocol 3-24-08 V5.0.doc 2-1

456 457 458 459 460 461 462 463 464 465 466 467 468 469 470 471 472 473 474 475 476 477 478 479 480 481 482 483 484 485 486 487 488 489 490 491 492 493 494 495 496 497 3. At least one eye meets the study eye criteria listed in section 2.2.2. 4. Fellow eye (if not a study eye) meets criteria in section 2.2.3. 5. Able and willing to provide informed consent. Exclusion A subject is not eligible if any of the following exclusion criteria (6-15) are present: 6. Significant renal disease, defined as a history of chronic renal failure requiring dialysis or kidney transplant. 7. A condition that, in the opinion of the investigator, would preclude participation in the study (e.g., unstable medical status including blood pressure, cardiovascular disease, and glycemic control). Subjects in poor glycemic control who, within the last 4 months, initiated intensive insulin treatment (a pump or multiple daily injections) or plan to do so in the next 4 months should not be enrolled. 8. Participation in an investigational trial within 30 days of randomization that involved treatment with any drug that has not received regulatory approval at the time of study entry. Note: subjects cannot receive another investigational drug while participating in the study. 9. Known allergy to any component of the study drugs. 10. Blood pressure > 180/110 (systolic above 180 or diastolic above 110). If blood pressure is brought below 180/110 by anti-hypertensive treatment, subject can become eligible. 11. Major surgery within 28 days prior to randomization or major surgery planned during the next 6 months. Major surgery is defined as a surgical procedure that is more extensive than fine needle biopsy/aspiration, placement of a central venous access device, removal/biopsy of a skin lesion, or placement of a peripheral venous catheter. 12. Myocardial infarction, other cardiac event requiring hospitalization, stroke, transient ischemic attack, or treatment for acute congestive heart failure within 4 months prior to randomization. 13. Systemic anti-vegf or pro-vegf treatment within 4 months prior to randomization. These drugs cannot be used during the study. 14. For women of child-bearing potential: pregnant or lactating or intending to become pregnant within the next 12 months. Women who are potential subjects should be questioned about the potential for pregnancy. Investigator judgment is used to determine when a pregnancy test is needed. 15. Subject is expecting to move out of the area of the clinical center to an area not covered by another clinical center during the 12 months of the study. 2.2.2 Study Eye Criteria The subject must have at least one eye meeting all of the inclusion criteria (a-e) and none of the exclusion criteria (f-u) listed below. J- LRT for PDR Protocol 3-24-08 V5.0.doc 2-2

498 499 500 501 502 503 504 505 506 507 508 509 510 511 512 513 514 515 516 517 518 519 520 521 522 523 524 525 526 527 528 529 530 531 532 533 534 535 536 537 538 539 540 541 A subject can have two study eyes only if both are eligible at the time of randomization. For subjects with two eligible eyes, the logistical complexities of the protocol must be considered for each subject prior to randomizing both eyes. The eligibility criteria for a study eye are as follows: Inclusion a. Presence of severe nonproliferative or proliferative diabetic retinopathy for which investigator intends to complete panretinal photocoagulation within 49 days after randomization. b. Diabetic macular edema present on clinical exam and central subfield thickness on OCT >250 microns, within 8 days of randomization. c. Best corrected E-ETDRS visual acuity letter score >=24 (i.e., 20/320 or better), within 8 days of randomization. d. Media clarity, pupillary dilation, and subject cooperation sufficient to administer panretinal photocoagulation and obtain adequate fundus photographs and OCT. e. If prior macular photocoagulation has been performed, the investigator believes that the study eye may possibly benefit from additional focal photocoagulation. If the investigator believes that an eye has already received maximal macular laser photocoagulation, the eye is not eligible. Exclusion The following exclusions apply to the study eye only (i.e., they may be present for the nonstudy eye unless otherwise specified in section 2.2.3): f. Prior panretinal photocoagulation that was sufficiently extensive that the investigator does not believe that at least 1200 additional burns are needed or possible within 49 days after randomization. This allows entry of eyes that have had minimal, insufficient prior photocoagulation but excludes eyes that have had a full panretinal photocoagulation treatment. g. Macular edema is considered to be due to a cause other than diabetic macular edema. An eye should not be considered eligible if: (1) the macular edema is considered to be related to ocular surgery such as cataract extraction or (2) clinical exam and/or OCT suggest that vitreoretinal interface abnormalities disease (e.g., a taut posterior hyaloid or epiretinal membrane) is the primary cause of the macular edema. h. An ocular condition is present such that, in the opinion of the investigator, preventing visual acuity loss would not improve from resolution of macular edema (e.g., foveal atrophy, pigment abnormalities, dense subfoveal hard exudates, nonretinal condition). i. An ocular condition is present (other than diabetes) that, in the opinion of the investigator, might affect macular edema or alter visual acuity during the course of the study (e.g., retinal vein or artery occlusion, uveitis or other ocular inflammatory disease, neovascular glaucoma, etc.). A vitreous or preretinal hemorrhage is not an exclusion if it is out of the visual axis and in the investigator s judgment is not having any affect on visual acuity. J- LRT for PDR Protocol 3-24-08 V5.0.doc 2-3

542 543 544 545 546 547 548 549 550 551 552 553 554 555 556 557 558 559 560 561 562 563 564 565 566 567 568 569 570 571 572 573 574 575 576 577 578 579 580 581 582 583 j. Substantial cataract that, in the opinion of the investigator, is likely to be decreasing visual acuity by 3 lines or more (i.e., cataract would be reducing acuity to 20/40 or worse if eye was otherwise normal). k. History of treatment for DME at any time in the past 4 months (such as focal/grid macular photocoagulation, intravitreal or peribulbar corticosteroids, anti-vegf drugs, or any other treatment). If the investigator believes that there may still be a substantial effect 4 months after prior treatment (e.g., dose of intravitreal triamcinolone higher than 4 mg), the eye should not be included. l. History of major ocular surgery (including vitrectomy, cataract extraction, scleral buckle, any intraocular surgery, etc.) within prior 4 months or anticipated within the next 6 months following randomization. m. History of YAG capsulotomy performed within 2 months prior to randomization. n. Aphakia. o. Intraocular pressure >= 25 mmhg. p. History of open-angle glaucoma (either primary open-angle glaucoma or other cause of openangle glaucoma; note: angle-closure glaucoma is not an exclusion criterion). A history of ocular hypertension is not an exclusion as long as (1) intraocular pressure is <25 mm Hg, (2) the subject is using no more than one topical glaucoma medication, (3) the most recent visual field, performed within the last 12 months, is normal (if abnormalities are present on the visual field they must be attributable to the subject s diabetic retinopathy), and (4) the optic disc does not appear glaucomatous. Note: if the intraocular pressure is 22 to <25 mm Hg, then the above criteria for ocular hypertension eligibility must be met. q. History of steroid-induced intraocular pressure elevation that required IOP-lowering treatment. r. History of prior herpetic ocular infection. s. Exam evidence of ocular toxoplasmosis. t. Exam evidence of pseudoexfoliation. u. Exam evidence of external ocular infection, including conjunctivitis, chalazion, or significant blepharitis. 2.2.3 Fellow Eye Criteria The fellow eye must meet the following criteria: a. Intraocular pressure < 25 mmhg. b. No history of open-angle glaucoma (either primary open-angle glaucoma or other cause of open-angle glaucoma; note: angle-closure glaucoma is not an exclusion criterion). A history of ocular hypertension is not an exclusion as long as (1) intraocular pressure is <25 mmhg, (2) the subject is using no more than one topical glaucoma medication, (3) the most recent visual field, performed within the last 12 months, is normal (if abnormalities are present on the visual field they must be attributable to the subject s diabetic retinopathy), and (4) the optic disc does not appear glaucomatous. J- LRT for PDR Protocol 3-24-08 V5.0.doc 2-4

584 585 586 587 588 589 590 591 592 593 594 595 596 597 598 599 600 601 602 603 604 605 606 607 608 609 610 611 612 613 614 615 616 617 618 619 620 621 622 623 624 625 Note: if the intraocular pressure is 22 to <25 mmhg, then the above criteria for ocular hypertension eligibility must be met. c. No history of steroid-induced intraocular pressure elevation that required IOP-lowering treatment. d. No exam evidence of pseudoexfoliation. 2.3 Screening Evaluation and Baseline Testing 2.3.1 Historical Information A history will be elicited from the subject and extracted from available medical records. Data to be collected will include: age, gender, ethnicity and race, diabetes history and current management, other medical conditions, medications being used, as well as ocular diseases, surgeries, and treatment. 2.3.2 Baseline Testing Procedures The following procedures are needed to assess eligibility and/or to serve as baseline measures for the study. If a procedure has been performed (using the study technique and by study certified personnel) as part of usual care, it does not need to be repeated specifically for the study if it was performed within the defined time windows specified below. The testing procedures are detailed in the DRCR.net Procedures Manuals (Visual Acuity- Refraction Testing Procedures Manual, Photography Testing Procedures Manual, and Study Procedures Manual). Visual acuity testing, ocular exam, fundus photography, and OCT will be performed by DRCR.net certified personnel. The fundus photographs will be sent to the Fundus Photograph Reading Center for grading. OCTs meeting DRCR.net criteria for manual grading will be sent to the Reading Center but subject eligibility is determined by the site (i.e., subjects deemed eligible by the investigator will be randomized without pre-randomization Reading Center confirmation). 1. Electronic-ETDRS visual acuity testing at 3 meters using the Electronic Visual Acuity Tester (including protocol refraction) in each eye. (within 8 days prior to randomization) This testing procedure has been validated against 4-meter ETDRS chart testing. 51 2. OCT in study eye (within 8 days prior to randomization) 3. Ocular examination of each eye including slit lamp, measurement of intraocular pressure, cataract assessment, and dilated fundus examination (within 21 days prior to randomization) 4. ETDRS protocol 7-standard field stereoscopic fundus photography in each eye (fields 1M, 2, 3M, 4, 5, 6, 7, and red reflex; within 21 days prior to randomization) 5. Measurement of blood pressure 6. Laboratory testing- HbA1c HbA1c does not need to be repeated if available in the prior 3 months. If not available at the time of randomization, the subject may be enrolled but the test must be obtained within 3 weeks after randomization. J- LRT for PDR Protocol 3-24-08 V5.0.doc 2-5

626 627 628 629 630 631 632 633 634 635 636 637 638 639 640 641 642 643 644 645 646 647 648 649 650 651 652 653 654 655 656 2.4 Enrollment/Randomization of Eligible Subjects 1. Prior to randomization, the subject s understanding of the trial, willingness to accept the assigned treatment group, and commitment to the follow-up schedule should be reconfirmed. 2. The baseline injection (or sham injection) must be given on the day of randomization; therefore, a subject should not be randomized until this is possible. For subjects with two study eyes, both the sham and study drug injection must be given on the day of randomization. 3. Randomization is completed on the DRCRnet website. Subjects with one study eye will be randomly assigned (stratified by visual acuity letter score: >= 66 / <= 65 and planned PRP regimen) with equal probability to one of the 3 treatment groups: o A: Intravitreal injection of 0.5 mg ranibizumab o B: Intravitreal injection of 4 mg triamcinolone acetonide o C: Sham injection For subjects with two study eyes (both eyes eligible at the time of randomization), o The subject will be randomized with equal probability to receive either: Sham in the eye with greater visual acuity score and intravitreal injection of 0.5 mg ranibizumab in the eye with lower visual acuity score Sham injection in the eye with greater visual acuity score and intravitreal injection of 4 mg triamcinolone acetonide in the eye with lower visual acuity score Intravitreal injection of 0.5 mg ranibizumab in the eye with greater visual acuity score and sham in the eye with lower visual acuity score. Intravitreal injection of 4 mg triamcinolone acetonide in the eye with greater visual acuity score and sham in the eye with lower visual acuity score. Note: if both eyes have the same visual acuity letter score, the right eye will be considered the eye with the greater visual acuity score. J- LRT for PDR Protocol 3-24-08 V5.0.doc 2-6

657 658 659 660 661 662 663 664 665 666 667 668 669 670 671 672 673 674 675 676 677 678 679 680 681 682 683 684 685 686 CHAPTER 3. TREATMENT REGIMENS 3.1 Introduction All study eyes will receive focal and panretinal (full scatter) photocoagulation and be randomly assigned to one of the following three injection groups: Intravitreal injection of ranibizumab at baseline and 4 weeks Intravitreal injection of triamcinolone acetonide at baseline and sham injection at 4 weeks Sham injection at baseline and 4 weeks The initial injection (or sham) is given on the day of randomization. Focal photocoagulation is given 3 to 10 days following the injection. Panretinal photocoagulation can be initiated either on the same day as the focal photocoagulation (immediately following the focal photocoagulation) or on a subsequent day but must be initiated within 14 days of the baseline injection. 3.2 Panretinal Photocoagulation Regimen All study eyes will receive panretinal photocoagulation with 1200 to1600 burns given over 1 to 3 sittings that is initiated 3 to 14 days after randomization and completed within 49 days of randomization. To avoid bias, the investigator will need to declare prior to randomization (entered on the website) the number of sittings planned, the approximate number of burns planned for each sitting, and whether the scatter treatment will be initiated on the same day as the macular photocoagulation. The burn characteristics for non-automated photocoagulation will be as follows: Size (on retina) Exposure Intensity Distribution No. of Sessions/Sittings 1 to 3 Nasal proximity to disk Temp. proximity to center Superior/inferior limit Extent 500 microns [e.g. argon laser using 200 micron spot size with Rodenstock lens (or equivalent) or 500 micron spot size with 3 mirror contact lens] 0.1 seconds recommended, 0.05 to 0.2 allowed mild white (i.e. 2+ to 3+ burns) edges 1 burn width apart No closer than 500 microns No closer than 3000 microns No further posterior than 1 burn within the temporal arcades Arcades (~3000 microns from the macular center) to at least the J- LRT for PDR Protocol 3-24-08 V5.0.doc 3-1

equator 687 688 689 690 691 692 693 694 695 696 697 698 699 700 701 702 703 704 705 706 707 708 709 710 711 712 713 714 715 716 717 718 719 720 721 722 723 724 725 726 727 728 729 Total # of burns 1200 to 1600 Wavelength Green or yellow (red can be used if vitreous hemorrhage is present precluding use of green or yellow) An anesthetic injection (retrobulbar, peribulbar or sub-tenon s) can be used at investigator discretion. An indirect laser approach can be used at investigator discretion.. If a laser is used that has the capability of producing an automated pattern (e.g. the PASCAL laser), the automated pattern producing mode is permissible. Guidelines for use of the automated pattern are included in the DRCRnet procedure manual. 3.2.1 Additional Scatter Photocoagulation for Proliferative Diabetic Retinopathy If the size or amount of neovascularization increases following completion of the PRP session, additional scatter photocoagulation can be given. Scatter photocoagulation can be augmented by fill-in scatter between existing burns. In cases in which there is a new vitreous hemorrhage, supplemental scatter treatment should only be given if the size/extent of the retinal neovascularization has increased. Additional adjunctive therapy should not be given prior to the 14-week exam. 3.2.2 Deferral of Additional Scatter Photocoagulation for Decreased Visual Acuity from Exacerbation of Macular Edema Before the completion of each PRP sitting, visual acuity testing should be completed using usual care methods. If visual acuity is decreased from baseline by 10 or more letters (2 or more lines), a study protocol refraction and E-ETDRS best corrected visual acuity should be completed (unless the decrease is due to vitreous hemorrhage). An OCT is to be performed if the E-ETDRS best corrected visual acuity is decreased by 10 or more letters. Dilated ophthalmoscopic examination should be carried out to determine that the decreasing vision is not secondary to vitreous hemorrhage. If vitreous hemorrhage is the cause of decreased vision, appropriate scatter therapy for proliferative diabetic retinopathy should continue. If proliferative diabetic retinopathy and vitreous hemorrhage are not responsible for the decreased vision, PRP still should be carried out whenever possible. However, if the investigator believes that exacerbation of macular edema is the cause of the decreased vision, at the investigator's discretion, additional scatter photocoagulation can be deferred for two weeks. If treatment is deferred because of exacerbation of macular edema, a two-week follow up visit should be scheduled. Visual acuity (with study protocol refraction if 10 or more letters worse than baseline) and OCT are repeated. Continuation of the scatter photocoagulation should be considered and in general is appropriate even if there is a decrease in visual acuity. However, if the visual acuity remains decreased by 10 or more letters and this decrease is secondary to macular edema, the investigator may again defer completion of scatter treatment for an additional two weeks and repeat the process again. The 14-week outcome visit will be performed even if the PRP session has not been completed. J- LRT for PDR Protocol 3-24-08 V5.0.doc 3-2