Perioperative anti-VEGF injections improve vision and reduce bleeding in proliferative diabetic retinopathy

PURPOSE: Proliferative diabetic retinopathy causes severe vision loss. Although anti-vascular endothelial growth factor (VEGF) injections aid surgery outcomes, optimal timing is unclear. We evaluated the efficacy and safety of anti-VEGF injections at various perioperative time points. METHOD: This network meta-analysis comprehensively searched PubMed, Cochrane Library, Web of Science, Embase, ClinicalTrials.gov, and WHO ICTRP from inception to November 2024 for randomized controlled trials examining perioperative anti-VEGF injection. Two authors independently screened the studies, collected the data, and assessed the risk of bias. The protocol was registered with PROSPERO (CRD42024614758). RESULTS: Thirty studies involving 2 646 eyes were analyzed. Perioperative anti-VEGF treatment significantly improved postoperative best-corrected visual acuity (preoperatively >7 days: standardized mean difference [SMD] = 0.57, 95% CI: 0.01-1.13; preoperatively 3-7 days: SMD = 0.50, 95% CI: 0.29-0.70; intraoperative: SMD = 0.34, 95% CI: 0.10-0.66). It also reduced recurrent vitreous hemorrhage (intraoperative: odds ratio [OR] = 0.28, 95% CI: 0.09-0.87), and intraoperative bleeding (preoperatively >7 days: OR = 0.11, 95% CI: 0.03-0.39; preoperatively 3-7 days: OR = 0.22, 95% CI: 0.04-1.13). Additionally, it shortened surgical time (preoperatively >7 days vs preoperatively 1-3 days: WMD = -17.90, 95% CI: -29.99 to -5.81). No significant effects on silicone oil use or recurrent retinal detachment were observed. The safety profile of anti-VEGF has been found to be favourable. CONCLUSIONS: The combination of perioperative anti-VEGF injections provides several advantages. Clinicians may select the optimal timing based on individualized treatment objectives. However, because of the variability in evidence quality and the heterogeneity among the included studies, these conclusions should be approached with caution.