Intravitreous Anti-VEGF vs. Prompt Vitrectomy for Vitreous Hemorrhage From Proliferative Diabetic Retinopathy
Phase: PHASE2
Conditions: Proliferative Diabetic Retinopathy, Vitreous Hemorrhage
Sponsor: Jaeb Center for Health Research

Vx for Vitreous Hemorrhage Protocol 1.0 7-28-16 
 
 
 
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Diabetic Retinopathy Clinical Research 
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Network 
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Intravitreous Anti-VEGF vs. Prompt 
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Vitrectomy for Vitreous Hemorrhage 
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from Proliferative Diabetic Retinopathy 
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NCT 02858076 
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Version 1.0 
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July 28, 2016 
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Vx for Vitreous Hemorrhage Protocol 1.0 7-28-16 
 
 
Table of Contents 
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Chapter 1. Background Information and Study Synopsis ..................................................... 1-1 
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1.1 Background and Rationale ............................................................................................... 1-1 
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1.1.1 Public Health Impact of Diabetic Retinopathy ........................................................... 1-1 
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1.1.2 Treatment Options for VH from PDR ........................................................................ 1-1 
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1.1.3 Aflibercept .................................................................................................................. 1-3 
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1.1.4 Summary of Study Rationale ...................................................................................... 1-4 
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1.2 Study Objectives .............................................................................................................. 1-4 
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1.3 Study Design and Synopsis of Protocol ........................................................................... 1-4 
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1.4 General Considerations .................................................................................................... 1-7 
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Chapter 2. Study Participant Eligibility and Enrollment ...................................................... 2-1 
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2.1 Identifying Eligible Participants and Obtaining Informed Consent .................................. 2-1 
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2.2 Participant Eligibility Criteria ............................................................................................ 2-1 
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2.2.1 Participant-level Criteria ............................................................................................. 2-1 
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2.2.2 Study Eye Criteria ....................................................................................................... 2-2 
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2.2.3 Non-Study Eye Criteria............................................................................................... 2-4 
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2.3 Screening Evaluation and Baseline Testing ....................................................................... 2-4 
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2.3.1 Historical Information ................................................................................................. 2-4 
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2.3.2 Baseline Testing Procedures ....................................................................................... 2-4 
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2.4 Enrollment/Randomization of Eligible Participants .......................................................... 2-5 
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Chapter 3. Follow-Up Visits and Testing ................................................................................. 3-1 
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3.1 Visit Schedule .................................................................................................................... 3-1 
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3.2 Testing Procedures ............................................................................................................. 3-1 
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Chapter 4. Treatment Regimen ................................................................................................ 4-1 
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4.1 Introduction ........................................................................................................................ 4-1 
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4.2 Intravitreous Injections ...................................................................................................... 4-1 
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4.2.1 Inravitreous Aflibercept Injection (Eylea®) ............................................................... 4-1 
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4.2.2 Intravitreous Injection Technique ............................................................................... 4-1 
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4.2.3 Delay in Giving Injections .......................................................................................... 4-1 
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4.2.4 Deferral of Injections Due to Pregnancy .................................................................... 4-1 
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4.2.5 Non-Study Eye Injections ........................................................................................ 4-2 
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4.3 Aflibercept Group Follow-Up Treatment .......................................................................... 4-2 
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4.3.1 Retreatment with Intravitreous Injections of Aflibercept for Vitreous Hemorrhage and 
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underlying PDR ................................................................................................................... 4-2 
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4.3.2 PRP during Follow-Up ............................................................................................... 4-2 
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4.3.3 Vitrectomy during Follow-Up .................................................................................... 4-3 
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4.4 Vitrectomy ......................................................................................................................... 4-3 
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4.4.1 Vitreous and Aqueous Sample Collection .................................................................. 4-4 
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4.4.2 Deferral or Cancellation of Surgery in the Vitrectomy Group ................................... 4-4 
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4.5 Vitrectomy Group Intra- and Post-Operative Treatment ................................................... 4-4 
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4.5.1 Panretinal Photocoagulation in the Vitrectomy Group ............................................... 4-4 
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4.5.2 Treatment for Recurrent Vitreous Hemorrhage in the Vitrectomy Group ................. 4-5 
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4.6 Cataract Surgery (Both Groups) ........................................................................................ 4-5 
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4.7 Treatment for Diabetic Macular Edema (Both Groups) .................................................... 4-5 
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4.7.1. Intravitreous Injection Retreatment for DME ............................................................ 4-5 
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4.7.2. Focal/Grid Laser Treatment for DME ....................................................................... 4-6 
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Chapter 5. Miscellaneous Considerations in Follow-up ......................................................... 5-1 
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5.1 Endophthalmitis ................................................................................................................. 5-1 
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5.2 Treatment of Diabetic Retinopathy in Non-study Eye ...................................................... 5-1 
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5.3 Use of Intravitreal Anti-VEGF for Conditions Other than DME in the Study Eye ........... 5-1 
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5.4 Diabetes Management ........................................................................................................ 5-1 
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5.5 Study Participant Withdrawal and Losses to Follow-up.................................................... 5-1 
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5.6 Discontinuation of Study ................................................................................................... 5-1 
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5.7 Contact Information Provided to the Coordinating Center ................................................ 5-2 
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5.8 Study Participant Reimbursement...................................................................................... 5-2 
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Chapter 6. Adverse Events ........................................................................................................ 6-1 
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6.1 Definition ........................................................................................................................... 6-1 
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6.2 Recording of Adverse Events ............................................................................................ 6-1 
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6.3 Reporting Serious or Unexpected Adverse Events ............................................................ 6-2 
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6.4 Data and Safety Monitoring Committee Review of Adverse Events ................................ 6-2 
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6.5 Risks ................................................................................................................................... 6-2 
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6.5.1 Potential Adverse Effects of Aflibercept .................................................................... 6-2 
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6.5.2 Potential Adverse Effects of Intravitreous Injection ................................................... 6-3 
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6.5.3  Risks of Vitrectomy ................................................................................................... 6-3 
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6.5.4  Risks of Panretinal Photocoagulation Treatment ....................................................... 6-4 
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6.5.5 Risks of Eye Examination and Tests .......................................................................... 6-4 
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Chapter 7. Statistical Methods.................................................................................................. 7-1 
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7.1 Sample Size ........................................................................................................................ 7-1 
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7.1.1 Sample Size Assumptions ........................................................................................... 7-1 
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7.1.2 Sample Size Estimation .............................................................................................. 7-2 
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7.1.3 Statistical Power.......................................................................................................... 7-3 
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7.2 Primary Analysis Plan........................................................................................................ 7-4 
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7.2.1 Principles for Analysis ................................................................................................ 7-4 
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7.2.2 Per-Protocol Analysis ................................................................................................. 7-4 
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7.2.3 Interim Analysis Plan .................................................................................................. 7-5 
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7.3 Secondary Outcomes ......................................................................................................... 7-5 
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7.3.1 Outcomes within Treatment Groups ........................................................................... 7-5 
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7.3.2 Economic Analysis ..................................................................................................... 7-5 
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7.4 Safety Analysis Plan .......................................................................................................... 7-6 
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7.5 Additional Tabulations and Analyses ................................................................................ 7-7 
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7.6 Statistical Modeling Techniques ........................................................................................ 7-7 
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Chapter 8. References ................................................................................................................ 8-1 
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CHAPTER 1.                                                                                         
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BACKGROUND INFORMATION AND STUDY SYNOPSIS                                            
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1.1 Background and Rationale 
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1.1.1 Public Health Impact of Diabetic Retinopathy 
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Diabetic Retinopathy (DR) is the leading cause of visual loss and new-onset blindness in the 
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United States for those 20 through 74 years of age.1 As of 2010, 3.63 million people worldwide 
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are estimated to have at least moderate vision loss due to the complications of DR, and 850 
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thousand are estimated to suffer from blindness due to DR.2  Proliferaitve diabetic retinopathy 
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(PDR) can lead to vitreous hemorrhage (VH) which may affect vision and is a leading indication 
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for vitrectomy. Vitreous hemorrhage also can preclude performing panretinal photocoagulation 
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(PRP), as well as the evaluation and treatment of other diabetic and non-diabetic retinal 
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pathology such as diabetic macular edema (DME) and age-related macular degeneration.  Even 
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in the modern era of using either PRP or anti-vascular endothelial growth factor (anti-VEGF) 
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therapy to treat PDR, a Diabetic Retinopathy Clinical Research Network (DRCR.net) clinical 
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trial showed that 27% to 34% of eyes developed VH over 2 years even after treatment was 
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initiated with either anti-VEGF or PRP, respectively.3  Given the increasing prevalence of 
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diabetes in the United States and worldwide, the public health impact of PDR and its 
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complications are large.2, 4  
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1.1.2 Treatment Options for VH from PDR 
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Although VH by itself is not detrimental to the eye, rapid clearance of the hemorrhage is 
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desirable for both functional and anatomic reasons and also allows evaluation and treatment of 
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the eye for other pathology such as DME.  Functional central and peripheral visual acuity (VA) 
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is commonly affected adversely by intraocular hemorrhage. As long as the retinal status remains 
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stable, VA usually improves once the blood resolves.  However, vitreous traction on or 
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contraction of fibrous proliferans associated with retinal neovascularization, leading to VH, can 
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lead to further complications causing VA loss if left unchecked.  Prior to the advent of anti-
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VEGF therapy, in most cases of VH, PRP was performed as soon as the media cleared 
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sufficiently to allow visibility and laser uptake.  The goal of the PRP was to achieve regression 
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of new vessels or at least stabilization of the neovascularization in order to decrease the 
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probability of new or worsening VH or traction or rhegmatogenous retinal detachment while 
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further clearing of the hemorrhage occurred.  PRP generally leads to regression or quiescence of 
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retinal neovascularization after a limited number of treatments and results in a reduction of 
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severe vision loss over 5 years to rates as low as 4%. 5  
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Although PRP has been the standard care for PDR for several decades, results from the 
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DRCR.net Protocol S (Prompt Panretinal Photocoagulation versus Intravitreal Ranibizumab with 
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Deferred Panretinal Photocoagulation for Proliferative Diabetic Retinopathy) published in 
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November 2015 suggest that anti-VEGF therapy is a safe and effective treatment alternative for 
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PDR, with advantages over PRP in reductions in visual field sensitivity loss, need for vitrectomy 
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and development of DME.3  This study demonstrated  non-inferiority of mean visual acuity letter 
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improvement at 2 years for eyes treated with ranibizumab and deferred PRP as compared to 
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those given prompt PRP for baseline PDR (difference +2.2, 95% confidence interval [CI]: -0.5 to 
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+5.0, non-inferiority P<0.001).  Although visual change at 2 years was not superior in the anti-
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VEGF group, the average visual acuity over 2 years (area under the curve) was significantly 
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better in eyes that received anti-VEGF with a mean treatment group difference of +4.2 (95% CI: 
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+3.0 to +5.4, P<0.001).  In addition, eyes that underwent prompt PRP had greater visual field 
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sensitivity loss (mean dB difference 372; 95% CI: 213 to 531, P<0.001), more frequent 
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vitrectomy (15% versus 4%, difference 9%, 95% CI: 4% to 15%, P<0.001), and, among those 
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without DME causing VA loss at baseline, were more likely to develop DME causing VA loss 
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(28% versus 9%, difference 19%, 95% CI: 10% to 28%, P<0.001) over the course of 2 years. 
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Two approaches for the management of VH from PDR are vitrectomy and treatment with anti-
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VEGF agents, the latter being highly effective even at small doses in regressing PDR.6 Although 
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clinical results suggest that both these methods are effective at improving retinal 
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neovascularization, to date there has not been a randomized clinical trial with head to head 
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comparison of their relative efficacy in improving VA in eyes with VH from PDR.  
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A standard approach for treatment of VH associated with PDR is to proceed to prompt 
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vitrectomy in order to provide the fastest possible improvement in VA.  Vitrectomy, or surgical 
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removal of the vitreous gel and associated hemorrhage, enables rapid clearance of VH and 
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concurrent delivery of panretinal endolaser.  In cases in which traction retinal detachments or 
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rhegmatogenous detachments occur, vitrectomy can also eliminate extensive neovascularization 
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and treat existing retinal detachments.7  Many advances in instrumentation and technique have 
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resulted in dramatically faster surgical times, easier patient recovery and a reduction in 
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complications over the last few decades.8  In particular, the advent of 23 gauge surgical 
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techniques, and smaller, have resulted in smaller surgical incisions and the possibility of 
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sutureless surgery in addition to smaller instruments that allow more delicate manipulations of 
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fibrovascular retinal tissue.8  According to Castellarin et al,  surgical complications still remain, 
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including recurrent hemorrhage,9 neovascular glaucoma, retinal detachment, fibrinoid syndrome, 
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endophthalmitis and hypotony with subsequent phthisis bulbi.10  It should be noted that many 
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reports of vitrectomy outcomes in the diabetic population combine results from eyes with 
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complex traction retinal detachments together with those from uncomplicated VH.11, 12  
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However, data acquired from a cross-sectional population based study in the United Kingdom 
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suggest that eyes with simple VH have substantially better functional and anatomic outcomes 
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than those with any component of traction retinal detachment.13   
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The Diabetic Retinopathy Vitrectomy Study from the 1980s found a benefit for early vitrectomy 
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within 6 months as compared to delayed vitrectomy after 12 months, particularly in eyes of type 
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1 diabetic patients with severe vision loss from dense VH.14  In addition, a retrospective 
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comparison of immediate versus delayed vitrectomy for VH from PDR found that although final 
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vision did not differ significantly between the groups, the area under the curve for logMAR 
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visual acuity from first presentation to last follow-up was significantly greater, meaning more 
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time with decreased vision, for eyes that had delayed versus immediate vitrectomy, suggesting a 
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possible visual benefit over time in eyes undergoing vitrectomy sooner.15  Recent large scale, 
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multi-center randomized trials of vitrectomy for the sole indication of VH from PDR are lacking. 
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At this time, there is rationale for comparing current outcomes utilizing newer surgical 
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techniques to alternative treatment modalities for PDR associated VH, including anti-VEGF 
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therapy. 
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VEGF is a major causative factor in eye diseases that are characterized by neovascularization or 
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increased vascular permeability, such as DR.16-25  Anti-VEGF drugs are highly effective at 
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causing regression of retinal neovascularization, and therefore can be useful in cases of VH due 
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to PDR by reducing the chance of additional VH or traction or rhegmatogenous retinal 
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detachments from new vessels. Once the hemorrhage is reabsorbed and the neovascularization is 
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temporarily stabilized by the anti-VEGF drug, either PRP can be completed or a longer-term 
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course of anti-VEGF can be initiated to increase the chance of permanent regression of the PDR 
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and lower the likelihood of subsequent VH or traction detachment of the macula or both without 
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having to perform vitrectomy.   
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Anti-VEGF therapy has been evaluated in eyes with VH from PDR in the DRCR.net Protocol N 
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(An Evaluation of Intravitreous Ranibizumab for Vitreous Hemorrhage Due to Proliferative 
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Diabetic Retinopathy), although the endpoint of this study was short-term avoidance of 
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vitrectomy (16 weeks after randomization) rather than VA recovery.26 This study compared the 
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safety and efficacy of anti-VEGF treatment with saline injection for prevention of vitrectomy in 
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eyes with VH from PDR.  Although Protocol N did not show a difference in vitrectomy rates at 
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16 weeks comparing ranibizumab with saline injections, both treatment groups had lower than 
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expected vitrectomy rates (12% vs. 17% respectively), and the ranibizumab group had greater 
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visual acuity improvements (22±23 vs. 16±31, P = 0.04), increased PRP completion rates (44% 
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vs. 31%, P = 0.05), and a reduced rate of recurrent VH (6% vs. 17%, P = 0.01) compared with 
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saline injections. 26  Therefore, it is possible that anti-VEGF drugs have at least a short term 
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biologic effect.  Rates of vitrectomy at 16 weeks in Protocol N were substantially lower than 
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those suggested by previous studies with observation arms, suggesting that the management of 
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eyes with VH from PDR with anti-VEGF therapy might avoid further surgical intervention in 
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many eyes.  Indeed, by 52 weeks (with 12 weeks through 52 weeks of treatment at investigator 
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discretion), only 40% of eyes in both groups received vitrectomy; thus, by 1 year approximately 
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60% of eyes did not need vitrectomy. The efficacy of anti-VEGF treatment in allowing clearance 
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of VH while avoiding surgery, especially in eyes that have already received PRP is supported by 
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another recent case series, which reported treatment with bevacizumab in 18 eyes of 18 patients 
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with new onset VH after previous full PRP.27  By 12 months, 72.2% of eyes had complete 
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clearing of VH.  However, although 9 (50%) of the eyes gained vision, overall there was no 
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statistically significant visual gain over 12 months (mean best corrected VA improved from 
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1.32±1.03 to 1.09±1.10 logMAR, p = 0.433), and 2 eyes (11%) had severe vision loss of 3 or 
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more lines of vision due to traction retinal detachment.   
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1.1.3 Aflibercept 
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The anti-VEGF agent to be used in this trial is intravitreous aflibercept injection, also known as 
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VEGF Trap-Eye or Aflibercept (Eylea®), which is a soluble decoy receptor fusion protein that 
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has a high binding affinity to all isoforms of VEGF as well as to placental growth factor.  
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Aflibercept received approval by the United States Food and Drug Administration (FDA) for the 
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treatment of neovascular age-related macular degeneration in 201128, treatment of macular 
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edema due to central retinal vein occlusion in 201229-31, and treatment of macular edema due to 
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branch retinal vein occlusion and treatment of DME in 2014.32   
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Based on data from the VIVID and VISTA phase III DME studies, aflibercept also became 
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approved for treatment of diabetic retinopathy in patients with DME in 2015.  Change in diabetic 
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retinopathy severity level among eyes with DME and DR at baseline was a pre-specified 
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secondary efficacy outcome, and the proportion of patients improving by at least 2 steps was 
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significantly greater in aflibercept-treatment groups compared to the control group at 100 weeks 
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in both trials.33 
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Although there is no currently available head-to-head data on the available anti-VEGF agents for 
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treatment of PDR, a comparative effectiveness trial in DME reported that aflibercept was more 
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effective than ranibizumab and bevacizumab in improving vision in eyes starting with CI-DME 
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and worse levels of visual acuity (approximately 20/50 or worse).34    
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1.1.4 Summary of Study Rationale 
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Although VH from PDR can cause acute and dramatic vision loss for patients with diabetes, 
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there is no current, evidence-based clinical guidance as to what treatment method is most likely 
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to provide the best visual outcomes once intervention is desired.  Intravitreous anti-VEGF 
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therapy alone or vitrectomy combined with intraoperative PRP each provide the opportunity to 
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stabilize or regress retinal neovascularization.  However, clinical trials are lacking to elucidate 
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the relative time frame of visual recovery or final visual outcome in prompt vitrectomy compared 
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with initial anti-VEGF treatment.  The DRCR.net Protocol N demonstrated short-term trends 
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consistent with a possible beneficial effect of anti-VEGF treatment in eyes with VH from PDR, 
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including greater VA improvement and reduced rates of recurrent VH as compared with saline 
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injection.  It is possible that a study with a longer duration of follow-up with structured anti-
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VEGF retreatment would demonstrate even greater effectiveness of anti-VEGF for VH to avoid 
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vitrectomy and its attendant adverse events while also improving visual acuity.  On the other 
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hand, advances in surgical techniques leading to faster operative times, quicker patient recovery, 
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and reduced complication rates may make prompt vitrectomy a more attractive alternative since 
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it results in the immediate ability to clear hemorrhage and to perform PRP if desired, often as 
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part of one procedure.  This proposed study will evaluate the safety and efficacy of two treatment 
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approaches for eyes with VH from PDR:  prompt vitrectomy + PRP and intravitreous aflibercept 
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injections. 
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1.2 Study Objectives  
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The objectives of this study are to 1) evaluate and compare visual acuity outcomes over the 
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course of the study of a prompt vitrectomy + PRP regimen and an intravitreous aflibercept  
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regimen in eyes with VH from PDR for which intervention is deemed necessary, and 2) 
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characterize the follow-up course for the two treatment regimens, including but not limited to 
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post-operative complications for the vitrectomy group, and number of injections needed and 
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percent requiring vitrectomy in the intravitreous aflibercept group.   
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1.3 Study Design and Synopsis of Protocol 
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A. Study Design 
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• Multi-center randomized clinical trial  
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B. Major Eligibility Criteria 
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• Age >=18 years 
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• Type 1 or type 2 diabetes 
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• Study eye with:  
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o Vitreous hemorrhage causing vision impairment, presumed to be from 
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proliferative diabetic retinopathy, for which intervention is deemed necessary 
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• Note: Prior PRP is neither a requirement nor an exclusion  
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o Best corrected visual acuity letter score 78 or worse (approximate Snellen 
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equivalent 20/32 or worse) with at least light perception  
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• Investigators should use particular caution when considering enrollment 
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of an eye with visual acuity letter score 78 to 69 (approximate Snellen 
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equivalent 20/32 to 20/40) to ensure that the need for vitrectomy and its 
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potential benefits outweigh the potential risks.   
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o No evidence of rhegmatogenous retinal detachment or evidence of traction retinal 
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detachment involving or threatening the macula 
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• If the density of the hemorrhage precludes a visual assessment on clinical 
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exam to confirm eligibility, then it is recommended that assessment be 
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performed with ultrasound as standard care. 
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o No history of vitrectomy 
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C. Treatment Groups 
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Eligible eyes, one per participant, will be assigned randomly (1:1) to one of the following 
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groups: 
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A. Intravitreous 2 mg aflibercept injections 
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B. Prompt vitrectomy + PRP 
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For the intravitreous aflibercept group, the initial injection must be given on the day of 
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randomization.  Follow-up injections will be performed as often as every 4 weeks unless criteria 
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for deferral are met (see section 4.3.1).  Vitrectomy and PRP can only be performed if protocol 
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criteria are met (see sections 4.3.2 and 4.3.3). 
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For the prompt vitrectomy + PRP group, the vitrectomy must be scheduled to be performed 
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within 2 weeks of randomization. Vitrectomy will be performed according to the investigator’s 
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usual routine, including pre-operative care, surgical procedure, and post-operative care, although 
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anti-VEGF may not be given post-operatively unless there is recurrent hemorrhage (see section 
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4.5.2). 
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D. Sample Size 
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A minimum of 200 study eyes, one per participant, will be randomized.   
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E. Duration of Follow-Up 
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Primary outcome: 24 weeks 
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Total duration: 104 weeks  
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F. Follow-up Schedule 
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➢ Outcome Visits: 
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All participants in both groups will have visits at the following times post-randomization: 
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• Year 1: 4, 12, 24, 36, 52 weeks 
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• Year 2: 68 weeks, 84 weeks, 104 weeks 
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It is recognized that the time between initial treatment and outcome visits will differ 
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between the two groups due to the timing of the initial treatment; however, the 
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differential timing of treatments is representative of clinical care in which anti-VEGF can 
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be given immediately and vitrectomy would need to be scheduled in advance.  Therefore, 
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the area under the curve analysis will be representative of clinical care based on the time 
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point that the decision is made to intervene.   
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➢ Treatment Visits: 
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• Participants receiving intravitreous aflibercept also will have treatment 
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assessment visits as often as every 4 weeks, depending on recent treatment 
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administered. 
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➢ Additional Visits:  
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• Participants undergoing vitrectomy will have a study visit 1 week post-vitrectomy 
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for safety evaluation.  Investigators may schedule an initial (e.g. 1 day) post-
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operative visit earlier as standard care at their discretion. 
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G. Main Efficacy Outcomes 
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Treatment Group Comparisons 
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Primary Outcome:  Visual acuity area under the curve between randomization and 24 weeks  
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Additional Key Outcomes (at 24, 52, and 104 weeks unless otherwise indicated): 
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• Visual acuity area under the curve between randomization and 52 and 104 weeks 
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• Mean visual acuity at 4, 12, and 24 weeks, and annual visits 
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• Percent 20/20 or better, 20/32 or better, 20/40 or better, 20/200 or worse, and 20/800 
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or worse at 4, 12, and 24 weeks, and annual visits  
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• Proportion of eyes with at least 15 and at least 30 letter gains or losses from baseline 
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• Rates of recurrent VH on clinical exam 
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• Percentage of eyes with retinal neovascularization  
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• Mean OCT central subfield thickness  
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• Treatment and follow-up costs 
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• Mean change in four Workplace Productivity and Activity Impairment Questionnaire 
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(WPAIQ) scales and area under the curve analyses of the Work Productivity Loss and 
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Activity Impairment scales at 4, 12, and 24 weeks, and annual visits  
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Key Outcomes within Treatment Groups 
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• Percent undergoing vitrectomy (initial vitrectomy in aflibercept group or repeat 
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vitrectomy in vitrectomy group) 
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• Number of aflibercept injections performed 
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• Percent receiving PRP (aflibercept group only) 
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The primary outcome of visual acuity area under the curve at 24 weeks was primarily selected 
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for sample size considerations.  The long-term additional key outcomes and within-group 
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outcomes will be equally important as the area under the curve outcome for evaluating the 
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overall follow-up course for these two treatment approaches.  Therefore, publication is not 
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planned until the full 104 week follow-up has closed.  
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H. Main Safety Outcomes 
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Ocular: endophthalmitis, retinal detachment, visually significant cataract, cataract surgery 
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Systemic: Antiplatelet Trialist Collaboration (APTC) events 
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I. Schedule of Study Visits and Procedures 
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Vitreous/aqueous 
samplingg 
X* 
 
 
 
 
*Vitrectomy group at baseline and aflibercept group if vitrectomy is performed during follow-up 
404 
**Every 4 to 16 weeks, as needed, for eyes receiving aflibercept 
405 
†At 12, 36, 68 and 84 weeks 
406 
a=both eyes including protocol refraction in the study eye only at outcome visits and DME treatment visits and on both 
407 
eyes at annual visits.   E-ETDRS refers to electronic ETDRS testing using the Electronic Visual Acuity Tester that has 
408 
been validated against 4-meter chart ETDRS testing.  
409 
b=study eye only; at annual visits and if evaluating for DME treatment  
410 
c= study eye only if needed as part of standard care if the density of the vitreous hemorrhage precludes assessment of 
411 
retinal detachment. 
412 
d=both eyes at baseline and study eye only at follow-up. Includes slit lamp exam (including assessment of lens), 
413 
measurement of intraocular pressure, and dilated ophthalmoscopy; examination of the angle required if NVI or 
414 
increased intraocular pressure present. 
415 
e=can be obtained up to 3 weeks after randomization; does not need to be repeated if HbA1c is available from within 
416 
the prior 3 months 
417 
f= Workplace Productivity and Activity Impairment Questionnaire 
418 
g=if investigator has agreed to perform sample collection and participant consents to this ancillary component; 
419 
participants will be given the option of providing vitreous sample only or both vitreous and aqueous samples at the time 
420 
of vitrectomy. 
421 
 
422 
1.4 General Considerations 
423 
The study is being conducted in compliance with the policies described in the DRCR.net Policies 
424 
document, with the ethical principles that have their origin in the Declaration of Helsinki, with 
425 
the protocol described herein, and with the standards of Good Clinical Practice. 
426 
 
427 

Vx for Vitreous Hemorrhage Protocol 1.0 7-28-16 
 
1-8 
The DRCR.net Procedures Manuals (Visual Acuity-Refraction Testing Procedures Manual, OCT 
428 
Procedures Manual, and Study Procedures Manual) provide details of the examination 
429 
procedures and intravitreous injection procedure.   
430 
 
431 
Visual acuity testers will be masked to treatment group at all outcome visits.  Investigators and 
432 
study participants are not masked to treatment group. 
433 
   
434 
Data will be directly collected in electronic case report forms, which will be considered the 
435 
source data. 
436 
 
437 
There is no restriction on the number of study participants to be enrolled by a site. 
438 
 
439 
A risk-based monitoring approach will be followed, consistent with the FDA “Guidance for 
440 
Industry Oversight of Clinical Investigations — A Risk-Based Approach to Monitoring” (August 
441 
2013). 
442 
 
443 
The risk level is considered to be research involving greater than minimal risk. 
444 
 
445 

Vx for Vitreous Hemorrhage Protocol 1.0 7-28-16 
 
2-1 
                                                                                                                                   
446 
CHAPTER 2. STUDY PARTICIPANT ELIGIBILITY AND ENROLLMENT 
447 
2.1 Identifying Eligible Participants and Obtaining Informed Consent 
448 
A minimum of 200 eyes (1 per participant) are expected to be enrolled into the randomized trial.  
449 
As the enrollment goal approaches, sites will be notified of the end date for recruitment.  Study 
450 
participants who have signed an informed consent form can be randomized up until the end date, 
451 
which means the recruitment goal might be exceeded.   
452 
 
453 
Potential eligibility will be assessed as part of a routine-care examination.  Prior to completing 
454 
any procedures or collecting any data that are not part of usual care, written informed consent 
455 
will be obtained.  For patients who are considered potentially eligible for the study based on a 
456 
routine-care exam, the study protocol will be discussed with the potential study participant by a 
457 
study investigator and clinic coordinator.  The potential study participant will be given the 
458 
Informed Consent Form to read.  Potential study participants will be encouraged to discuss the 
459 
study with family members and their personal physician(s) before deciding whether to participate 
460 
in the study.   
461 
 
462 
Consent may be given in two stages (if approved by the IRB).  The initial stage will provide 
463 
consent to complete any of the screening procedures needed to assess eligibility that have not 
464 
already been performed as part of a usual-care exam.  The second stage will be obtained prior to 
465 
randomization and will be for participation in the study.  A single consent form will have two 
466 
signature/date lines for the study participant:  one for a study participant to give consent for the 
467 
completion of the screening procedures and one for the study participant to document consent for 
468 
the randomized trial.  Study participants will be provided with a copy of the signed Informed 
469 
Consent Form. 
470 
 
471 
Once a study participant is randomized, that participant will be counted regardless of whether the 
472 
assigned treatment is received.  Thus, the investigator must not proceed to randomize an 
473 
individual until he/she is convinced that the individual is eligible and will accept assignment to 
474 
either of the two treatment groups, including ability to undergo vitrectomy within 2 weeks of 
475 
randomization.   
476 
 
477 
2.2 Participant Eligibility Criteria 
478 
2.2.1 Participant-level Criteria 
479 
Inclusion 
480 
To be eligible, the following inclusion criteria must be met: 
481 
1. Age >= 18 years  
482 
• Participants <18 years old are not being included because proliferative diabetic 
483 
retinopathy is so rare in this age group that the diagnosis may be questionable.  
484 
2. Diagnosis of diabetes mellitus (type 1 or type 2)  
485 
• Any one of the following will be considered to be sufficient evidence that diabetes is 
486 
present:  
487 
➢ Current regular use of insulin for the treatment of diabetes 
488 
➢ Current regular use of oral anti-hyperglycemia agents for the treatment of diabetes 
489 
➢ Documented diabetes by ADA and/or WHO criteria (see Procedures Manual for 
490 
definitions) 
491 

Vx for Vitreous Hemorrhage Protocol 1.0 7-28-16 
 
2-2 
3. At least one eye meets the study eye criteria listed in section 2.2.2. 
492 
4. Able and willing to provide informed consent. 
493 
5. Patient is willing and able to undergo vitrectomy within next 2 weeks and the vitrectomy can 
494 
be scheduled within that time frame. 
495 
Exclusion 
496 
A potential participant is not eligible if any of the following exclusion criteria  are present:  
497 
6. History of chronic renal failure requiring dialysis (including placement of fistula if performed 
498 
in preparation for dialysis) or kidney transplant. 
499 
7. A condition that, in the opinion of the investigator, would preclude participation in the study 
500 
(e.g., unstable medical status including blood pressure, cardiovascular disease, and glycemic 
501 
control).  
502 
8. Initiation of intensive insulin treatment (a pump or multiple daily injections) within 4 months 
503 
prior to randomization or plans to do so in the next 4 months. 
504 
9. A condition that, in the opinion of the investigator, would preclude participant undergoing 
505 
elective vitrectomy surgery if indicated during the study. 
506 
10. Participation in an investigational trial within 30 days of randomization that involved 
507 
treatment with any drug that has not received regulatory approval for the indication being 
508 
studied. 
509 
• Note: participants cannot receive another investigational drug while participating in the 
510 
study. 
511 
11. Known allergy to any component of the study drug or any drug used in the injection prep 
512 
(including povidone iodine).  
513 
12. Blood pressure > 180/110 (systolic above 180 or diastolic above 110). 
514 
• If blood pressure is brought below 180/110 by anti-hypertensive treatment, potential 
515 
participant can   become eligible.  
516 
13. Systemic anti-VEGF or pro-VEGF treatment within 4 months prior to randomization. 
517 
• These drugs cannot be used during the study. 
518 
14. For women of child-bearing potential: pregnant or lactating or intending to become pregnant 
519 
within the next two years. 
520 
• Women who are potential participants should be questioned about the potential for 
521 
pregnancy.  Investigator judgment is used to determine when a pregnancy test is needed. 
522 
15. Potential participant is expecting to move out of the area of the clinical center to an area not 
523 
covered by another clinical center during the two years. 
524 
 
525 
2.2.2 Study Eye Criteria 
526 
The participant must have at least one eye meeting all of the inclusion criteria and none of the 
527 
exclusion criteria listed below.   
528 
 
529 
A participant can have only one study eye.  If both eyes are eligible at the time of randomization, 
530 
the study eye will be selected by the investigator and participant before randomization. 
531 
 
532 
The eligibility criteria for a study eye are as follows: 
533 
 
534 

Vx for Vitreous Hemorrhage Protocol 1.0 7-28-16 
 
2-3 
Inclusion 
535 
a. Vitreous hemorrhage causing vision impairment, presumed to be from proliferative diabetic 
536 
retinopathy, for which intervention is deemed necessary.  
537 
• Note: Prior PRP is neither a requirement nor an exclusion. 
538 
• Subhyaloid hemorrhage alone does not make an eye eligible; however, presence of 
539 
subhyaloid hemorrhage in addition to the criteria above will not preclude participation 
540 
provided the investigator is comfortable with either treatment regimen. 
541 
b. Immediate vitrectomy not required (investigator and participant are willing to wait at least 4 
542 
months to see if hemorrhage clears sufficiently with anti-VEGF without having to proceed to 
543 
vitrectomy). 
544 
c. Visual acuity letter score ≤78 (approximate Snellen equivalent 20/32) and at least light 
545 
perception.  
546 
• Investigators should use particular caution when considering enrollment of an eye with 
547 
visual acuity letter score 69 to 78 (approximate Snellen equivalent 20/32 to 20/40) to 
548 
ensure that the need for vitrectomy and its potential benefits outweigh the potential risks.   
549 
 
550 
Exclusion 
551 
d. Evidence of traction detachment involving or threatening the macula.  
552 
• If the density of the hemorrhage precludes a visual assessment on clinical exam to 
553 
confirm eligibility, then it is recommended that assessment be performed with ultrasound 
554 
as standard care. 
555 
e. Evidence of rhegmatogenous retinal detachment. 
556 
• If the density of the hemorrhage precludes a visual assessment on clinical exam to 
557 
confirm eligibility, then it is recommended that assessment be performed with ultrasound 
558 
as standard care. 
559 
f. Evidence of neovascular glaucoma (iris or angle neovascularization is not an exclusion). 
560 
g. Known diabetic macular edema (DME), defined as either 
561 
i. OCT central subfield thickness (microns): 
562 
1. Zeiss Cirrus: ≥290 in women; ≥305 in men 
563 
2. Heidelberg Spectralis: ≥305 in women; ≥320 in men  
564 
OR 
565 
ii. DME on clinical exam that the investigator believes currently requires treatment.  
566 
h. History of intravitreous anti-VEGF treatment within 2 months prior to current vitreous 
567 
hemorrhage onset or after onset.   
568 
i. History of intraocular corticosteroid treatment within 4 months prior to current vitreous 
569 
hemorrhage onset or after onset.   
570 
j. History of major ocular surgery (including cataract extraction, scleral buckle, any intraocular 
571 
surgery, etc.) within prior 4 months or major ocular surgery other than vitrectomy anticipated 
572 
within the next 6 months following randomization.  
573 
k. History of vitrectomy. 
574 

Vx for Vitreous Hemorrhage Protocol 1.0 7-28-16 
 
2-4 
l. History of YAG capsulotomy performed within 2 months prior to randomization.  
575 
m. Aphakia. 
576 
n. Uncontrolled glaucoma (in investigator’s judgment). 
577 
o. Exam evidence of severe external ocular infection, including conjunctivitis, chalazion, or 
578 
substantial blepharitis. 
579 
 
580 
2.2.3 Non-Study Eye Criteria 
581 
If anti-VEGF treatment is indicated for any condition in the non-study eye at any time during the 
582 
study, the investigator must be willing to use the study anti-VEGF drug (2 mg aflibercept) for the 
583 
non-study eye.  If the non-study eye is currently being treated with a different anti-VEGF drug 
584 
for any condition, then the investigator and patient must be willing to switch to aflibercept.  If 
585 
the investigator or patient is unwilling to change anti-VEGF treatment in the non-study eye, the 
586 
patient should not be enrolled.    
587 
 
588 
2.3 Screening Evaluation and Baseline Testing 
589 
2.3.1 Historical Information 
590 
A history will be elicited from the participant and extracted from available medical records.  
591 
Data to be collected will include:  age, gender, ethnicity and race, diabetes history and current 
592 
management, other medical conditions, medications being used, as well as ocular diseases, 
593 
surgeries, and treatment. 
594 
2.3.2 Baseline Testing Procedures 
595 
The following procedures are needed to assess eligibility and/or to serve as baseline measures for 
596 
the study.   
597 
• If a procedure has been performed (using the study technique and by study certified 
598 
personnel) as part of usual care, it does not need to be repeated specifically for the study 
599 
if it was performed within the defined time windows specified below.  
600 
• The testing procedures are detailed in the DRCR.net Procedures Manuals (Visual Acuity-
601 
Refraction Testing Procedures Manual and Study Procedures Manual).  Visual acuity 
602 
testing and ocular exam will be performed by DRCR.net certified personnel.  
603 
 
604 
1. Electronic-ETDRS visual acuity testing at 3 meters using the Electronic Visual Acuity Tester 
605 
(including protocol refraction) in each eye. (on day of randomization) 
606 
➢ If the E-ETDRS visual acuity letter score is 0, then counting fingers, hand motion, 
607 
and light perception are assessed. 
608 
2. Workplace Productivity and Activity Impairment Questionnaire (on day of randomization).  
609 
3. OCT on the study eye (within 8 days prior to randomization)  
610 
➢ Unless insufficient view precludes obtaining an accurate measurement  
611 
4. Ocular examination of each eye including slit lamp, measurement of intraocular pressure, 
612 
lens assessment, and dilated ophthalmoscopy (on day of randomization) 
613 
5. B-Scan ultrasound as part of standard care on the study eye if the density of the vitreous 
614 
hemorrhage precludes assessment of traction or rhegmatogenous retinal detachment 
615 
6. Measurement of blood pressure 
616 
7. Laboratory testing- HbA1c 
617 

Vx for Vitreous Hemorrhage Protocol 1.0 7-28-16 
 
2-5 
➢ HbA1c does not need to be repeated if available in the prior 3 months.  If not 
618 
available at the time of randomization, the participant may be enrolled but the test 
619 
must be obtained within 3 weeks after randomization.  
620 
2.4 Enrollment/Randomization of Eligible Participants  
621 
1. Prior to randomization, the participant’s understanding of the trial, willingness to accept the 
622 
assigned treatment group, and commitment to the follow-up schedule should be reconfirmed. 
623 
2. The baseline injection must be given on the day of randomization and vitrectomy must be 
624 
performed within 2 weeks, depending on treatment group; therefore, a participant should not 
625 
be randomized until this is possible.   
626 
3. Randomization is completed on the DRCR.net website.   
627 
• Study eyes will be randomly assigned (stratified by site) with equal probability to one of 
628 
two treatment groups:  
629 
o Group A: Intravitreous 2 mg aflibercept injections 
630 
o Group B: Prompt vitrectomy + PRP 
631 
 
632 

Vx for Vitreous Hemorrhage Protocol 1.0 7-28-16 
 
     3-1 
 
633 
CHAPTER 3. FOLLOW-UP VISITS AND TESTING                                                            
634 
3.1 Visit Schedule 
635 
The schedule of protocol-specified follow-up visits is as follows: 
636 
 
637 
➢ Outcome Visits: 
638 
All participants in both groups will have visit at the following time points post-
639 
randomization: 
640 
• Year 1: 4 (±1) weeks, 12 (±4) weeks, 24(±4) weeks, 36 (±4) weeks, 52(±4) weeks 
641 
• Year 2: 68 (±4) weeks, 84  (±4) weeks, 104  (±4) weeks 
642 
 
643 
➢ Vitreous Hemorrhage Treatment Assessment Visits: 
644 
 
645 
Aflibercept Group 
646 
Participants in the aflibercept group, will have treatment assessment visits as often as 
647 
every 4 weeks, depending on treatment administered: 
648 
• Visits every 4±1 weeks for the first 24 weeks and as long as injections are given 
649 
(with a minimum of 21 days between injections). 
650 
• After 24 weeks, if the injection is deferred at the current and previous 2 visits (see 
651 
section 4.3.1 for retreatment criteria), the next study follow-up visit is in twice the 
652 
time since the last visit up to a maximum of 16 weeks between visits.  Otherwise, 
653 
the next study follow-up visit is in 4 weeks. 
654 
 
655 
Vitrectomy Group 
656 
Eyes for which aflibercept is initiated for recurrent hemorrhage post-vitrectomy will 
657 
have treatment assessment visits as often as every 4 weeks until the hemorrhage has 
658 
cleared or repeat vitrectomy is performed (see section 4.5.2). 
659 
 
660 
➢ DME Treatment Visits 
661 
• If aflibercept for DME has been initiated, follow-up visits for DME treatment occur 
662 
every 4 weeks for the first 24 weeks from initial aflibercept treatment for DME. After 
663 
24 weeks, if the injection is deferred at the current and previous 2 visits (see section 
664 
4.7 for retreatment criteria), the next study follow-up visit is in twice the time since 
665 
the last visit up to a maximum of 16 weeks between visits.  Otherwise, the next study 
666 
follow-up visit is in 4 weeks. 
667 
 
668 
➢ Additional Protocol Visits:  
669 
Participants undergoing vitrectomy will have a study visit 1 week (±3 days) post-
670 
vitrectomy for safety evaluation only. Investigators may schedule an initial (e.g. 1 day) 
671 
post-operative visit earlier as standard care.  
672 
 
673 
Additional visits may occur as required for usual care of the study participant. 
674 
3.2 Testing Procedures  
675 
The 1-week post-operative visit will include a safety evaluation only.  Otherwise, the following 
676 
procedures will be performed at each protocol-specified visit on the study eye only, unless 
677 
otherwise specified. A grid in section 1.3 summarizes the testing performed at each visit.  
678 

Vx for Vitreous Hemorrhage Protocol 1.0 7-28-16 
 
     3-2 
 
679 
1. E-ETDRS visual acuity testing (best corrected) in each eye. 
680 
• A protocol refraction in the study eye is required at Outcome Visits (listed above) and 
681 
DME treatment visits.  Refraction in the non-study eye is only required at annual visits.  
682 
When a refraction is not performed, the most recently performed refraction is used for the 
683 
testing. 
684 
2. Workplace Productivity and Activity Impairment Questionnaire (WPAIQ) at all outcome 
685 
visits (listed above).  
686 
3. OCT at the 24-week visit, annual visits, and DME treatment visits only. 
687 
➢ Unless insufficient view precludes obtaining an accurate measurement.   
688 
4. Ocular exam, including slit lamp examination (including lens assessment), measurement of 
689 
intraocular pressure, and dilated ophthalmoscopy.  
690 
• Undilated exam of the iris is at the discretion of the investigator; examination of the 
691 
angle is required if neovascularization of the iris is present or increased IOP (defined 
692 
as one of the following: a) IOP ≥ 30mm Hg b) first time IOP has increased at least 
693 
10mm Hg since baseline c) IOP has increased at least 10mm Hg since last visit or d) 
694 
IOP lowering medication initiated since last visit). 
695 
5. B-Scan ultrasound as needed as part of standard care if vitreous hemorrhage precludes ability 
696 
to assess for traction or rhegmatogenous retinal detachment. 
697 
 
698 
6. Laboratory testing of Hemoglobin A1c at the 24-week visit and annual visits only. 
699 
• HbA1c does not need to be repeated if available in the prior 3 months.  
700 
7. Blood pressure at the 24-week visit and annual visits only. 
701 
 
702 
All of the testing procedures do not need to be performed on the same day, provided that they are 
703 
completed within the time window of a visit and prior to initiating any retreatment.  
704 
 
705 
Testing procedures at unscheduled visits are at investigator discretion.  However, it is 
706 
recommended that procedures that are performed should follow the standard DRCR.net protocol 
707 
for each procedure 
708 

Vx for Vitreous Hemorrhage Protocol 1.0 7-28-16 
 
     4-1 
CHAPTER 4. TREATMENT REGIMEN     
709 
4.1 Introduction 
710 
All study eyes will be randomly assigned to one of the following two treatment groups:    
711 
• Intravitreous 2 mg aflibercept injections  
712 
• Prompt vitrectomy + PRP 
713 
 
714 
For the intravitreous aflibercept group, the initial injection must be given on the day of 
715 
randomization.  Follow-up injections will be performed as often as every 4 weeks according to 
716 
the retreatment criteria below.  Vitrectomy and PRP can only be performed if protocol criteria 
717 
are met. 
718 
 
719 
For the prompt vitrectomy + PRP group, the vitrectomy must be scheduled within 2 weeks of 
720 
randomization. The vitrectomy procedure and follow-up treatment are described below. 
721 
 
722 
4.2 Intravitreous Injections 
723 
4.2.1 Inravitreous Aflibercept Injection (Eylea®) 
724 
Eylea® (intravitreal aflibercept injection) is made by Regeneron Pharmaceuticals, Inc. and is 
725 
approved by the FDA for the treatment of neovascular age-related macular degeneration, 
726 
macular edema due to central retinal vein occlusion, macular edema due to branch retinal vein 
727 
occlusion, diabetic macular edema, and diabetic retinopathy in eyes with diabetic macular 
728 
edema.   
729 
 
730 
Study eyes that receive anti-VEGF will receive a dose of 2 mg aflibercept in 0.05 cc each time a 
731 
study injection is performed.  The physical, chemical and pharmaceutical properties and 
732 
formulation are provided in the Clinical Investigator Brochure. Aflibercept for the study and 
733 
non-study eye will be distributed by the Network. 
734 
 
735 
4.2.2 Intravitreous Injection Technique 
736 
The injection is preceded by a povidone iodine prep of the conjunctiva.  In general, topical 
737 
antibiotics in the pre-, peri-, or post-injection period should not be used.  
738 
 
739 
The injection will be performed using sterile technique.  The full injection procedure is described 
740 
in the DRCR.net Study Procedures Manual. 
741 
 
742 
4.2.3 Delay in Giving Injections 
743 
If a scheduled injection is not given by the end of the visit window, it can still be given up to 1 
744 
week prior to the next visit window opening.  If it is not given by that time, it will be considered 
745 
missed. 
746 
 
747 
If an injection is given late, the next scheduled injection should occur no sooner than 3 weeks 
748 
after the previous injection. 
749 
 
750 
4.2.4 Deferral of Injections Due to Pregnancy 
751 
Female study participants of child-bearing age must be questioned regarding the possibility of 
752 
pregnancy prior to each injection. In the event of pregnancy, study injections must be 
753 
discontinued during the pregnancy and any post-partum period of breastfeeding.   
754 
 
755 

Vx for Vitreous Hemorrhage Protocol 1.0 7-28-16 
 
     4-2 
4.2.5 Non-Study Eye Injections 
756 
If the non-study eye is going to be treated for any condition which requires treatment with an 
757 
anti-VEGF agent, study provided aflibercept must be used.  However, if intravitreous treatment 
758 
is planned on the same day as an intravitreous injection in the study eye, the study eye will be 
759 
injected first, followed by the non-study eye (see Procedures Manual for additional details).  If a 
760 
non-study anti-VEGF medication is desired to be administered by intravitreous injection in the 
761 
non-study eye, a discussion with the Protocol Chair is required first. 
762 
 
763 
4.3 Aflibercept Group Follow-Up Treatment 
764 
4.3.1 Retreatment with Intravitreous Injections of Aflibercept for Vitreous Hemorrhage 
765 
and underlying PDR 
766 
All eyes will receive an injection of aflibercept at the 4-week, 8-week and 12-week visits, unless 
767 
an adverse event precludes treatment. 
768 
 
 
769 
Starting at the 16-week visit, eyes with no contraindication to additional aflibercept injections 
770 
will be evaluated for retreatment based on the status of the hemorrhage and neovascularization.  
771 
In general, the eye will receive an injection at each treatment assessment visit unless one of the 
772 
below criteria is met:  
773 
1. Success: the vitreous hemorrhage has sufficiently cleared such that there is an 
774 
adequate view of the entire fundus and neovascularization is absent 
775 
➢ Injection is deferred. 
776 
2. Stability: it has been at least 24 weeks since the initial injection, the eye has received 
777 
at least 2 prior consecutive injections, and the size and density of the hemorrhage and 
778 
any neovascularization is clinically unchanged since the last visit.   
779 
➢ Injection is deferred. 
780 
3. A vitrectomy has already been performed  
781 
➢ Eyes in the aflibercept group that receive vitrectomy will follow the intra- and 
782 
post-operative anti-VEGF treatment regimen described in sections 4.4 and 
783 
4.5.2 for the Vitrectomy Group. 
784 
 
785 
4.3.2 PRP during Follow-Up 
786 
PRP must not be given unless failure criteria are met (see below for cases that first require 
787 
discussion with the Protocol Chair or Coordinating Center designee).  In addition, if any future 
788 
treatment with aflibercept is contraindicated based on a previous adverse reaction, treatment with 
789 
PRP for PDR is at investigator discretion after discussion with and approval from the Protocol 
790 
Chair or Coordinating Center designee.   
791 
 
792 
• Failure criteria are defined as  
793 
1. growth of NV or new NV of the retina, disc OR iris since the last visit such that 
794 
the NV, including fibrosis, is greater than when first adequately visualized and at 
795 
least 4 study injections have been given over the previous 4 months.  The 
796 
investigator may perform PRP.   
797 
 
798 
OR 
799 
 
800 
2. New or worsened NV of the angle* has developed since the last visit. The 
801 
investigator may perform PRP.   
802 

Vx for Vitreous Hemorrhage Protocol 1.0 7-28-16 
 
     4-3 
 
803 
OR  
804 
 
805 
3. definite worsening of NV or fibrous proliferation of the retina, disc OR iris at 
806 
least 1 day after the last injection that the investigator believes is likely to lead to 
807 
substantial vision loss if PRP is not performed within 1 week.  PRP may only be 
808 
performed after discussion with and approval from the Protocol Chair or 
809 
Coordinating Center designee. 
810 
 
811 
4.3.3 Vitrectomy during Follow-Up 
812 
Vitrectomy may be performed in the aflibercept group according to the criteria below.  See 
813 
section 4.4 regarding the vitrectomy procedure. Eyes in the aflibercept group that undergo 
814 
vitrectomy must also receive intraoperative PRP until “complete”.   
815 
 
816 
4.3.3.1 Prior to 16 Weeks 
817 
Vitrectomy prior to 16 weeks should not be performed unless one of the following is present: 
818 
➢ Traction retinal detachment involving (within 1 disc diameter) or actively threatening the 
819 
macula  
820 
➢ Rhegmatogenous retinal detachment  
821 
➢ Neovascular glaucoma resulting in increased intraocular pressure that cannot be 
822 
controlled medically, angle neovascularization, or progressive neovascularization of the 
823 
iris (at least 2 clock hours) 
824 
➢ Ghost cell glaucoma resulting in increased intraocular pressure that cannot be controlled 
825 
medically  
826 
 
827 
If other circumstances develop for which vitrectomy is being considered prior to 16 weeks, the 
828 
Protocol Chair will be contacted for approval. 
829 
 
830 
4.3.3.2 At and After 16 weeks 
831 
After the 16 week visit, vitrectomy may be performed (but is not required) if there is 1) persistent 
832 
vitreous hemorrhage causing vision impairment and 2) the eye has received at least 2 consecutive 
833 
prior injections.  However, if this is the 3rd or more time the hemorrhage recurred after a period 
834 
of clearance during the study, vitrectomy may be performed at investigator discretion without 
835 
first performing 2 additional injections.   
836 
 
837 
If the investigator believes vitrectomy is required for the safety of the participant and the study 
838 
eye does not meet these criteria, protocol chair approval is required to proceed.   
839 
 
840 
4.4 Vitrectomy 
841 
For study eyes receiving vitrectomy, vitrectomy will be performed according to the 
842 
investigator’s usual routine, including pre-operative care, surgical procedure, and post-operative 
843 
care. However, a 23 or smaller gauge vitrectomy system must be used (20 gauge is not 
844 
permitted).   
845 
 
846 
Optional additional procedures at the discretion of the investigator include, but are not limited to: 
847 
• Removal of the internal limiting membrane. 
848 
• Use of agents to improve visualization of membranes, (e.g. triamcinolone acetonide, 
849 
indocyanine green dye, or other staining agents). 
850 

Vx for Vitreous Hemorrhage Protocol 1.0 7-28-16 
 
     4-4 
• Use of corticosteroids (intravitreous, sub-tenon’s, sub-conjunctival) at the close of the 
851 
procedure. 
852 
• Cataract extraction. 
853 
 
854 
Study intravitreous aflibercept may be given pre-operatively, but then should not be given 
855 
thereafter unless there is recurrent hemorrhage (see section 4.5.2 below). If pre-op aflibercept is 
856 
given, it is strongly recommended that it be given between 1 day to 1 week prior to the 
857 
procedure, although it can be administered up to 2 weeks prior if necessary.   
858 
     
859 
4.4.1 Vitreous and Aqueous Sample Collection 
860 
Participation in the ancillary sample collection component is not a requirement for participation 
861 
in this study.  It is expected that sites with the capability to obtain and ship intraocular fluids will 
862 
participate.  At the time of consent into the main study, participants will have the option of 
863 
signing the ancillary sample collection portion of the informed consent form to indicate their 
864 
willingness to provide either a vitreous sample only (at least 1 cc of undiluted vitreous collected 
865 
during the vitrectomy procedure) or to provide both vitreous and an additional aqueous sample 
866 
(requiring an additional anterior paracentesis to collect at least 0.1 cc of aqueous fluid).    
867 
 
868 
If consent for vitreous and/or aqueous sampling is obtained, the sample(s) will be collected and 
869 
shipped on dry ice to a central laboratory for storage until analyses are completed. Details 
870 
regarding collection, sample labeling, storage, and shipment can be found in the ancillary study 
871 
procedures manual. 
872 
 
873 
4.4.2 Deferral or Cancellation of Surgery in the Vitrectomy Group 
874 
Surgery may be cancelled if there is substantial improvement in vitreous hemorrhage such that 
875 
visual acuity is no longer affected. 
876 
 
877 
If surgery is postponed for reasons other than substantial vitreous hemorrhage improvement, it 
878 
should be re-scheduled as soon as possible. 
879 
 
880 
Whether surgery is deferred or cancelled, protocol follow-up visits will continue as scheduled 
881 
based on time from randomization.   
882 
 
883 
4.5 Vitrectomy Group Intra- and Post-Operative Treatment 
884 
4.5.1 Panretinal Photocoagulation in the Vitrectomy Group 
885 
PRP should be placed to the extent that it is considered “complete”.  “Complete” PRP is defined 
886 
as 500 micron size burns on the retina placed no further than 1 to 2 burn widths apart beginning 
887 
~3000 microns from the macular center and extending at least to the equator for 12 clock hours. 
888 
See procedures manual for additional details, including use of automated pattern. 
889 
 
890 
If it is determined during surgery that the eye has already received “complete” PRP, further PRP 
891 
treatment is not required.  PRP treatment can be performed using the investigator’s standard 
892 
procedure and may include indirect delivery.     
893 
 
894 
If the size or amount of neovascularization increases following completion of the initial PRP 
895 
session, additional PRP should be given if possible.  Aflibercept may be given for 
896 
neovascularization in the absence of recurrent hemorrhage after discussion with the protocol 
897 
chair (see below for treatment of recurrent hemorrhage from NV).       
898 

Vx for Vitreous Hemorrhage Protocol 1.0 7-28-16 
 
     4-5 
 
899 
4.5.2 Treatment for Recurrent Vitreous Hemorrhage in the Vitrectomy Group 
900 
If there is recurrent hemorrhage, no treatment should be given within the first 4 weeks post-
901 
vitrectomy.  After 4 weeks, if the investigator determines there is recurrent hemorrhage from 
902 
neovascularization, two injections of study aflibercept will be given, 4(±1) weeks apart.  
903 
Additional aflibercept may be given every 4(±1) weeks thereafter, at the discretion of the 
904 
investigator.  Repeat vitrectomy (or air/fluid exchange) may only be performed if the recurrent 
905 
hemorrhage has not cleared after at least 2 consecutive 4-week injections.  Otherwise, protocol 
906 
chair approval is required to re-operate.    
907 
 
908 
4.6 Cataract Surgery (Both Groups) 
909 
Investigators should evaluate lens changes throughout the course of follow-up and consider 
910 
cataract surgery (or referral for possible cataract surgery) when a lens change is thought to be 
911 
visually significant based on the investigator’s judgment.  If the visual potential of the study eye 
912 
is unknown, the investigator should assume that there is potential for clinically relevant 
913 
improvement in vision.  Cataract surgery may be performed as part of the surgeon’s usual 
914 
routine.  Limited data will be collected for the study.   
915 
4.7 Treatment for Diabetic Macular Edema (Both Groups) 
916 
No anti-VEGF should be given for DME within 6 weeks of the initial randomized treatment. For 
917 
post-surgical edema, steroid drops or other alternatives may be given at the discretion of the 
918 
investigator.  After 6 weeks, if DME is present (OCT CSF above gender and OCT machine-
919 
specific thresholds and investigator has confirmed thickening is due to diabetic macular edema 
920 
and not post-surgical macular edema or other cause) and vision is 20/32 or worse, treatment with 
921 
intravitreous aflibercept and deferred focal/grid laser will be given, using the DRCR.net 
922 
intravitreous anti-VEGF retreatment protocol (section 4.7.1 below). 
923 
 
924 
For eyes with DME and best-corrected visual acuity better than 20/32, protocol chair approval is 
925 
required to initiate anti-VEGF treatment.  Once initiated, the DRCR.net intravitreous anti-VEGF 
926 
retreatment protocol regimen must be followed.   
927 
 
928 
4.7.1. Intravitreous Injection Retreatment for DME 
929 
Once aflibercept treatment has been initiated for DME, the eye will be evaluated at each visit for 
930 
retreatment. In general, an eye will continue to receive an injection if the eye is improving or 
931 
worsening on OCT or visual acuity. The first time an eye has not improved or worsened the eye 
932 
will receive an injection.  If the eye has not improved or worsened for at least 2 consecutive 4-
933 
week injections and the OCT CSF thickness is less than the gender specific spectral domain OCT 
934 
threshold (see below) and visual acuity is 20/20 or better, then injection will be deferred.  If the 
935 
eye has not improved or worsened for at least 2 consecutive 4-week visits and the OCT CSF 
936 
thickness is ≥ the gender specific spectral domain OCT threshold or visual acuity is worse than 
937 
20/20, the following will be done: 
938 
• If less than 24 weeks from the initial injection for DME, an injection will be given. 
939 
• At and after 24 weeks, the injection will be deferred. 
940 
 
941 
The protocol chair or designee must be contacted prior to deviation from the injection protocol.  
942 
See the DRCR.net Procedure Manual for additional details. 
943 
 
944 
Spectral domain OCT central subfield gender-specific threshold: 
945 

Vx for Vitreous Hemorrhage Protocol 1.0 7-28-16 
 
     4-6 
➢ Zeiss Cirrus: 290 microns in women, and 305 microns in men 
946 
➢ Heidelberg Spectralis: 305 microns in women, and 320 microns in men 
947 
 
948 
4.7.2. Focal/Grid Laser Treatment for DME 
949 
In general, focal/grid laser will be initiated at or after 24 weeks from the initial injection for 
950 
DME if 1) the OCT central subfield thickness is greater than the OCT central subfield gender-
951 
specific threshold (above) or there is edema that is threatening the fovea and 2) the eye has not 
952 
improved on OCT or visual acuity from the last two consecutive injections.  Once focal/grid 
953 
laser has been initiated, retreatment with focal/grid laser will be given unless one of the 
954 
following is present: 1) focal/grid laser has been given in the previous 13 weeks, 2) complete 
955 
focal/grid laser has already been given in the investigator’s judgment, 3) the OCT central 
956 
subfield thickness is less than the OCT central subfield gender-specific threshold (above) and 
957 
there is no edema threatening the fovea, 4) the eye has improved since the last laser treatment. 
958 
The protocol chair or designee must be contacted prior to deviating from the focal/grid laser 
959 
protocol.  See the DRCR.net Procedure Manual for additional details. 
960 
 
961 

Vx for Vitreous Hemorrhage Protocol 1.0 7-28-16 
 
     5-1 
 
962 
CHAPTER 5.                                                                                               
963 
MISCELLANEOUS CONSIDERATIONS IN FOLLOW-UP 
964 
 
965 
5.1 Endophthalmitis  
966 
Diagnosis of endophthalmitis following intravitreous injections is based on investigator’s 
967 
judgment.  A culture is required prior to initiating antibiotic treatment for presumed 
968 
endophthalmitis.   
969 
5.2 Treatment of Diabetic Retinopathy in Non-study Eye 
970 
Treatment of diabetic retinopathy, including DME, in the non-study eye is at investigator 
971 
discretion. However, if anti-VEGF treatment will be given in the non-study eye, study aflibercept 
972 
must be used. 
973 
5.3 Use of Intravitreal Anti-VEGF for Conditions Other than DME in the Study Eye 
974 
If an ocular condition other than DME or DR develops in the study eye for which aflibercept is 
975 
an FDA approved treatment (e.g. neovascular AMD, macular edema following central retinal 
976 
vein occlusion), the use of study aflibercept is at the discretion of the investigator.  Any off-label 
977 
use of anti-VEGF in the study eye for an ocular condition other than DR, will require discussion 
978 
with and approval by the protocol chair or designee. Study aflibercept must be used for any anti-
979 
VEGF treatment in the study eye.   
980 
5.4 Diabetes Management 
981 
Diabetes management is left to the study participant’s medical care provider. 
982 
5.5 Study Participant Withdrawal and Losses to Follow-up 
983 
A study participant has the right to withdraw from the study at any time.  If a study participant is 
984 
considering withdrawal from the study, the principal investigator should personally speak to the 
985 
individual about the reasons, and every effort should be made to accommodate him or her.   
986 
 
987 
The goal for the study is to have as few losses to follow-up as possible.  The Coordinating Center 
988 
will assist in the tracking of study participants who cannot be contacted by the site.  The 
989 
Coordinating Center will be responsible for classifying a study participant as lost to follow-up. 
990 
 
991 
Study participants who withdraw will be asked to have a final closeout visit at which the testing 
992 
described for the protocol visits will be performed.  Study participants who have an adverse 
993 
effect attributable to a study treatment or procedure will be asked to continue in follow-up until 
994 
the adverse event has resolved or stabilized. 
995 
 
996 
Study participants who withdraw or are determined to have been ineligible post-randomization 
997 
will not be replaced. 
998 
5.6 Discontinuation of Study 
999 
The study may be discontinued by the Executive Committee (with approval of the Data and 
1000 
Safety Monitoring Committee) prior to the preplanned completion of follow-up for all study 
1001 
participants. 
1002 

Vx for Vitreous Hemorrhage Protocol 1.0 7-28-16 
 
     5-2 
5.7 Contact Information Provided to the Coordinating Center 
1003 
The Coordinating Center will be provided with contact information for each study participant.  
1004 
Permission to obtain such information will be included in the Informed Consent Form.  The 
1005 
contact information may be maintained in a secure database and will be maintained separately 
1006 
from the study data. 
1007 
 
1008 
Phone contact from the Coordinating Center will be made with each study participant in the first 
1009 
month after enrollment, and approximately every six months thereafter.  Additional phone 
1010 
contacts from the Coordinating Center will be made if necessary to facilitate the scheduling of 
1011 
the study participant for follow-up visits.  A participant-oriented newsletter may be sent twice a 
1012 
year.  A study logo item may be sent once a year.  
1013 
 
1014 
Study participants will be provided with a summary of the study results in a newsletter format 
1015 
after completion of the study by all participants.   
1016 
5.8 Study Participant Reimbursement 
1017 
The study will be providing the study participant with a $25 merchandise or money card per 
1018 
completed protocol visit.  Additional travel expenses may be paid in cases for participants with 
1019 
higher expenses. In situations of financial hardship supplemental funds for patient expenses may 
1020 
be available on a case by case basis. 
1021 

Vx for Vitreous Hemorrhage Protocol 1.0 7-28-16 
 
     6-1 
1022 
CHAPTER 6.                                                                                           
1023 
ADVERSE EVENTS 
1024 
 
1025 
6.1 Definition 
1026 
An adverse event is any untoward medical occurrence in a study participant, irrespective of 
1027 
whether or not the event is considered treatment-related. 
1028 
 
1029 
6.2 Recording of Adverse Events 
1030 
Throughout the course of the study, all efforts will be made to remain alert to possible adverse 
1031 
events or untoward findings.  The first concern will be the safety of the study participant, and 
1032 
appropriate medical intervention will be made. 
1033 
 
1034 
All adverse events whether volunteered by the participant, discovered by study personnel during 
1035 
questioning, or detected through physical examination, laboratory test, or other means will be 
1036 
reported on an adverse event form online.  Each adverse event form is reviewed by the 
1037 
Coordinating Center to verify the coding and the reporting that is required.  
1038 
 
1039 
The study investigator will assess the relationship of any adverse event to be related or unrelated 
1040 
by determining if there is a reasonable possibility that the adverse event may have been caused 
1041 
by the treatment (including treatment of the non-study eye with study treatment). 
1042 
 
1043 
To ensure consistency of adverse event causality assessments, investigators should apply the 
1044 
following general guideline when determining whether an adverse event is related: 
1045 
 
1046 
Yes 
1047 
There is a plausible temporal relationship between the onset of the adverse event and 
1048 
administration of the study treatment, and the adverse event cannot be readily explained by the 
1049 
participant’s clinical state, intercurrent illness, or concomitant therapies; and/or the adverse event 
1050 
follows a known pattern of response to the study treatment; and/or the adverse event abates or 
1051 
resolves upon discontinuation of the study treatment or dose reduction and, if applicable, 
1052 
reappears upon re-challenge. 
1053 
 
1054 
No 
1055 
Evidence exists that the adverse event has an etiology other than the study treatment (e.g., 
1056 
preexisting medical condition, underlying disease, intercurrent illness, or concomitant 
1057 
medication); and/or the adverse event has no plausible temporal relationship to study treatment 
1058 
administration (e.g., cancer diagnosed 2 days after first dose of study drug).    
1059 
 
1060 
The intensity of adverse events will be rated on a three-point scale: (1) mild, (2) moderate, or (3) 
1061 
severe.  It is emphasized that the term severe is a measure of intensity: thus, a severe adverse 
1062 
event is not necessarily serious. For example, itching for several days may be rated as severe, but 
1063 
may not be clinically serious. 
1064 
 
1065 
Adverse events will be coded using the MedDRA dictionary.  
1066 
 
1067 
Definitions of relationship and intensity are listed on the DRCR.net website data entry form.   
1068 

 
Vx for Vitreous Hemorrhage Protocol 1.0 7-28-16 
   
6-2 
 
1069 
Adverse events that continue after the study participant’s discontinuation or completion of the 
1070 
study will be followed until their medical outcome is determined or until no further change in the 
1071 
condition is expected.   
1072 
 
1073 
6.3 Reporting Serious or Unexpected Adverse Events 
1074 
A serious adverse event is any untoward occurrence that: 
1075 
• Results in death. 
1076 
• Is life-threatening; (a non-life-threatening event which, had it been more severe, might have 
1077 
become life-threatening, is not necessarily considered a serious adverse event). 
1078 
• Requires inpatient hospitalization or prolongation of existing hospitalization. 
1079 
• Results in persistent or significant disability/incapacity or substantial disruption of the ability 
1080 
to conduct normal life functions (sight threatening). 
1081 
• Is a congenital anomaly or birth defect. 
1082 
• Is considered a significant medical event by the investigator based on medical judgment (e.g., 
1083 
may jeopardize the participant or may require medical/surgical intervention to prevent one of 
1084 
the outcomes listed above). 
1085 
 
1086 
Unexpected adverse events are those that are not identified in nature, severity, or frequency in 
1087 
the current Clinical Investigator’s Brochure.   
1088 
 
1089 
Serious or unexpected adverse events must be reported to the Coordinating Center immediately 
1090 
via completion of the online serious adverse event form. If the study participant required 
1091 
hospitalization, the hospital discharge summary must also be sent to the Coordinating Center.   
1092 
 
1093 
The Coordinating Center will notify all participating investigators of any adverse event that is 
1094 
both serious and unexpected.  Notification will be made within 10 days after the Coordinating 
1095 
Center becomes aware of the event.   
1096 
 
 
1097 
Each principal investigator is responsible for reporting serious study-related adverse events and 
1098 
abiding by any other reporting requirements specific to their Institutional Review Board.  
1099 
 
1100 
6.4 Data and Safety Monitoring Committee Review of Adverse Events 
1101 
A Data and Safety Monitoring Committee (DSMC) will approve the protocol, template informed 
1102 
consent form, and substantive amendments and provide independent monitoring of adverse 
1103 
events.  Cumulative adverse event data are tabulated semi-annually for review by the DSMC.  
1104 
Following each DSMC data review, a summary will be provided to IRBs.  A list of specific 
1105 
adverse events to be reported expeditiously to the DSMC will be compiled and included as part 
1106 
of the DSMC Standard Operating Procedures document.   
1107 
 
1108 
6.5 Risks 
1109 
6.5.1 Potential Adverse Effects of Aflibercept 
1110 
The most common adverse reactions (≥5%) reported in patients receiving aflibercept were 
1111 
conjunctival hemorrhage, eye pain, cataract, vitreous floaters, intraocular pressure increased, 
1112 
vitreous detachment, and vitreous floaters.   
1113 
 
1114 
Serious adverse reactions related to the injection procedure have occurred in <0.1% of 
1115 
intravitreal injections with aflibercept including endophthalmitis and retinal detachment. 
1116 

 
Vx for Vitreous Hemorrhage Protocol 1.0 7-28-16 
   
6-3 
 
1117 
 
1118 
Safety data specific to the diabetes population were published from phase III studies VISTA and 
1119 
VIVID, which included 872 eyes with DME with central involvement that received either 
1120 
intravitreal aﬂibercept every 4 weeks, intravitreal aflibercept every 8 weeks after 5 initial 
1121 
monthly doses, or macular laser photocoagulation.  Overall, the incidences of ocular and non-
1122 
ocular adverse events were similar across treatment groups at 52 weeks.32  The incidence of 
1123 
APTC-defined thromboembolic events was similar across treatment groups.  There were no 
1124 
reported cases of endophthalmitis, and intraocular inflammation occurred in less than 1% of 
1125 
injections.  Through 100 weeks, an integrated safety analysis found that the most frequent 
1126 
serious ocular adverse event was cataract (2.4% and 1.0% in the aflibercept groups compared 
1127 
with 0.3% in the laser group).33   The incidence of APTC ATEs in VISTA and VIVID 
1128 
during the 100 weeks study duration was 6.4% (37out of 578) in the combined EYLEA groups 
1129 
compared with 4.2% (12 out of 287) in the control group.33 
1130 
 
1131 
There may be side effects and discomforts that are not yet known.   
1132 
 
1133 
6.5.2 Potential Adverse Effects of Intravitreous Injection 
1134 
Rarely, the drugs used to anesthetize the eye before the injections (proparacaine, tetracaine, or 
1135 
xylocaine) can cause an allergic reaction, seizures, and an irregular heartbeat less than 1% of 
1136 
the time.   
1137 
 
1138 
Sub-conjunctival hemorrhage or floaters will commonly occur as a result of the intravitreous 
1139 
injection.  Mild discomfort, ocular hyperemia, increased lacrimation, discharge or itching lasting 
1140 
for up to a few days is also likely (more than 10% of the time). 
1141 
 
1142 
Immediately following the injection, there may be elevation of intraocular pressure. It usually 
1143 
returns to normal spontaneously, but may need to be treated with topical drugs or a 
1144 
paracentesis to lower the pressure.  The likelihood of permanent loss of vision from elevated 
1145 
intraocular pressure is less than 1%. 
1146 
 
1147 
As a result of the injection, endophthalmitis (infection in the eye) could develop.  If this occurs, it is 
1148 
treated by intravitreous injection of antibiotics, but there is a risk of permanent loss of vision including 
1149 
blindness. The risk of endophthalmitis is less than 1%. 
1150 
 
1151 
As a result of the injection, a retinal detachment could occur.  If this occurs, surgery may be 
1152 
needed to repair the retina.  The surgery is usually successful at reattaching the retina.  
1153 
However, a retinal detachment can produce permanent loss of vision and even blindness.  The 
1154 
risk of retinal detachment is less than 1%. 
1155 
 
1156 
The injection could cause a vitreous hemorrhage.  Usually the blood will resolve 
1157 
spontaneously, but if not, surgery may be needed to remove the blood.  Although the surgery 
1158 
usually successfully removes the blood, there is a small risk of permanent loss of vision and 
1159 
even blindness.  The risk of having a vitreous hemorrhage due to the injection is less than 1%. 
1160 
6.5.3  Risks of Vitrectomy 
1161 
6.5.3.1 Anesthesia 
1162 

 
Vx for Vitreous Hemorrhage Protocol 1.0 7-28-16 
   
6-4 
Anesthesia may be general endotracheal or local retrobulbar/peribulbar, usually with systemic 
1163 
sedation.  Risks of systemic sedation and general anesthesia include cardiac arrhythmia and 
1164 
death.  The risks of retrobulbar/peribulbar anesthesia include:  retrobulbar hemorrhage; 
1165 
perforation of the eye by the needle; damage to the optic nerve; double vision lasting up to 24 
1166 
hours or more; drooping of the eye lid lasting up to 24 hours or more; difficulty speaking or 
1167 
breathing; lightheadedness/syncope/vasovagal response; allergy to any components of the 
1168 
injection; life threatening response due to the spread of anesthesia to the brain stem, resulting in 
1169 
epileptic fits, drowsiness, confusion, loss of verbalization, convulsions, respiratory arrest, or 
1170 
cardiac arrest.   
1171 
 
1172 
6.5.3.2 Surgical Procedure 
1173 
Risks of the vitrectomy procedure include a retinal tear (5%) and retinal detachment (1%).  
1174 
Uncommon risks include infection (1/5,000) and serious hemorrhage (1/5,000).  Very rare risks 
1175 
include visual field defect, visual loss due to macular toxicity of light or dye (if used) or 
1176 
manipulation, and optic neuropathy.  In phakic eyes, cataract progression is likely.   
1177 
6.5.4  Risks of Panretinal Photocoagulation Treatment 
1178 
Panretinal photocoagulation can reduce peripheral and night vision. In addition, it can reduce 
1179 
transient or permanent central vision loss. Rarely, it can cause transient increase in intraocular 
1180 
pressure, presumably through secondary angle closure as the lens-iris diaphragm shifts forward 
1181 
with transient swelling of the posterior tissues. 
1182 
 
1183 
In some cases retrobulbar or peribulbar injection may be used to anesthetize the eye and to 
1184 
reduce eye movements.  Complications of retrobulbar and peribulbar injections are rare.  They 
1185 
include, but are not limited to, the following: retrobulbar hemorrhage (bleeding behind the 
1186 
eyeball); perforation of the eye by the needle; damage to the optic nerve; diplopia lasting up to 
1187 
24 hours or more; ptosis lasting up to 24 hours or more; difficulty speaking or breathing; 
1188 
lightheadedness/syncope/vasovagal response; allergy to any components of the injection; life 
1189 
threatening response due to the spread of anesthesia to the brain stem, resulting in seizures, 
1190 
drowsiness, confusion, loss of ability to talk, convulsions, stoppage of breathing, or stoppage of 
1191 
heartbeat. All of these complications are rare. 
1192 
 
1193 
6.5.5 Risks of Eye Examination and Tests 
1194 
There is a very rare risk of an allergic response to the topical medications used to anesthetize the 
1195 
eye or dilate the pupil that occurs in less than 1% of eyes. Dilating drops rarely could cause an 
1196 
acute angle closure glaucoma attack (less than 1 in 1000)35, but this is highly unlikely since the 
1197 
participants in the study will have had their pupils dilated many times previously.   
1198 
 
1199 
There are no known risks associated with OCT.  
1200 
 
1201 
 
1202 

 
Vx for Vitreous Hemorrhage Protocol 1.0 7-28-16 
7-1 
CHAPTER 7.                                                                                     
1203 
STATISTICAL METHODS 
1204 
The approach to sample size and statistical analysis is summarized below. 
1205 
7.1 Sample Size 
1206 
The sample size has been chosen for the primary study objective, which is to compare visual 
1207 
acuity outcomes over time of prompt vitrectomy + PRP regimen versus intravitreous aflibercept 
1208 
regimen in eyes with vitreous hemorrhage from PDR for which intervention is deemed 
1209 
necessary. The primary outcome is visual acuity area under the curve (AUC) from baseline to 24 
1210 
weeks. The resulting analysis is a treatment group comparison of mean AUC adjusting for 
1211 
baseline visual acuity and baseline lens status. 
1212 
7.1.1 Sample Size Assumptions 
1213 
Aflibercept Group:  To provide estimates for the aflibercept arm, data from the DRCR.net 
1214 
Protocol N trial (An Evaluation of Intravitreal Ranibizumab for Vitreous Hemorrhage Due to 
1215 
Proliferative Diabetic Retinopathy) were reviewed for eyes with baseline visual acuity 20/32 or 
1216 
worse. Eyes in Protocol N had structured treatment through 16 weeks and visits at 4, 8, and 12 
1217 
weeks. Treatment was at investigator discretion between 16 and 52 weeks, at which time visual 
1218 
acuity was measured. Based on visual acuity data (Table 1), the standard deviation of the AUC at 
1219 
12 weeks was 19.2 (95% CI 17.1, 22.0) and the correlation with baseline visual acuity was -0.39 
1220 
(95% CI -0.53, -0.23). Assuming a true standard deviation of 19.2, this adjustment yields an 
1221 
effective standard deviation of 17.7 (95% CI 16.3 to 18.7). 
1222 
Table 1. Visual acuity data from eyes in the ranibizumab group of Protocol N with baseline 
1223 
visual acuity 20/32 or worse. Visits in common with this protocol are in boldface. 
1224 
Visit 
Mean 
SD 
Baseline 
33 
28 
4-week 
44 
29 
8-week 
50 
29 
12-week 
56 
27 
52-week 
64 
22 
Vitrectomy Group:  For the vitrectomy arm, data from a randomized trial comparing vitrectomy 
1225 
with and without bevacizumab for proliferative diabetic retinopathy were reviewed (Manabe et 
1226 
al., 2015).36 In the sham group, mean baseline visual acuity was 1.14 logMAR (28 letters) and 30 
1227 
of the 34 participants (88%) were enrolled to treat persistent vitreous hemorrhage. At one month 
1228 
after surgery, mean visual acuity improved to 0.43 logMAR (64 letters). Without participant-
1229 
level data, the standard deviation of the AUC cannot be estimated. However, the standard 
1230 
deviation of visual acuity at one month was 0.48 logMAR (24 letters), which is less than the 29 
1231 
letter standard deviation for visual acuity observed in the ranibizumab group at 4 weeks in 
1232 
Protocol N (Table 1). Therefore, assuming the standard deviation of AUC for this group is 
1233 
similar to the anti-VEGF group is likely a conservative approach. 
1234 
Projected Difference:  The estimated treatment group difference in AUC at 24 weeks (6 months) 
1235 
was calculated using the above data, assuming that both groups have baseline visual acuity of 33 
1236 
letters, and the aflibercept arm reaches a visual acuity of 64 letters by 6 months (Figure 1). These 
1237 

 
Vx for Vitreous Hemorrhage Protocol 1.0 7-28-16 
7-2 
calculations projected an AUC difference of +8.3 letters in favor the of the vitrectomy arm. If 
1238 
visual acuity in the aflibercept arm did not reach 64 letters until 1 year, and had a visual acuity of 
1239 
only 60 letters at 6 months, the difference would be +9.3 letters. 
1240 
Figure 1. Projected trajectories of visual acuity in the aflibercept and vitrectomy arms. 
1241 
 
1242 
7.1.2 Sample Size Estimation 
1243 
Table 2 shows sample sizes estimates under several scenarios. The final sample size has been 
1244 
computed with type 1 error rate of 0.049 (0.001 adjustment for DSMC review) and 80% power. 
1245 
Assuming an effective standard deviation of 18 (after adjusting for correlation between baseline 
1246 
and outcome), and a true difference in mean AUC of 8 letters, the required total sample size is 
1247 
162 eyes. This will be increased to 200 eyes to account for uncertainty in our projections and loss 
1248 
to follow-up; if the rate of loss to follow-up is 7.5%, then the power for an effective sample size 
1249 
of 185 would be 85%.   
1250 
Table 2. Sample size estimates for a range of true mean differences and effective standard 
1251 
deviations (after adjustment for correlation between baseline and outcome). Total number of 
1252 
eyes required for 80% / 90% power are shown in cells. The type I error rate is 0.049. 
1253 
Power: 80% / 90% 
Effective Standard Deviation 
True Mean Difference 
17 
18 
19 
7 
190 / 252 
212 / 282 
236 / 314 
8 
146 / 194 
162 / 216 
182 / 242 
9 
116 / 154 
130 / 172 
144 / 192 
 
1254 

 
Vx for Vitreous Hemorrhage Protocol 1.0 7-28-16 
7-3 
7.1.3 Statistical Power 
1255 
As there are several binary variables of interest as secondary outcomes (Section 7.3), confidence 
1256 
interval half-widths (Table 3) and statistical power (Table 4) for the difference of two 
1257 
percentages have been calculated based on an effective total sample size of 186 eyes (200 eyes 
1258 
enrolled with 7% loss to follow-up). In Protocol N, among eyes in the ranibizumab group with 
1259 
baseline visual acuity of 20/32 or worse, 37% achieved 20/32 vision or greater by one year. As 
1260 
power for the difference of two percentages is dependent upon the absolute value of the 
1261 
percentages, this estimate is used as a starting point for the calculations below. 
1262 
Table 3. Expected half-widths of a 95% confidence interval for the difference of two percentages 
1263 
(effective sample size of 186). The width depends upon the true percentages. 
1264 
Outcome Rate 
in Group A 
Difference in Group B 
+10% 
+15% 
+20% 
10% 
10% 
11% 
11% 
30% 
14% 
14% 
14% 
50% 
14% 
14% 
14% 
Table 4. Power for the comparison of two percentages (effective sample size of 186). The power 
1265 
depends upon the true percentages. 
1266 
Outcome Rate 
in Group A 
Difference in Group B 
+10% 
+15% 
+20% 
10% 
41% 
72% 
91% 
30% 
25% 
50% 
76% 
50% 
23% 
49% 
76% 
The expected half-widths for a within-group binary 95% confidence interval (e.g., percentage of 
1267 
eyes in aflibercept group requiring vitrectomy) are shown in Table 5. The expected half-widths 
1268 
for a 95% confidence interval of a difference of means (e.g., visual acuity letter score) are shown 
1269 
in Table 6. 
1270 
Table 5. Expected half-widths of a 95% confidence interval for a within-group binary outcome 
1271 
(effective sample size of 93). The half-width depends upon the true outcome rate. 
1272 
Outcome Rate 
10% 
30% 
50% 
6% 
9% 
10% 
Table 6. Expected half-widths of a 95% confidence interval for a between-group difference of 
1273 
means (effective sample size of 186). The half-width depends upon the common standard 
1274 
deviation. 
1275 
Standard Deviation 
15 
20 
25 
4.3 
5.7 
7.2 

 
Vx for Vitreous Hemorrhage Protocol 1.0 7-28-16 
7-4 
7.2 Primary Analysis Plan 
1276 
7.2.1 Principles for Analysis 
1277 
The primary analysis will consist of a treatment group comparison of mean visual acuity AUC 
1278 
from baseline to 24 weeks between the two treatment groups adjusting for baseline visual acuity 
1279 
and phakic status using analysis of covariance. Only baseline and outcome visits (4, 12, 24, 36, 
1280 
52, 68, 84, and 104 weeks), which are common to both groups, will be used to calculate AUC 
1281 
through the appropriate visit for the primary and secondary outcomes (e.g., 24 weeks for primary 
1282 
outcome). AUC will be calculated for each participant by the trapezoidal rule using the following 
1283 
formula: 
1284 
𝐴𝑈𝐶= ∑(𝑉𝑖+ 𝑉𝑖+1
2
× 𝑑)
𝑛
𝑖=1
  
1285 
Where Vi is the visual acuity from baseline measured at the ith visit, d is the number of days 
1286 
between visits i and i+1, and n is the number of outcome visits included in the analysis. For 
1287 
example, the primary outcome has n = 4 as the analysis will include visits at baseline, 4 weeks, 
1288 
12 weeks, and 24 weeks. For presentation, AUC will be divided by the number of days between 
1289 
baseline and the nth visit so that the value shown will have units of letters rather than letterdays. 
1290 
This statistic can then be interpreted as the average visual acuity over the time period between 
1291 
baseline and the nth visit. 
1292 
The primary analysis will include all randomized eyes according to treatment group assignment 
1293 
at randomization. Rubin’s multiple imputation will be used to handle missing data. A sensitivity 
1294 
analysis using only observed data will also be conducted. If the analyses of imputed and 
1295 
observed data differ substantially, then exploratory analyses will be performed to evaluate 
1296 
factors that may have contributed to the differences. 
1297 
Pre-planned subgroup analyses will be described in the detailed Statistical Analysis Plan and 
1298 
include analyses by history of PRP, treatment for DME, and phakic status. 
1299 
Imbalances between groups in important covariates are not expected to be of sufficient 
1300 
magnitude to produce confounding. However, the presence of confounding will be evaluated in 
1301 
the primary analysis by including factors potentially associated with the outcome for which there 
1302 
is an imbalance between groups. 
1303 
There are no data to suggest that the treatment effect will vary by gender or race/ethnicity. 
1304 
However, both of these factors will be evaluated in exploratory analyses. 
1305 
The primary outcome was primarily selected for sample size considerations. The long-term 
1306 
additional key outcomes and within-group outcomes will be equally important as the area under 
1307 
the curve outcome for evaluating the overall follow-up course for these two treatment 
1308 
approaches. Therefore, publication is not planned until the full 104 week follow-up has closed. 
1309 
7.2.2 Per-Protocol Analysis 
1310 
A per-protocol analysis will be conducted that will include all randomized eyes except those in 
1311 
the prompt vitrectomy + PRP group that never receive vitrectomy and eyes from the aflibercept 
1312 
group that missed an injection. The intent-to-treat analysis is considered the primary analysis. If 
1313 

 
Vx for Vitreous Hemorrhage Protocol 1.0 7-28-16 
7-5 
the results of the primary and per-protocol analyses differ substantially, then exploratory 
1314 
analyses will be performed to evaluate the factors that have contributed to the differences. 
1315 
7.2.3 Interim Analysis Plan 
1316 
There is no formal interim data monitoring for efficacy or futility planned.   
1317 
7.3 Secondary Outcomes 
1318 
Additional analyses of visual acuity and other outcomes are summarized in the table below. 
1319 
Analyses will include adjustments for baseline visual acuity and phakic status. Analyses will be 
1320 
conducted at 24, 52, and 104 weeks (note that visual acuity AUC at 24 weeks is the primary 
1321 
outcome, not a secondary outcome). In addition, mean visual acuity, visual acuity AUC, and 
1322 
percentage of eyes with various visual acuity cutoffs will also be compared at the 4 and 12 week 
1323 
visits as the between-group difference in vision is expected to be greatest during the first months 
1324 
of the trial. 
1325 
Table 3. Analyses of Secondary Outcomes. 
1326 
Outcome 
Analysis Technique 
Mean visual acuity and AUC 
Analysis of covariance 
Percentage of eyes ≥ 20/20, 20/32, or 20/40, ≤ 
20/200 and ≤ 20/800  
Binomial regression 
Percentage of eyes with recurrent vitreous 
hemorrhage on clinical exam 
Binomial regression 
Percentage of eyes with retinal 
neovascularization 
Binomial regression 
OCT central subfield thickness 
Analysis of covariance*† 
*No adjustment for visual acuity.  
1327 
†No adjustment for baseline central subfield thickness as vitreous hemorrhage will prevent 
1328 
obtaining usable scans for many participants. 
1329 
7.3.1 Outcomes within Treatment Groups 
1330 
Within each treatment group, the following outcomes and their 95% confidence intervals will be 
1331 
tabulated: 
1332 
• Percentage of eyes undergoing vitrectomy (initial vitrectomy in aflibercept group and 
1333 
repeat vitrectomy in vitrectomy group) 
1334 
• Number of intravitreous aflibercept injections performed 
1335 
• Percentage of eyes receiving PRP (aflibercept group only) 
1336 
7.3.2 Economic Analysis 
1337 
The purpose of the economic analysis is to compare the treatment groups with respect to cost, 
1338 
cost-effectiveness and workplace productivity loss. The analysis plan is briefly described and 
1339 
will be detailed in a separate document. 
1340 
Data from the clinical trial on number of clinic visits completed, number of procedures 
1341 
performed (e.g. vitrectomy, OCT, exam), and number of study aflibercept injections will be used 
1342 
to estimate an average cost per patient for each treatment arm, using the Medicare Fee Schedule 
1343 

 
Vx for Vitreous Hemorrhage Protocol 1.0 7-28-16 
7-6 
to estimate medical costs. The cost estimates in combination with the percent productivity loss 
1344 
for each treatment arm will be incorporated into the analysis. 
1345 
Scores from the WPAIQ, administered at baseline, 4, 12, 24, 52, and 104 weeks, will be 
1346 
analyzed by treatment group using analysis of covariance to adjust for baseline score and phakic 
1347 
status. Adjusted 95% confidence intervals for treatment group differences will be calculated. 
1348 
Mean change at each visit in the following four scores will be analyzed: 
1349 
• Absenteeism:  percent work time missed due to vision 
1350 
• Presenteeism:  percent impairment while working due to vision  
1351 
• Work Productivity Loss:  percent overall work impairment due to vision  
1352 
o Combination of absenteeism and presenteeism scores 
1353 
• Activity Impairment:  percent activity impairment due to vision 
1354 
In addition, area under the curve analyses will be conducted using data from all available 
1355 
outcome visits for the Work Productivity Loss and Activity Impairment scores. 
1356 
7.4 Safety Analysis Plan 
1357 
Adverse events will be categorized as systemic, study eye, or non-study eye. The events will be 
1358 
tabulated by treatment group. As only one study eye shall be enrolled, there is no group of 
1359 
patients with two study eyes, which would need to be tabulated separately. The frequency of the 
1360 
event occurring at least once will be calculated. Rates of adverse events will be compared 
1361 
between treatment groups using Barnard’s unconditional exact test.  
1362 
The following ocular adverse events will be assessed: 
1363 
o Endophthalmitis 
1364 
o Any retinal detachment 
1365 
o Rhegmatogenous retinal detachment 
1366 
o Tractional retinal detachment 
1367 
o Retinal tear 
1368 
o Ocular inflammation (defined as anterior chamber cell, anterior chamber flare, 
1369 
choroiditis, episcleritis, uveitis, iritis, or vitreal cells) 
1370 
o Adverse intraocular pressure (IOP) events 
1371 
▪ Increase in IOP ≥ 10 mmHg from baseline 
1372 
▪ IOP ≥ 30 mmHg 
1373 
▪ Initiation of medication to lower IOP that was not in use at baseline 
1374 
▪ Glaucoma surgery 
1375 
o Neovascularization of the iris 
1376 
o Cataract extraction in eyes phakic at baseline 
1377 
o Visually significant cataract on clinical exam 
1378 
The following serious systemic adverse events will be assessed: 
1379 
o Primary: 
1380 
▪ Death 
1381 
▪ Serious adverse event (at least one) 
1382 
▪ Hospitalization (at least one) 
1383 

 
Vx for Vitreous Hemorrhage Protocol 1.0 7-28-16 
7-7 
▪ Cardiovascular/cerebrovascular events according to Antiplatelet Trialists’ 
1384 
Collaboration (excerpted from BMJ Jan 8, 1994): 
1385 
• Non-fatal myocardial infarction 
1386 
• Non-fatal stroke (counted only if symptoms lasted at least 24 hours) 
1387 
• Death attributed to cardiac, cerebral, hemorrhagic, embolic, other 
1388 
vascular (does not need to be ischemic in origin), or unknown cause 
1389 
• At least one event (non-fatal myocardial infarction, non-fatal stroke, or 
1390 
death attributed to potential vascular or unknown cause) 
1391 
APTC Notes:  Transient ischemic attacks, angina, and possible myocardial 
1392 
infarction or stroke are not counted. ‘Nonfatal’ myocardial infarction or 
1393 
stroke required that the participant was alive at the end of the study. If not, 
1394 
only the death is counted. 
1395 
o Secondary: 
1396 
▪ Frequency of at least one event per participant in each Medical Dictionary for 
1397 
Regulatory Activities (MedDRA) system organ class 
1398 
 
1399 
An additional tabulation will be made for adverse events possibly related to study treatment. 
1400 
7.5 Additional Tabulations and Analyses 
1401 
The following will be tabulated according to treatment group: 
1402 
• Baseline demographic and clinical characteristics 
1403 
• Visit completion rate 
1404 
• Treatment completion 
1405 
7.6 Statistical Modeling Techniques 
1406 
All model assumptions, including linearity, normality of residuals, and homoscedasticity will be 
1407 
verified where applicable. If model assumptions are not reasonably satisfied, then a 
1408 
transformation, nonparametric analysis, or other appropriate approach will be considered. 
1409 

 
Vx for Vitreous Hemorrhage Protocol 1.0 7-28-16 
8-1 
CHAPTER 8. REFERENCES 
1410 
 
1411 
 
1412 
1. Vision disorders in diabetes.Available at: 
1413 
http://diabetes.niddk.nih.gov/dm/pubs/america/pdf/chapter14.pdf. Accessed August 21, 2009 
1414 
2. Bourne RR, Stevens GA, White RA, et al. Causes of vision loss worldwide, 1990-2010: a 
1415 
systematic analysis. Lancet Glob Health 2013;1:e339-49. 
1416 
3. Writing Committee for the Diabetic Retinopathy Clinical Research Network. Panretinal 
1417 
photocoagulation vs intravitreous ranibizumab for proliferative diabetic retinopathy: A 
1418 
randomized clinical trial. JAMA 2015;314:2137-46. 
1419 
4. Kempen JH, O'Colmain BJ, Leske MC, et al. The prevalence of diabetic retinopathy among 
1420 
adults in the United States. Arch Ophthalmol 2004;122:552-63. 
1421 
5. Ferris FL, 3rd. How effective are treatments for diabetic retinopathy? JAMA 1993;269:1290-
1422 
1. 
1423 
6. Avery RL, Pearlman J, Pieramici DJ, et al. Intravitreal bevacizumab (Avastin) in the 
1424 
treatment of proliferative diabetic retinopathy. Ophthalmology 2006;113:1695 e1-15. 
1425 
7. Ho T, Smiddy W, Flynn Jr H. Vitrectomy in the Management of Diabetic Eye Disease. Surv 
1426 
Ophthalmol 1992;37:190-202. 
1427 
8. Misra A, Ho-Yen G, Burton RL. 23-gauge sutureless vitrectomy and 20-gauge vitrectomy: a 
1428 
case series comparison. Eye (Lond) 2009;23:1187-91. 
1429 
9. Khuthaila MK, Hsu J, Chiang A, et al. Postoperative vitreous hemorrhage after diabetic 23-
1430 
gauge pars plana vitrectomy. Am J Ophthalmol 2013;155:757-63, 63 e1-2. 
1431 
10. Castellarin A, Grigorian R, Bhagat N, et al. Vitrectomy with silicone oil infusion in severe 
1432 
diabetic retinopathy. Br J Ophthalmol 2003;87:318-21. 
1433 
11. Ostri C, La Cour M, Lund-Andersen H. Diabetic vitrectomy in a large type 1 diabetes patient 
1434 
population: long-term incidence and risk factors. Acta Ophthalmol 2014;92:439-43. 
1435 
12. Ostri C, Lux A, Lund-Andersen H, et al. Long-term results, prognostic factors and cataract 
1436 
surgery after diabetic vitrectomy: a 10-year follow-up study. Acta Ophthalmol 2014;92:571-
1437 
6. 
1438 
13. Gupta B, Sivaprasad S, Wong R, et al. Visual and anatomical outcomes following vitrectomy 
1439 
for complications of diabetic retinopathy: the DRIVE UK study. Eye (Lond) 2012;26:510-6. 
1440 
14. The Diabetic Retinopathy Vitrectomy Study Research Group. Early vitrectomy for severe 
1441 
vitreous hemorrhage in diabetic retinopathy. Two-year results of a randomized trial. Diabetic 
1442 
Retinopathy Vitrectomy Study report 2 Arch Ophthalmol 1985;103:1644-52. 
1443 
15. Fassbender JM, Ozkok A, Canter H, et al. A Comparison of Immediate and Delayed 
1444 
Vitrectomy for the Management of Vitreous Hemorrhage due to Proliferative Diabetic 
1445 
Retinopathy. Ophthalmic Surg Lasers Imaging Retina 2016;47:35-41. 
1446 
16. Adamis AP, Miller JW, Bernal MT, et al. Increased vascular endothelial growth factor levels 
1447 
in the vitreous of eyes with proliferative diabetic retinopathy. Am J Ophthalmol 
1448 
1994;118:445-50. 
1449 
17. Adamis AP, Shima DT, Tolentino MJ, et al. Inhibition of vascular endothelial growth factor 
1450 
prevents retinal ischemia-associated iris neovascularization in a nonhuman primate. Arch 
1451 
Ophthalmol 1996;114. 
1452 
18. Aiello LP, Avery RL, Arrigg PG, et al. Vascular endothelial growth factor in ocular fluid of 
1453 
patients with diabetic retinopathy and other retinal disorders. N Engl J Med 1994;331:1480-
1454 
7. 
1455 
19. Aiello LP, Pierce EA, Foley ED, et al. Suppression of retinal neovascularization in vivo by 
1456 
inhibition of vascular endothelial growth factor (VEGF) using soluble VEGF-receptor 
1457 
chimeric proteins. Proc Natl Acad Sci USA 1995;92:10457-61. 
1458 

 
Vx for Vitreous Hemorrhage Protocol 1.0 7-28-16 
8-2 
20. Amano S, Rohan R, Kuroki M, et al. Requirement for vascular endothelial growth factor in 
1459 
wound- and inflammation-related corneal neovascularization. Invest Ophthalmol Vis Sci 
1460 
1998;39:18-22. 
1461 
21. Krzystolik MG, Afshari MA, Adamis AP, et al. Prevention of experimental choroidal 
1462 
neovascularization with intravitreal anti-vascular endothelial growth factor antibody 
1463 
fragment. Arch Ophthalmol 2002;120:338-46. 
1464 
22. Malecaze F, Clamens S, Simorre-Pinatel V, et al. Detection of vascular endothelial growth 
1465 
factor messenger RNA and vascular endothelial growth factor-like activity in proliferative 
1466 
diabetic retinopathy. Arch Ophthalmol 1994;112:1476-82. 
1467 
23. Schwesinger C, Yee C, Rohan RM, et al. Intrachoroidal neovascularization in transgenic 
1468 
mice overexpressing vascular endothelial growth factor in the retinal pigment epithelium. 
1469 
Am J Pathol 2001;158:1161-72. 
1470 
24. Tolentino MJ, Miller JW, Gragoudas ES, et al. Vascular endothelial growth factor is 
1471 
sufficient to produce iris neovascularization and neovascular glaucoma in a nonhuman 
1472 
primate. Arch Ophthalmol 1996;114:964-70. 
1473 
25. Aiello LP, Bursell SE, Clermont A, et al. Vascular endothelial growth factor-induced retinal 
1474 
permeability is mediated by protein kinase C in vivo and suppressed by an orally effective 
1475 
beta-isoform-selective inhibitor. Diabetes 1997;46:1473-80. 
1476 
26. Diabetic Retinopathy Clinical Research N. Randomized clinical trial evaluating intravitreal 
1477 
ranibizumab or saline for vitreous hemorrhage from proliferative diabetic retinopathy. JAMA 
1478 
Ophthalmol 2013;131:283-93. 
1479 
27. Sinawat S, Rattanapakorn T, Sanquansak T, et al. Intravitreal bevacizumab for proliferative 
1480 
diabetic retinopathy with new dense vitreous hemorrhage after full panretinal 
1481 
photocoagulation. Eye (Lond) 2013;27:1391-6. 
1482 
28. US FDA approves EYLEA (aflibercept) injection for the treatment of we age-related macular 
1483 
degeneration.Available at: 
1484 
http://www.press.bayer.com/baynews/baynews.nsf/0/EB1AAB6D8405A0BDC125794A0056
1485 
C856. accessed January 1, 2012 
1486 
29. Holz FG, Roider J, Ogura Y, et al. VEGF Trap-Eye for macular oedema secondary to central 
1487 
retinal vein occlusion: 6-month results of the phase III GALILEO study. Br J Ophthalmol 
1488 
2013;97:278-84. 
1489 
30. Brown DM, Heier JS, Clark WL, et al. Intravitreal aflibercept injection for macular edema 
1490 
secondary to central retinal vein occlusion: 1-year results from the phase 3 COPERNICUS 
1491 
study edema secondary to central retinal vein occlusion: 1-year results from the phase 3 
1492 
COPERNICUS study. Am J Ophthalmol 2013;155:429-37. 
1493 
31. Boyer D, Heier J, Brown DM, et al. Vascular endothelial growth factor Trap-Eye for macular 
1494 
edema secondary to central retinal vein occlusion: six-month results of the phase 3 
1495 
COPERNICUS study. Ophthalmology 2012;119:1024-32. 
1496 
32. Korobelnik JF, Do DV, Schmidt-Erfurth U, et al. Intravitreal aflibercept for diabetic macular 
1497 
edema. Ophthalmology 2014;121:2247-54. 
1498 
33. Brown DM, Schmidt-Erfurth U, Do DV, et al. Intravitreal Aflibercept for Diabetic Macular 
1499 
Edema: 100-Week Results From the VISTA and VIVID Studies. Ophthalmology 2015. 
1500 
34. Wells JA, Glassman AR, Ayala AR, et al. Aflibercept, bevacizumab, or ranibizumab for 
1501 
diabetic macular edema. N Engl J Med 2015;372:1193-203. 
1502 
35. Wolfs RC, Grobbee DE, Hofman A, et al. Risk of acute angle-closure glaucoma after 
1503 
diagnostic mydriasis in nonselected subjects: the Rotterdam Study. Invest Ophthalmol Vis 
1504 
Sci 1997;38:2683-7. 
1505 

 
Vx for Vitreous Hemorrhage Protocol 1.0 7-28-16 
8-3 
36. Manabe A, Shimada H, Hattori T, et al. Randomized controlled study of intravitreal 
1506 
bevacizumab 0.16 mg injected one day before surgery for proliferative diabetic retinopathy. 
1507 
Retina 2015;35:1800-7. 
1508 
 
1509