Clinical trial NCT02503540
Conditions: Retinal Vein Occlusion Diabetic Macular Edema Branch Retinal Vein Occlusion Central Retinal Vein Occlusion
Keywords: macular edema rvo diabetic macular edema
Sponsor: Justis Ehlers
Start date: 2015-08-18; Completion date: 2018-02-06
Enrollment: 31 participants; Allocation: NA; Intervention model: SINGLE_GROUP

Brief summary:
This interventional study will evaluate the retinal vascular dynamics associated with Intravitreal Aflibercept Injection (IAI) therapy in eyes with diabetic macular edema (DME) or macular edema secondary to retinal vein occlusion (RVO). Ultra-widefield fluorescein angiography and optical coherence tomography (OCT) angiography will be performed at multiple timepoints to assess the changes in retinal vascular leakage, ischemia, and vascular abnormalities throughout the study duration and compare these alterations to baseline.

Detailed description:
Diabetic macular edema (DME) and macular edema secondary to retinal venous occlusive diseases are the most common cause of vision loss from a retinal vascular disease. Recently, vascular endothelial growth factor (VEGF) inhibitors (bevacizumab, aflibercept, and ranibizumab) have been described as new first-line therapies for these conditions. Aflibercept is the most recently approved VEGF inhibitor for the management of these conditions. Clinical trials have shown that treatment with aflibercept improves visual acuity and reduces macular edema in a large percentage of patients.

This study will examine the changes that occur with intravitreal aflibercept to perfusion and leakage in treatment naive eyes over the course of 1 year.

Arms: arm 1: Monthly aflibercept for 6 months and then every other month for 6 months.
Interventions: intervention 1: Aflibercept
Intervention descriptions: intervention 1: Intravitreal aflibercept will be given q4 wks for 6 treatments and then q 8 weeks through month 12.

Protocol documents:
Prot_SAP_000.pdf: 
 
 
 
 
 
 
PROTOCOL 
 
 
 
 
 
NCT NUMBER 
 
DOCUMENT DATE 
Peripheral and Macular Retinal Vascular Perfusion and 
Leakage Dynamics in Diabetic Macular Edema and 
Retinal Venous Occlusions During Intravitreal 
Aflibercept Injection (IAI) Treatment for Retinal Edema: 
PERMEATE Study 
 
 
 
NCT02503540 
 
 
January 20, 2017 
 
 
 
 


 
 
 
 
Clinical Study Protocol 
 
Peripheral and Macular Retinal Vascular Perfusion and Leakage Dynamics in 
Diabetic Macular Edema and Retinal Venous Occlusions During Intravitreal 
Aflibercept Injection (IAI) Treatment for Retinal Edema: PERMEATE Study 
 
 
 
Compound: 
Intravitreal aflibercept injection 
 
 
Study Name: 
PERMEATE Study 
 
 
Clinical Phase: 
Phase IV 
 
 
Date of Issue: 
January 20, 2017 
 
 
 
 
 
 
Confidential: This document contains confidential information that is the property of 
The Cleveland Clinic Foundation and must not be disclosed to anyone other than 
designees of each party for the conduct of the study, the recipient clinical 
Investigator(s) and their designees and members of the Institutional Review Board.  
This information must not be used for any purpose other than the evaluation or conduct 
of the clinical investigation without the prior written consent of Cleveland Clinic. 


 
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CLINICAL STUDY PROTOCOL SYNOPSIS 
TITLE 
Peripheral and Macular Retinal Vascular Perfusion and 
Leakage Dynamics in Diabetic Macular Edema and 
Retinal Venous Occlusions During Intravitreal 
Aflibercept Injection (IAI) Treatment for Retinal 
Edema: PERMEATE Study 
 
TITLE IN LAY TERMS 
Treatment of diabetic macular edema and retinal vein 
occlusions with IAI 
SITE LOCATION(S) 
 
Principal Investigator 
 
Justis P. Ehlers MD 
Cole Eye Institute 
Cleveland Clinic 
Cleveland, Ohio 


 
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OBJECTIVE(S) 
This interventional study will evaluate the retinal 
vascular dynamics associated with IAI therapy in eyes 
with diabetic macular edema (DME) or macular edema 
secondary to retinal vein occlusion (RVO), as follows:  
 
(1) To characterize the longitudinal retinal vascular 
dynamics in DME and RVO in the retinal periphery and 
macular area over a 12-month period while being treated 
with IAI with a novel angiographic quantitative 
assessment tool.    
 
(2) To assess the efficacy and safety of IAI therapy 
based on assessment of the retinal vascular dynamics in 
DME and RVO. 
 
(3) To develop potential imaging biomarkers based on 
high-resolution quantitative analysis of ultra-widefield 
angiography and optical coherence tomography that are 
predictors of response to IAI therapy in DME and RVO. 
 
STUDY DESIGN 
This study is an interventional, single arm, investigator 
initiated study.  Subjects will be given 2 mg (0.05 mL or 
50 microliters) of IAI injection administered monthly for 
the first 6 months, followed by 2 mg (0.05 mL) once 
every 2 months.  Each subject will be evaluated for 12 
months. Thus, the study duration will be 12 months plus 
the recruitment period.  
 
Subjects will be evaluated every month for safety, 
efficacy as measured by SDOCT and best corrected 
visual acuity (BCVA) using the Electronic Early 
Treatment Diabetic Retinopathy Study (E-ETDRS) 
protocol.   In addition, ultra-widefield angiography will 
be performed at baseline, month 3, month 6, month 9, 
and at the final visit.   
 
Only one eye per subject may be enrolled in the study. If 
a 
subject’s fellow (non-study) eye requires treatment for at 
study entry, or during the subject’s participation in the 
study, the fellow eye can receive IAI injection for DME 
or macular edema secondary to RVO.  
 
STUDY DURATION 
12 Months 


 
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ESTIMATED STUDY 
COMPLETION DATE 
 
February 1, 2018 
POPULATION 
 
 
Sample Size: 
30 Subjects 
 
Target Population: 
Patients presenting with foveal-involving macular edema 
secondary to diabetes and retinal vein occlusive disease   
TREATMENT(S) 
IAI injection will be supplied by Regeneron 
Pharmaceuticals, Inc. and will be administered using 
standard techniques.   
 
Subjects will be given 2 mg (0.05 mL or 50 microliters) 
administered by intravitreal injection every month for 
the first 6 months, followed by 2 mg (0.05 mL) via 
intravitreal injection once every 2 months. 
ENDPOINT(S) 
 
 
Primary: 
§ The primary study endpoint is the mean change 
in total leakage index at month 12 as measured 
by ultra-widefield angiography (defined as the 
proportion of retinal area involved in 
angiographic leakage). 
 
 
Secondary: 
Secondary endpoints would include  
§ The mean change in total leakage index at month 
6 
§ The diabetic retinopathy severity at month 6 and 
12 (if applicable) 
§ The amount of hemorrhage at month 6 and 12 
§ The change in ischemic index (defined as the 
proportion of retinal area with nonperfusion) at 
month 6 and 12 
§ The mean absolute change from baseline central 
subfield thickness at month 6 and 12 
§ The mean change from baseline in best-corrected 
visual acuity (BCVA) score at months 6 and 12 
§ The percentage of subjects that were 
anatomically ‘dry’ by SDOCT at months 6 and 
12, 
§ The percentage of participants who gained or lost 
10 letters or more of vision at months 6 and 12 
§ The percentage of subjects who gained or lost 15 
letters or more of vision at months 6 and 12 
§ The percentage of patients that are 20/40 or 
better at months 6 and 12 


 
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§ The percentage of patients that are 20/200 or 
worse at months 6 and 12 
§ The incidence and severity of ocular and non-
ocular adverse events (AEs) and serious AEs. 
 
 
 
PROCEDURES AND 
ASSESSMENTS 
Ongoing assessments will include BCVA measurement, 
ophthalmic examinations and recording and evaluation 
of clinical adverse events.  Subjects will undergo 
SDOCT at each visit.  Ultra-widefield angiography will 
be performed at baseline, month 3, month 6, month 9 
and month 12.  Optional, OCT angiography will be 
performed at baseline, month 3, month 6, month 9, and 
month 12. 
 
Subjects will be given 2 mg (0.05 mL or 50 microliters) 
IAI administered by intravitreal injection every month 
for the first 6 months, followed by 2 mg (0.05 mL) via 
intravitreal injection once every 2 months.  The fellow 
eye may also received IAI as needed for DME or 
macular edema secondary to RVO as determined by the 
investigator. 
 
STATISTICAL PLAN 
The patients will be compared to their baseline 
measurement for the primary and secondary outcome.  
Trends and statistical significant difference will be 
reported. 
 
 
 


 
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TABLE OF CONTENTS 
Clinical Study Protocol Synopsis .................................................................................. 3 
List of Figures ............................................................................................................. 10 
List of Abbreviations and Definitions of Terms......................................................... 11 
1. Introduction and Rationale .................................................................................. 12 
1.1 Introduction.......................................................................................................... 12 
1.2 Rationale .............................................................................................................. 13 
1.2.1 Rationale for Study Design ........................................................................ 13 
1.2.2 Rationale for Dose Selection ...................................................................... 15 
2. Study Objectives ................................................................................................... 15 
2.1 Primary Objective ................................................................................................ 15 
2.2 Secondary Objective(s) ........................................................................................ 15 
Study Design................................................................................................................ 16 
2.3 Study Description and Duration............................................................................ 16 
2.4 Study Committees ................................................................................................ 16 
3. Selection, Withdrawal, and Replacement of Subjects ........................................ 16 
3.1 Number of Subjects Planned ................................................................................ 16 
3.2 Study Population .................................................................................................. 16 
3.2.1 ...................................................................................................................... 16 
Inclusion Criteria ................................................................................................... 16 
3.3 Premature Withdrawal from the Study .................................................................. 19 
3.4 Replacement of Subjects ...................................................................................... 19 
4. Study Treatments ................................................................................................. 19 
4.1 Additional Treatment ........................................................................................... 19 
4.2 Dose Modification and Stopping Rules................................................................. 19 
4.2.1 Dose Modification ..................................................................................... 19 
4.2.2 Study Drug Stopping Rules ........................................................................ 19 
4.3 Method of Treatment Assignment ........................................................................ 19 
4.3.1 Blinding/Masking ...................................................................................... 20 
4.3.2 Packaging, Labeling, and Storage .............................................................. 20 
4.3.3 Supply and Disposition of Treatments........................................................ 20 
4.3.4 Treatment Accountability .......................................................................... 20 
4.3.5 Treatment Compliance ............................................................................... 21 


 
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4.4 Concomitant Medications and Procedures ............................................................ 21 
4.4.1 Permitted Medications and Procedures ....................................................... 21 
4.4.2 Prohibited Medications and Procedures...................................................... 21 
4.5 Post-Study Treatment ........................................................................................... 21 
5. Study Schedule of Events and Visit Descriptions ................................................ 21 
5.1 Schedule of Events ............................................................................................... 21 
5.2 Study Visit Descriptions ....................................................................................... 23 
5.2.1 Screening/Baseline Visit, Day 0, ................................................................ 23 
5.2.2 Follow-up Period ....................................................................................... 23 
5.2.2.1 
Month 1--Month 5 (+/- 7 Days) ........................................................... 23 
5.2.2.2 
Months 6, 8, and 10 (+/- 7 Days) ......................................................... 24 
5.2.2.3 
Months 7, 9, and 11 (+/- 7 Days) ......................................................... 24 
5.2.2.4 
End of Treatment/Month 12 (+/- 7 Days)/Early Termination visit ....... 25 
5.2.3 Additional Visits ........................................................................................ 25 
5.2.3.1 
Unscheduled visit................................................................................ 25 
5.2.4 Early Termination Visit ............................................................................. 25 
5.2.5 Unscheduled Visits .................................................................................... 26 
5.3 Study Procedures.................................................................................................. 26 
5.3.1 Procedures Performed only at the Screening/Baseline Visit........................ 26 
5.3.2 Efficacy Procedures ................................................................................... 26 
5.3.3 Safety Procedures ...................................................................................... 27 
5.3.3.1 
Adverse Event Information Collection ................................................ 27 
6. Safety Definitions, Reporting, and Monitoring ................................................... 27 
6.1 Definitions ........................................................................................................... 27 
6.1.1 Adverse Event ........................................................................................... 27 
6.1.2 Serious Adverse Event ............................................................................... 27 
6.2 Recording and Reporting Adverse Events ............................................................ 28 
6.2.1 Deaths ....................................................................................................... 28 
6.2.2 Pregnancy and Other Events that Require Accelerated Reporting ............... 28 
6.2.3 Reporting Adverse Events Leading to Withdrawal from the Study ............. 29 
6.2.4 Follow-up .................................................................................................. 29 
6.3 Evaluation of Severity and Causality .................................................................... 29 
6.3.1 Evaluation of Severity ............................................................................... 29 


 
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6.3.2 Evaluation of Causality .............................................................................. 29 
7. Study Variables .................................................................................................... 30 
7.1 Demographic and Baseline Characteristics ........................................................... 30 
7.2 Primary and Secondary Endpoints ........................................................................ 30 
7.3 Analysis Sets ........................................................................................................ 30 
7.3.1 Efficacy Analysis Sets ............................................................................... 30 
7.3.2 Safety Analysis Set .................................................................................... 30 
7.4 Subject Disposition .............................................................................................. 31 
7.5 Statistical Methods ............................................................................................... 31 
7.5.1 Demography and Baseline Characteristics ................................................. 31 
7.5.2 Efficacy Analyses ...................................................................................... 31 
7.5.2.1 
Primary Efficacy Analysis .................................................................. 31 
7.5.2.2 
Secondary Efficacy Analysis ............................................................... 31 
7.5.3 Safety Analysis .......................................................................................... 32 
7.5.3.1 
Adverse Events ................................................................................... 32 
8. Data Management and Electronic Systems ......................................................... 32 
8.1 Electronic Systems ............................................................................................... 32 
9. Study Monitoring ................................................................................................. 33 
9.1 Monitoring of Study Sites .................................................................................... 33 
9.2 Source Document Requirements........................................................................... 33 
9.3 Case Report Form Requirements .......................................................................... 33 
10. Audits and Inspections ....................................................................................... 33 
11. Ethical and Regulatory Considerations............................................................. 34 
11.1 Good Clinical Practice Statement ....................................................................... 34 
11.2 Informed Consent ............................................................................................... 34 
11.3 Subject Confidentiality and Data Protection ....................................................... 35 
11.4 Institutional Review Board ................................................................................. 35 
12. Protocol Amendments ........................................................................................ 35 
13. Premature Termination of the Study or Close-out of a Site ............................. 35 
13.1 Premature Termination of the Study ................................................................... 35 
14. Study Documentation ......................................................................................... 36 
14.1 Certification of Accuracy of Data ....................................................................... 36 
14.2 Retention of Records .......................................................................................... 36 


 
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List of Tables 
Table 1 
Schedule of Events .................................................................................... 22 
 
LIST OF FIGURES 
Figure 1        Branch retinal vein occlusion with longitudinal angiography……………..14 
Figure 2        Diabetic retinopathy and diabetic macular edema…………………………15 
 
 
LIST OF APPENDICES 
Appendix 1 
Injection Technique………………………………………………….......38 
Appendix 2:    References……………….........................................................................40


 
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LIST OF ABBREVIATIONS AND DEFINITIONS OF TERMS 
AE 
Adverse event 
CRF 
Case report form 
EC 
Ethics Committee 
eCRF 
Electronic case report form 
FAS 
Full analysis set 
ICF 
Informed consent form 
IRB 
Institutional Review Board 
MedDRA 
Medical Dictionary for Regulatory Activities 
SAE 
Serious adverse event 
SAP 
Statistical analysis plan 
TEAE 
Treatment-emergent adverse event 
 


 
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1. 
INTRODUCTION AND RATIONALE 
1.1 
Introduction 
Diabetic macular edema (DME) is the most common cause of vision loss from diabetic 
retinopathy.  It is characterized by macular swelling secondary to increased vascular 
permeability secondary to loss of pericytes in the macular vascular bed.  Clinically, 
microaneurysms and exudates are often seen in association with macular edema.  Foveal-
involving cystic changes and macular edema can have significant impact on visual loss.  
Extent of perfusion and ischemia also is important for visual prognosis.   Retinal vein 
occlusions (RVO) are the second most common retinal vascular disease following 
diabetic retinopathy.  Vision loss from RVO most commonly results from macular edema 
and/or retinal ischemia.   
VEGF is a homodimeric protein with a molecular weight of 34 to 42 kDa (Thickett, 
1999). VEGF binds to and activates 2 high affinity receptors, Flt-1 (VEGFR1) and Flk-1 
(VEGFR2), which are predominantly located on the vascular endothelium. 
 
Multiple factors play a role in the evolution of diabetic macular edema and retinal venous 
occlusive disease.  Vascular endothelial growth factor has been shown to be significantly 
elevated in diabetic retinopathy and may play an important role in the evolution and 
pathogenesis of DME.   Increasing VEGF levels are also seen in the setting of 
progressive ischemia, such as proliferative diabetic retinopathy when extensive peripheral 
nonperfusion may be present (Wessel et al, 2012). Additionally significant peripheral 
vascular perfusion abnormalities are often seen in RVO (Singer et al, 2014).  Reducing 
the active levels of VEGF may have significant positive consequences for outcomes 
related to DME and RVO management.  
 
VEGF has 2 properties that explain its important roles in normal fetal development and in 
biology: VEGF is a powerful mitogen for endothelial cells (Ferrara et al., 1991), thus 
promoting formation of new vessels that are required for normal and pathological tissue 
growth (Ferrara, 2000; Ferrara and Davis-Smyth, 1997).  
 
Injection of VEGF into the eye, or local over-expression of VEGF by transgenic 
methods, can induce vascular leakage and new blood vessel formation in the retina 
(Ohno-Matsui et al., 2002). Since VEGF appears to be a fundamental component of the 
process of vascular permeability, VEGF blockade constitutes a promising therapeutic 
approach in both DME and RVO. 
 
IAI is a recombinantly produced fusion protein consisting of portions of the 
human VEGF receptor extracellular domains fused to the Fc domain of human IgG1 
(Figure 1). IAI is comprised of portions of the extracellular domains of 2 different VEGF 
receptors. It contains sequences encoding Ig domain 2 from VEGFR1 fused to Ig domain 
3 from VEGFR2, which in turn is fused to the hinge region of the human IgG1 Fc 
domain. IAI is a dimeric glycoprotein with a protein molecular weight of 97 kDa, and 
contains ~15% glycosylation to give a total molecular weight of 115 kDa. 
 
 


 
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Figure 1. The IAI Molecule 
 
Figure 1. VEGFR1 and VEGFR2 are related receptors that have 7 Ig domains in the 
extracellular portion and a tyrosine kinase domain intracellularly. IAI contains the 
VEGFR1 Ig2 domain fused to the VEGFR2 Ig3 domain, which is in turn fused to the 
IgG1 Fc. 
 
IAI has several potential advantages over other VEGF blockers: it has a much higher 
affinity (~ 0.5 pM dissociation constant for VEGF165 and VEGF121) than a humanized 
monoclonal antibody. IAI also binds the related factors Placental Growth Factor 1 and 2 
(PLGF1 and PLGF2), which may be advantageous in certain disease situations, including 
retinal neovascularization (Rakic et al 2003). 
1.2 
Rationale 
1.2.1 
Rationale for Study Design 
Multiple phase III studies (e.g., COPERNICUS, GALILEO, VISTA, VIVID, 
VIBRANT), have evaluated intravitreal IAI for the management of DME and macular 
edema secondary to RVO.  Results from these studies demonstrated clinical efficacy for 
IAI and significant improvements in visual acuity and macular thickness.  In clinical 
practice, select patients continue to have variable response to anti-VEGF therapy 
including IAI.  Preliminary studies have suggested that there is a significant amount of 
retinal vascular changes (e.g., increased permeability, ischemia) in the retinal periphery 
in both DME and RVO ((Singer et al, 2014; Wessel et al, 2012).  Currently, assessment 
of angiographic phenotypes is limited primarily to subjective interpretation.  However, 
new advances in technology now allow for objective quantitative assessment of 
angiographic parameters (see figures below).  These global assessments of angiographic 
features, including leakage and ischemia, may allow for a better characterization of the 
disease burden and allow for the development of imaging biomarkers that have 
implications for therapeutic response or resistance.  Additionally, preliminary reports 
have suggested that some features (such as ischemic load) may be dynamic and 
influenced by anti-VEGF therapy.  This study will prospectively assess the alterations in 
angiographic parameters with a novel quantitative analysis tool to provide insights into 
the retinal vascular changes that occur during treatment with IAI and to examine the 
relationship between these features and treatment response. 


 
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Figure 1:  Branch retinal vein occlusion with longitudinal angiography following anti-
VEGF therapy with quantitative assessment of vascular leakage (green). 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


 
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Figure 2: Diabetic macular edema and proliferative diabetic retinopathy with automated 
identification of neovascular leakage (yellow), ischemia (blue) and retinal vascular 
leakage (green).  Longitudinal assessment following anti-VEGF treatment 
 
 
 
 
1.2.2 
Rationale for Dose Selection 
The dose and treatment regimen was selected based on the phase III studies and the drug 
package insert.  Specifically, subjects will be given 2 mg (0.05 mL or 50 microliters) 
administered by intravitreal injection every month for the first 6 months, followed by 2 mg 
(0.05 mL) via intravitreal injection once every 2 months. 
2. 
STUDY OBJECTIVES 
2.1 
Primary Objective 
To characterize the longitudinal retinal vascular dynamics in DME and RVO in the 
retinal periphery and macular area over a 12-month period while being treated with IAI 
with a novel angiographic quantitative assessment tool.    
 
2.2 
Secondary Objective(s) 
(1) To assess the efficacy and safety of IAI therapy for DME and RVO-related DME in 
treatment naïve eyes. 
(2) To develop potential imaging biomarkers based on high-resolution quantitative 
analysis of ultra-widefield angiography and optical coherence tomography that are 
predictors of response to IAI therapy in DME and RVO. 


 
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STUDY DESIGN 
2.3 
Study Description and Duration 
Subjects will be assigned to treatment with 2 mg IAI (0.05 mL or 50 microliters) 
administered monthly for the first 6 months, followed by 2 mg (0.05 mL) once every 2 
months.  Criteria for additional monthly treatment has been defined for subjects following 
the initial 6 months of the study.  
The planned enrollment for the 30 subjects needed for this study is estimated to be 12 
months. The study duration for each subject is scheduled to be 12 months. Evaluations will 
occur every month for the duration of the study. OCT examinations will be conducted at 
every visit.  
 
Only one eye will be designated as the study eye. For subjects who meet eligibility 
criteria in both eyes, the investigator and patient will select the study eye.  
 
2.4 
Study Committees 
Appropriate action, if needed, will be taken based upon this review and in consultation 
with the principal investigator.  All events will be managed and reported in compliance 
with all applicable regulations and included in the final clinical study report. 
3. 
SELECTION, WITHDRAWAL, AND REPLACEMENT OF SUBJECTS 
3.1 
Number of Subjects Planned 
The target enrollment for this study is 30 subjects.  
3.2 
Study Population 
Subjects will be recruited through clinics at the Cole Eye Institute, Cleveland OH and Cole 
Eye satellite offices.  The study will seek approval from the Cleveland Clinic 
Investigational Review Board (IRB) and all study related procedures will be performed in 
accordance with the Declaration of Helsinki and US Code 21 of Federal Regulations.   
All study-related procedures will be performed at Cole Eye Institute, Cleveland Clinic 
Main Campus or Cole Eye Hillcrest.  
3.2.1 
 
Inclusion Criteria 
A subject must meet the following criteria to be eligible for inclusion in the study: 
1. Signed Informed Consent. 
2. Men and women ≥ 18 years of age. 
3. Foveal-involving retinal edema secondary to DME or RVO based on 
investigator review of SDOCT. 


 
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4. E-ETDRS best-corrected visual acuity of: 20/25 to hand motions in the study 
eye. 
5. Willing, committed, and able to return for ALL clinic visits and complete all 
study related procedures. 
6. Able to read, (or, if unable to read due to visual impairment, be read to 
verbatim by the person administering the informed consent or a family 
member. See Appendix J.4) understand and willing to sign the informed 
consent form.  
 
 
Exclusion Criteria 
A subject who meets any of the following criteria will be excluded from the study: 
1. Any prior or concomitant therapy with another investigational agent to treat 
DME or RVO in the study eye. 
2. Prior panretinal photocoagulation in the study eye. 
3. Prior intravitreal anti-VEGF therapy in the study eye. 
4. Prior focal/grid laser photocoagulation in the study eye. 
5. Prior history of intravitreal steroid therapy in the study eye. 
6. Any history of allergy to fluorescein sodium or other reason that the patient is 
unable to undergo fluorescein angiography (e.g., inability to get vascular 
access, unable to tolerate procedure) 
7. Prior systemic anti-VEGF therapy, investigational or FDA-approved, is only 
allowed up to 3 months prior to first dose, and will not be allowed during the 
study. 
8. Significant vitreous hemorrhage obscuring view to the macula or the retinal 
periphery as determined by the investigator on clinical exam and ultra-widefield 
angiography. 
9. Presence of other causes of macular edema, including myopic degeneration, 
ocular histoplasmosis syndrome, angioid streaks, choroidal rupture, choroidal 
neovascularization, neovascular age-related macular degeneration or multifocal 
choroiditis in the study eye.  Epiretinal membranes are allowed. 
10. Presence of macula-threatening traction retinal detachment. 
11. Prior vitrectomy in the study eye. 
12. History of retinal detachment or treatment or surgery for retinal detachment in 
the study eye. 
13. Any history of macular hole of stage 2 and above in the study eye. 
14. Any intraocular or periocular surgery within 3 months of Day 1 on the study 
eye, except lid surgery, which may not have taken place within 1 month of day 
1, as long as it’s unlikely to interfere with the injection. 
15. Prior trabeculectomy or other filtration surgery in the study eye. 


 
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16. Uncontrolled glaucoma at baseline evaluation (defined as intraocular pressure 
≥25 mmHg despite treatment with anti-glaucoma medication) in the study eye. 
17. Active intraocular inflammation in either eye. 
18. Active ocular or periocular infection in either eye. 
19. Any ocular or periocular infection within the last 2 weeks prior to Screening in 
either eye. 
20. Any history of uveitis in either eye. 
21. Active scleritis or episcleritis in either eye. 
22. Presence or history of scleromalacia in either eye. 
23. Aphakia in the study eye. 
24. Previous therapeutic radiation in the region of the study eye. 
25. History of full-thickness penetrating keratoplasty in the study eye. Partial 
thickness corneal transplants, including DSAEK and DMEK are allowed. 
26. Significant media opacities, including cataract, in the study eye which might 
interfere with visual acuity, assessment of safety, or fundus photography. 
27. Any concurrent intraocular condition in the study eye (e.g. cataract) that, in the 
opinion of the investigator, could require either medical or surgical intervention 
during the 52 week study period. 
28. Any concurrent ocular condition in the study eye which, in the opinion of the 
investigator, could either increase the risk to the subject beyond what is to be 
expected from standard procedures of intraocular injection, or which otherwise 
may interfere with the injection procedure or with evaluation of efficacy or 
safety. 
29. Participation as a subject in any clinical study within the 12 weeks prior to Day 
1. 
30. Any systemic therapy with an investigational agent in the past 3 months prior 
to Day 1. 
31. Any history of allergy to povidone iodine. 
32. Pregnant or breast-feeding women 
33. Women of childbearing potential* who are unwilling to practice adequate 
contraception during the study (adequate contraceptive measures include stable 
use of oral contraceptives or other prescription pharmaceutical contraceptives 
for 2 or more menstrual cycles prior to screening; intrauterine device [IUD]; 
bilateral tubal ligation; vasectomy; condom plus contraceptive sponge, foam, 
or jelly, or diaphragm plus contraceptive sponge, foam, or jelly) 
*Postmenopausal women must be amenorrheic for at least 12 months in order not to be 
considered of child bearing potential.  Pregnancy testing and contraception are not required 
for women with documented hysterectomy or tubal ligation. 


 
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3.3 
Premature Withdrawal from the Study 
A subject has the right to withdraw from the study at any time, for any reason, and without 
repercussion. 
The investigator has the right to withdraw a subject from the study in the event of an 
intercurrent illness, AE, treatment failure, protocol violation, cure, and for administrative 
or other reasons.  An excessive rate of withdrawals would render the study uninterpretable; 
therefore, unnecessary withdrawal of subject should be avoided. 
Should a subject (or a subject’s legally authorized guardian or representative) decide to 
withdraw, all efforts will be made to complete and report observations as thoroughly as 
possible.  Early termination procedures should be followed, as delineated in section 5.2.4. 
3.4 
Replacement of Subjects 
Subjects prematurely discontinued from the study prior to visit 4 may be replaced at PI 
discretion. 
4. 
STUDY TREATMENTS 
Subjects will be assigned to treatment with 2 mg intravitreal IAI injection (0.05 mL or 50 
microliters) administered monthly for the first 6 months, followed by 2 mg (0.05 mL) once 
every 2 months.  
4.1 
Additional Treatment 
Additional treatment with IAI can be applied, if the subject experiences any of the 
following events within 56 days since the last treatment: 
• Loss of 10 or more ETDRS letters from best previous measurement  
• Increase in 75 microns of retinal thickness as compared to the best previous visit. 
 
If the subject meets additional treatment criteria at any time during the study, the subject 
can receive additional IAI at least every 28 days. Additional treatment can be withheld by 
the treating investigator if in the opinion of the investigator, additional treatment will not 
provide benefit.   
4.2 
Dose Modification and Stopping Rules 
4.2.1 
Dose Modification 
Dose modification for an individual subject is not allowed. 
4.2.2 
Study Drug Stopping Rules 
Information on follow-up for subjects who permanently discontinue from study drug, but 
choose to remain in the study is provided in section 6.2.4. 
4.3 
Method of Treatment Assignment 
All subjects are enrolled in the same cohort to receive treatment with intravitreal aflibercept 
injection. 


 
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4.3.1 
Blinding/Masking 
This is a single arm treatment study and the patients and physicians will be aware of their 
current treatment assignment and schema.   
4.3.2 
Packaging, Labeling, and Storage 
2.0 mg intravitreal IAI injection is formulated as a sterile liquid to a final concentration of 
40 mg/mL intravitreal IAI injection in 5% sucrose, 10 mM sodium phosphate pH 6.3, 
0.03% polysorbate 20, and 40 mM NaCl. Intravitreal IAI injection 2.0 mg study drug will 
be supplied by Regeneron Pharmaceuticals Inc. in sealed, sterile 3 mL vials with a 
“withdrawable” volume of approximately 0.5 mL. Vials must be used only once (defined 
as entered with a needle). The volume of injection will be 0.05 mL for the 2 mg dose. For 
study drug in vials, the study drug will be withdrawn using aseptic technique.  
 
Study drug will be shipped to the site via overnight shipping using cold packs to maintain 
a temperature of 2° to 8° C. The Investigator, or an approved representative (e.g. 
pharmacist), will ensure that all study drugs are stored in a secured area, under 
recommended storage conditions and in accordance with applicable regulatory 
requirements. The shipping box is to be opened and stored immediately at the site in a 
refrigerator intended for investigational products at a temperature of 2° to 8°C.  
 
When vials are removed from the refrigerator, the solution should be visually inspected 
and it should have no evidence of turbidity. If particulates, cloudiness, or discoloration 
are visible, the vial must not be used. Exposure of the material to temperatures outside 
these limits, except for warming prior to administration, is not recommended and may 
result in loss of activity. Records of actual storage conditions (i.e. temperature log) at the 
study site must be maintained; and must include a record of the dates, when the 
refrigerator was checked, the initials of person checking, and the temperature. 
4.3.3 
Supply and Disposition of Treatments 
Study drug will be shipped at a temperature of 2° to 8°C to the investigator or designee at 
regular intervals or as needed during the study. At the end of the study, and following drug 
reconciliation and documentation, all opened and unopened vials of study drug will be 
destroyed or returned to Regeneron Pharmaceuticals, Inc. or designee. 
4.3.4 
Treatment Accountability 
All drug accountability records will be kept current. 
The investigator will account for all opened and unopened vials of study drug.  These 
records will contain the dates, quantity, and study medication 
• dispensed to each patient – or - 
• disposed of at the site or returned to Regeneron Pharmaceuticals, Inc. or designee. 
All accountability records will be made available for inspection by regulatory agency 
inspectors. 


 
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4.3.5 
Treatment Compliance 
All drug compliance records must be kept current and must be made available for 
inspection by regulatory agency inspectors. 
 
4.4 
Concomitant Medications and Procedures 
Subjects may not receive any medications (approved or investigational) for their DME and 
RVO in the study eye other than the assigned study treatment (IAI as specified in this 
protocol, until they have completed the end of study (12 months) or ET visit assessments. 
This includes medications administered locally (eg, IVT, topical, juxtascleral or periorbital 
routes), as well as those administered systemically, with the intent of treating the study 
and/or fellow eye. Laser photocoagulation procedures will not be allowed during the first 
six months of the study.  After six months, focal/grid laser photocoagulation can be 
performed at the discretion of the investigator for persistent macular edema.  After six 
months, panretinal laser photocoagulation can be performed for the presence of 
proliferative disease with vitreous hemorrhage or other high risk characteristics (e.g., 
neovascularization of the disc).  If neovascularization was present at baseline, panretinal 
photocoagulation is encouraged at study exit to avoid rebound neovascularization if not 
performed during the study for high-risk characteristics. 
 
If a subject’s fellow (non-study) eye requires treatment for DME or RVO at study entry, 
or during the subject’s participation in the study, the fellow eye can receive IAI. 
Intravitreal aflibercept injection will be provided at no cost by Regeneron for the fellow 
eye.  Although the fellow eye can receive treatment, it will not be considered an 
additional study eye.  The fellow eye may also receive laser photocoagulation, as needed, 
at investigator discretion. 
 
4.4.1 
Permitted Medications and Procedures 
Any other medication that are considered necessary for the subject’s welfare, and that are 
not expected to interfere with the evaluation of the study drug, may be given at the 
discretion of the investigator. 
4.4.2 
Prohibited Medications and Procedures 
Systemic anti-angiogenic agents will not be permitted during the study. 
4.5 
Post-Study Treatment 
All medications are permitted post-study treatment.   
5. 
STUDY SCHEDULE OF EVENTS AND VISIT DESCRIPTIONS 
5.1 
Schedule of Events 
Study assessments and procedures are presented by study period and visit in Table 1. 


 
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Table 1 
Schedule of Events 
 
Treatment Period (Visit intervals after baseline are 28 days since last visit +/- 7 days) 
Additional 
Study Procedure 
Screening
& 
Baseline 
Visit 1 
2 
3 
4 
5 
6 
7* 
8 
9* 
10 
11* 
12 
End of 
Treatment 
Visit 13 
Unscheduled Follow 
up Visit 
Day/Month 
Month  
0 
M 1 
28 
days 
+/- 7 
days 
M 2 
28 
days 
+/- 7 
days 
M 3 
28 
days 
+/- 7 
days 
M 4 
28 
days 
+/- 7 
days 
M 5 
28 
days 
+/- 7 
days 
M 6 
28 
days 
+/- 7 
days 
M 7 
28 
days 
+/- 7 
days 
M 8 
28 
days 
+/- 7 
days 
M 9 
28 
days 
+/- 7 
days 
M 10 
28 
days 
+/- 7 
days 
M 11 
28 
days 
+/- 7 
days 
Month 12 
+/-7 days 
NA 
Inclusion/Exclusion 
x 
 
 
 
 
 
 
 
 
 
 
 
 
 
Informed Consent 
x 
 
 
 
 
 
 
 
 
 
 
 
 
 
Medical History 
x 
 
 
 
 
 
 
 
 
 
 
 
 
 
Demographics 
x 
 
 
 
 
 
 
 
 
 
 
 
 
 
ETDRS Manifest 
Refraction/Slit 
Lamp/Tonometry/ 
Fundus Exam study 
eye  
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
Ultra-widefield 
Fluorescein 
angiogram 
x 
 
 
 
x 
 
 
x 
 
 
x 
 
 
x 
*** 
SDOCT study eye  
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
X*** 
SDOCT 
angiography ** 
x 
 
 
x 
 
 
x 
 
 
x 
 
 
x 
*** 
Administer Study 
Drug (intravitreal 
IAI injection) 
x 
x 
x 
x 
x 
x 
 
x 
 
x 
 
x 
x 
*** 
Adverse Events 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
x 
 
* Additional treatment with intravitreal IAI injection if criteria met;  
** OCT angiography is optional at month 0, 3, 6, 9 and 12, and will not be performed at other timepoints.;. *** at investigator’s discretion 


 
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5.2 
Study Visit Descriptions 
5.2.1 
Screening/Baseline Visit, Day 0,  
After the subject has provided informed consent, the following information will be 
collected: 
• Inclusion/exclusion 
• Informed consent documentation 
• Demographics 
• Medical history and concurrent illnesses 
• Concomitant medications 
The following procedures and assessments will be conducted: 
• ETDRS visual acuity with manifest refraction 
• Slit lamp examination 
• Fundus examination 
• Tonometry 
• Spectral Domain OCT evaluation 
• Spectral Domain OCT angiography (optional) 
• Ultra-widefield fluorescein angiogram  
• Intravitreal afliberecpt injection 
 
5.2.2 
Follow-up Period 
5.2.2.1 
Month 1--Month 5 (+/- 7 Days) 
The following information will be collected: 
• Concomitant medications 
• AEs 
The following procedures and assessments will be conducted: 
• ETDRS visual acuity with manifest refraction 
• Slit lamp examination 
• Fundus examination 
• Tonometry 
• Spectral Domain OCT evaluation 
• Spectral Domain OCT angiography (month 3 only; optional) 


 
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• Ultra-widefield fluorescein angiography (month 3 only) 
• Intravitreal aflibercept injection 
 
5.2.2.2 
Months 6, 8, and 10 (+/- 7 Days) 
The following information will be collected: 
• Concomitant medications 
• AEs 
The following procedures and assessments will be conducted: 
• ETDRS visual acuity with manifest refraction 
• Slit lamp examination 
• Fundus examination 
• Tonometry 
• Spectral Domain OCT evaluation 
• Spectral Domain OCT angiography (month 6 only; optional) 
• Ultra-widefield fluorescein angiography (month 6 only) 
• Intravitreal aflibercept injection (if additional treatment criteria is met) 
 
5.2.2.3 
Months 7, 9, and 11 (+/- 7 Days) 
The following information will be collected: 
• Concomitant medications 
• AEs 
The following procedures and assessments will be conducted: 
• ETDRS visual acuity with manifest refraction 
• Slit lamp examination 
• Fundus examination 
• Tonometry 
• Spectral Domain OCT evaluation 
• Spectral Domain OCT angiography (month 9 only; optional) 
• Ultra-widefield fluorescein angiography (month 9 only) 
• Intravitreal aflibercept injection 
 


 
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5.2.2.4 
End of Treatment/Month 12 (+/- 7 Days)/Early Termination visit 
The following information will be collected: 
• Concomitant medications 
• AEs 
The following procedures and assessments will be conducted: 
• ETDRS visual acuity with manifest refraction 
• Slit lamp examination 
• Fundus examination 
• Tonometry 
• Spectral Domain OCT evaluation 
• Spectral Domain OCT angiography (month 12 only; optional) 
• Ultra-widefield fluorescein angiography 
 
5.2.3 
Additional Visits 
5.2.3.1 
Unscheduled visit 
The following information will be collected: 
• Concomitant medications 
• AEs 
The following procedures and assessments may be conducted: 
• ETDRS visual acuity with manifest refraction in both eyes 
• Slit lamp examination at investigator’s discretion 
• Fundus examination at investigator’s discretion 
• Spectral Domain OCT evaluation at investigator’s discretion 
• Intravitreal injection of aflibercept (if criteria for additional treatment met) in study 
eye 
• Intravitreal injection of aflibercept in fellow eye (if needed)  
 
5.2.4 
Early Termination Visit 
Subjects who are withdrawn from the study should be instructed to return to the clinic for 
end of study assessments. 


 
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5.2.5 
Unscheduled Visits 
All attempts should be made to keep subjects on the study schedule.  Unscheduled visits 
may be necessary to repeat testing following AEs, or for any other reason, as warranted. 
5.3 
Study Procedures 
5.3.1 
Procedures Performed only at the Screening/Baseline Visit 
No specific procedures other than above will be performed for the sole purpose of 
determining study eligibility or characterizing the baseline population. 
5.3.2 
Efficacy Procedures 
Vision: Visual Acuity Visual function of the study eye and the fellow eye will be 
assessed using the E-ETDRS protocol (The Early Treatment Diabetic Retinopathy Study 
Group, 1985). Visual Acuity examiners must be certified to ensure consistent 
measurement of BCVA.   
 
Spectral Domain Optical Coherence Tomography (OCT): Retinal characteristics will be 
evaluated using SDOCT on the study eye. At the Screen Visit (Visit 1) images will be 
captured and archived. The scanning protocol will consist of fast macular thickness maps 
as well as high definition 6.0 mm linear scans centered on the fovea. OCT scans will be 
recorded by scoring their morphological patterns, and by recording the foveal minimum 
and volumetric analysis for each subject (Cirrus OCT, Zeiss, San Leandro, CA, software 
version 5.0).  OCT images will read by a trained reader and also assessed with a 
computerized segmentation analysis tool. 
 
Fundus Evaluation, Fundus Photography, and Fluorescein Angiography (FA): 
The anatomical state of the retinal vasculature of the study eye will be evaluated by 
funduscopic examination. Ultra-widefield fluorescein angiography will be performed at 
the baseline visit, month 3, month 6, month 9, and at the month 12 visit.  Angiographic 
analysis will be performed by a trained reader and a computerized analysis tool.  Optional 
spectral domain OCT angiography will be performed at month 3, month 6, month 9, and 
at month 12 (Avanti XR, Optovue, CA).  At no other time points will OCT angiography 
be performed.  OCT angiography is non-invasive, non-contact diagnostic test that utilizes 
special software to convert the traditional OCT information into vascular network map.  
No injection of dye is required for OCT angiography.  
 
Intraocular Pressure: 
Intraocular pressure (IOP) of the study eye will be measured using applanation tonometry 
or Tonopen. The same method of IOP measurement must be used in each subject 
throughout the study. 


 
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5.3.3 
Safety Procedures 
5.3.3.1 
Adverse Event Information Collection 
The investigator (or designee) will record all AEs that occur during the study following the 
baseline visit. Information on follow-up for AEs is provided in section 6.2.4.   
The definition of an AE and SAE, and information on the determination of severity and 
relationship to treatment are provided in section 6. 
6. 
SAFETY DEFINITIONS, REPORTING, AND MONITORING 
6.1 
Definitions 
6.1.1 
Adverse Event 
An AE is any untoward medical occurrence in a patient administered a study drug which 
may or may not have a causal relationship with the study drug.  Therefore, an AE is any 
unfavorable and unintended sign (including abnormal laboratory finding), symptom, or 
disease which is temporally associated with the use of a study drug, whether or not 
considered related to the study drug.   
An AE also includes any worsening (i.e. any clinically significant change in frequency 
and/or intensity) of a pre-existing condition that is temporally associated with the use of 
the study drug. 
6.1.2 
Serious Adverse Event 
A SAE is any untoward medical occurrence that at any dose: 
• Results in death – includes all deaths, even those that appear to be completely 
unrelated to study drug (e.g. a car accident in which a patient is a passenger). 
• Is life-threatening – in the view of the investigator, the patient is at immediate 
risk of death at the time of the event.  This does not include an AE that had it 
occurred in a more severe form, might have caused death. 
• Requires in-patient hospitalization or prolongation of existing hospitalization.  
In-patient hospitalization is defined as admission to a hospital or an emergency 
room for longer than 24 hours.  Prolongation of existing hospitalization is defined 
as a hospital stay that is longer than was originally anticipated for the event, or is 
prolonged due to the development of a new AE as determined by the investigator 
or treating physician. 
• Results in persistent or significant disability/incapacity (substantial disruption of 
one’s ability to conduct normal life functions). 
• Is a congenital anomaly/birth defect. 
• Is an important medical event – Important medical events may not be 
immediately life-threatening or result in death or hospitalization, but may 
jeopardize the patient or may require intervention to prevent 1 of the other serious 
outcomes listed above (e.g., intensive treatment in an emergency room or at home 
for allergic bronchospasm; blood dyscrasias or convulsions that do not result in 
hospitalization; or development of drug dependency or drug abuse).  Any 


 
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malignancy (other than basal cell skin cancers) would be considered a medically 
important event. 
6.2 
Recording and Reporting Adverse Events 
All AEs and SAEs will be recorded in the patient’s source documents.  Laboratory values 
or vital signs will be recorded as AEs only if they are medically relevant. 
 
All SAEs, regardless of assessment of causal relationship to study drug will be reported 
to Regeneron Pharmaceuticals, Inc. 
 
The investigator will promptly report to the IRB all unanticipated problems involving 
risks to subjects.  This includes death from any cause and all SAEs related to the use of 
the study drug.  All SAEs will be reported to the IRB, regardless of assessed causality. 
6.2.1 
Deaths 
Any AE that results in death is considered a SAE.  Deaths that occur from the time the 
patient signs the informed consent form (“ICF”) until 30 days after dosing will be 
reported to the appropriate IRB and to Regeneron Pharmacovigilance and Risk 
Management (or designee) within 24 hours of learning of the death.   
 
Any available autopsy reports and relevant medical reports will be sent to Regeneron 
Pharmaceuticals, Inc. as soon as possible. 
 
To report an SAE, Regeneron will be contacted at the following: 
Medical.safety@regeneron.com 
Fax 914-345-7476 
SAE hotline: 914-593-1504 
6.2.2 
Pregnancy and Other Events that Require Accelerated Reporting 
The following events will be reported to Regeneron Pharmaceuticals, Inc. within 24 
hours of learning of the event: 
 
Overdose:  Accidental or intentional overdose of the study drug or concomitant 
medication, whether or not it is considered an AE. 
 
Pregnancy:  Although it is not considered an AE, the investigator will report to 
Regeneron Pharmaceuticals, Inc., any pregnancy occurring in a female patient or female 
partner of a male patient, during the study or within 30 days following the last dose of 
study drug.  The investigator will follow the pregnancy until delivery, or longer.  If the 
pregnancy continues to term (delivery), the health of the infant will also be reported to 
Regeneron Pharmaceuticals, Inc. 
 
To report an SAE, Regeneron will be contacted at the following: 
Medical.safety@regeneron.com 
Fax 914-345-7476 
SAE hotline: 914-593-1504 


 
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6.2.3 
Reporting Adverse Events Leading to Withdrawal from the Study 
All AEs that lead to a patient’s withdrawal from the study will be reported to Regeneron 
Pharmaceuticals Inc. within 30 days. All SAEs leading to a patient’s withdrawal from the 
study will be reported. To report an SAE, Regeneron will be contacted at the following: 
Medical.safety@regeneron.com 
Fax 914-345-7476 
SAE hotline: 914-593-1504 
6.2.4 
Follow-up 
Adverse event information will be collected until the end of study visit, or the early 
termination visit, if the patient withdraws consent. 
 
The investigator must make every effort to obtain follow-up information on the outcome 
of any SAE until the event is considered chronic and/or stable. 
 
6.3 
Evaluation of Severity and Causality 
6.3.1 
Evaluation of Severity 
The severity of an AE will be graded by the investigator using a 3–point scale (mild, 
moderate, or severe) and reported in detail as indicated on the CRF and/or SAE form, as 
appropriate. 
• Mild:  Does not interfere in a significant manner with the patient’s normal 
functioning level.  It may be an annoyance.  Prescription drugs are not ordinarily 
needed for relief of symptoms, but may be given because of personality of the 
patient. 
• Moderate:  Produces some impairment of functioning but is not hazardous to 
health.  It is uncomfortable or an embarrassment.  Treatment for symptom may be 
needed. 
• Severe:  Produces significant impairment of functioning or incapacitation and is a 
definite hazard to the patient’s health.  Treatment for symptom may be given 
and/or patient hospitalized. 
6.3.2 
Evaluation of Causality 
The relationship to treatment will be determined by the investigator and reported on the 
CRF and/or SAE form, as appropriate.  The following terms will be used: 
Not Related:  likely or clearly due to causes other than the study drug. 
Related:  possibly, probably, or definitely related to the study drug. 
 


 
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7. 
STUDY VARIABLES 
7.1 
Demographic and Baseline Characteristics 
Baseline characteristics will include standard demography (eg, age, race, etc.), disease 
characteristics including medical history, and medication history for each subject. 
7.2 
Primary and Secondary Endpoints 
Primary Endpoint: 
§ The primary study endpoint is the mean change in total leakage index at month 12 
as measured by ultra-widefield angiography (defined as the proportion of retinal 
area involved in angiographic leakage). 
 
Secondary Endpoint:  
§ The mean change in total leakage index at month 6 
§ The diabetic retinopathy severity at month 6 and 12 (if applicable) 
§ The amount hemorrhage at month 6 and 12 
§ The change in ischemic index (defined as the proportion of retinal area with 
nonperfusion) at month 6 and 12 
§ The mean absolute change from baseline central subfield thickness at month 6 and 
12 
§ The mean change from baseline in best-corrected visual acuity (BCVA) score at 
months 6 and 12 
§ The percentage of subjects that were anatomically ‘dry’ by SDOCT at months 6 
and 12, 
§ The percentage of participants who gained or lost 10 letters or more of vision at 
months 6 and 12 
§ The percentage of subjects who gained or lost 15 letters or more of vision at 
months 6 and 12 
§ The percentage of patients that are 20/40 or better at months 6 and 12 
§ The percentage of patients that are 20/200 or worse at months 6 and 12 
§ The incidence and severity of ocular and non-ocular adverse events (AEs) and 
serious AEs. 
 
7.3 
Analysis Sets 
7.3.1 
Efficacy Analysis Sets 
The full analysis set (FAS) includes all subjects who received any study drug.  Efficacy 
endpoints will be analyzed using the FAS. 
7.3.2 
Safety Analysis Set 
The safety analysis set (SAF) includes all subjects who received any study drug; it is based 
on the treatment received (as treated).  Treatment compliance/administration and all 
clinical safety variables will be analyzed using the SAF. 


 
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7.4 
Subject Disposition 
The following will be provided: 
• The total number of enrolled subjects  
• The total number of subjects who discontinued the study, and the reasons for 
discontinuation 
• A listing of subjects prematurely discontinued from treatment, along with reasons 
for discontinuation 
7.5 
Statistical Methods 
7.5.1 
Demography and Baseline Characteristics 
Demographic and baseline characteristics will be summarized descriptively by treatment 
group.  Continuous variables will be summarized with mean, median, standard deviation, 
minimum, and maximum.  Categorical variables will be summarized with frequency and 
percentage. 
7.5.2 
Efficacy Analyses 
7.5.2.1 
Primary Efficacy Analysis 
The primary efficacy variable will be the mean change in total leakage index at month 12 
as measured by ultra-widefield angiography (defined as the proportion of retinal area 
involved in angiographic leakage). 
7.5.2.2 
Secondary Efficacy Analysis 
Secondary efficacy variables include the following: 
§ The mean change in total leakage index at month 6 
§ Diabetic retinopathy severity at month 6 and 12 (if applicable) 
§ Amount of retinal hemorrhage at month 6 and 12 for RVO (if applicable) 
§ Change in ischemic index (defined as the proportion of retinal area with 
nonperfusion) at month 6 and 12 
§ Mean absolute change from baseline central subfield thickness at month 6 and 12 
§ Mean change from baseline in best-corrected visual acuity (BCVA) score at months 
6 and 12 
§ Percentage of subjects that were anatomically ‘dry’ by SDOCT at months 6 and 12 
§ Percentage of participants who gained 10 letters or more of vision at months 6 and 
12 
§ Percentage of participants who lost 10 letters or more of vision at months 6 and 12 
§ Percentage of participants who gained 15 letters or more of vision at months 6 and 
12 


 
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§ Percentage of subjects who lost 15 letters or more of vision at months 6 and 12 
§ Percentage of patients that are 20/40 or better at months 6 and 12 
§ Percentage of patients that are 20/200 or worse at months 6 and 12 
 
7.5.3 
Safety Analysis 
7.5.3.1 
Adverse Events 
Definitions 
For safety variables, two observation periods are defined: 
• The treatment period is defined as the day from first dose of study drug to the last 
dose of study drug.  
• The post-treatment period is defined as the time after the last dose of study drug. 
Treatment-emergent AEs (TEAEs) are defined as those that are not present at baseline or 
represent the exacerbation of a pre-existing condition during the on-treatment period. 
Analysis 
§ Incidence and severity of ocular and non-ocular adverse events (AEs) and serious 
AEs 
8. 
DATA MANAGEMENT AND ELECTRONIC SYSTEMS 
A data management plan specifying all relevant aspects of data processing for the study 
(including data validation, cleaning, correcting, releasing) will be maintained and stored at 
the Cleveland Clinic. 
A medical coding plan will specify the processes and the dictionary used for coding.  All 
data coding (eg, AEs, applicable baseline findings, medication, medical history / surgical 
history/ophthalmic history) will be done using internationally recognized and accepted 
dictionaries.   
The CRF data for this study will be collected with a paper Data Capture tool. 
8.1 
Electronic Systems 
Electronic systems used to process and/or collect data in this study will include the 
following: 
• Epic– EMR system 
• Statistical Analysis Software (SAS) – statistical review and analysis 


 
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9. 
STUDY MONITORING 
9.1 
Monitoring of Study Sites 
The study coordinator will review all documentation prior to enrollment of the first subject, 
and periodically during the study.  In accordance with International Conference on 
Harmonization (ICH) guidelines, the coordinator will compare the eCRF entries with the 
appropriate source documents.  Additional review may include, but is not limited to, 
subject ICFs, documentation of subject recruitment and follow-up, AEs, SAEs, and 
concomitant therapy; as well as records of study drug dispensing, compliance, and 
accountability.  A copy of the drug dispensing log must be provided to the designee upon 
request. 
9.2 
Source Document Requirements 
Investigators are required to prepare and maintain adequate and accurate subject records 
(source documents). 
The investigator must keep all source documents on file with the CRF.  Case report forms 
and source documents must be available at all times for inspection by authorized 
representatives of the designee and regulatory authorities. 
9.3 
Case Report Form Requirements 
A CRF for each subject enrolled in the study must be completed and signed by the study 
investigator or authorized designee. The CRF must be typed or filled out using indelible 
ink.  The writing must be legible. Errors should be crossed out but not obliterated, the 
correction inserted, and the change initialed and dated by the investigator or authorized 
designee. The investigator must ensure the accuracy, completeness, legibility, and 
timeliness of the data reported to the designee in the CRFs.  Case report forms must be 
available at all times for inspection by authorized representatives of the designee and 
regulatory authorities. 
10. 
AUDITS AND INSPECTIONS 
This study may be subject to a quality assurance audit or inspection by authorities.  Should 
this occur, the investigator is responsible for: 
• Informing the designee of a planned inspection by the authorities as soon as 
notification is received, and authorizing the designee’s participation in the 
inspection 
• Providing access to all necessary facilities, study data, and documents for the 
inspection or audit 
• Communicating any information arising from inspection by the regulatory 
authorities to the designee immediately 
• Taking all appropriate measures requested by the designee to resolve the problems 
found during the audit or inspection 


 
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Documents subject to audit or inspection include but are not limited to all source 
documents, CRFs, medical records, correspondence, ICFs, IRB files, documentation of 
certification and quality control of supporting laboratories, and records relevant to the study 
maintained in any supporting pharmacy facilities.  Conditions of study material storage are 
also subject to inspection.  In addition, representatives of the designee may observe the 
conduct of any aspect of the clinical study or its supporting activities both within and 
outside of the investigator's institution. 
In all instances, the confidentiality of the data must be respected. 
11. 
ETHICAL AND REGULATORY CONSIDERATIONS 
11.1 
Good Clinical Practice Statement 
It is the responsibility of both the designee and the investigator(s) to ensure that this clinical 
study will be conducted in accordance with the ethical principles that have their origin in 
the Declaration of Helsinki, and that are consistent with the ICH guidelines for Good 
Clinical Practice (GCP) and applicable regulatory requirements. 
11.2 
Informed Consent 
The principles of informed consent are described in ICH Guidelines for GCP. 
Regeneron will have the right to review and comment on the informed consent form. 
It is the responsibility of the investigator or designee (if acceptable by local regulations) to 
obtain written informed consent from each subject prior to his/her participation in the study 
and after the aims, methods, objectives, and potential hazards of the study have been 
explained to the subject in language that he/she can understand.  The ICF should be signed 
and dated by the subject and by the investigator or authorized designee who reviewed the 
ICF with the subject.   
• Subjects who can write but cannot read will have the ICF read to them before 
signing and dating the ICF. 
• Subjects who can understand but who can neither write nor read will have the ICF 
read to them in presence of an impartial witness, who will sign and date the ICF to 
confirm that informed consent was given. 
The original ICF must be retained by the investigator as part of the subject's study record, 
and a copy of the signed ICF must be given to the subject. 
If new safety information results in significant changes in the risk/benefit assessment, the 
ICF must be reviewed and updated appropriately.  All study subjects must be informed of 
the new information and provide their written consent if they wish to continue in the study.  
The original signed revised ICF must be maintained in the subject’s study record and a 
copy must be given to the subject. 
 


 
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11.3 
Subject Confidentiality and Data Protection 
The investigator must take all appropriate measures to ensure that the anonymity of each 
study subject will be maintained.  Subjects should be identified by their initials and a 
subject identification number, only, on CRFs or other documents submitted to the designee.  
Documents that will not be submitted to the designee (eg, signed ICF) must be kept in strict 
confidence. 
The subject's and investigator's personal data, which may be included in the investigator’s 
study database, will be treated in compliance with all applicable laws and regulations.  The 
investigator shall take all appropriate measures to safeguard and prevent access to this data 
by any unauthorized third party. 
11.4 
Institutional Review Board  
An appropriately constituted IRB, as described in ICH Guidelines for GCP, must review 
and approve:  
• The protocol, ICF, and any other materials to be provided to the subjects 
(eg, advertising) before any subject may be enrolled in the study  
• Any amendment or modification to the study protocol or ICF before 
implementation, unless the change is necessary to eliminate an immediate hazard 
to the subjects, in which case the IRB should be informed as soon as possible  
• Ongoing studies on an annual basis or at intervals appropriate to the degree of risk  
In addition, the IRB should be informed of any event likely to affect the safety of subjects 
or the continued conduct of the clinical study. 
A copy of the IRB approval letter with a current list of the IRB members and their functions 
must be received by Regeneron prior to shipment of drug supplies to the investigator.  The 
approval letter should include the study number and title, the documents reviewed, and the 
date of the review. 
Records of the IRB review and approval of all study documents (including approval of 
ongoing studies) must be kept on file by the investigator. 
12. 
PROTOCOL AMENDMENTS 
The investigator may not implement a change in the design or operation of the protocol or 
ICF without an IRB approved amendment. 
13. 
PREMATURE TERMINATION OF THE STUDY OR CLOSE-OUT OF A SITE 
13.1 
Premature Termination of the Study 
Cleveland Clinic or Regeneron has the right to terminate the study prematurely.  Reasons 
may include efficacy, safety, or futility, among others.   


 
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14. 
STUDY DOCUMENTATION 
14.1 
Certification of Accuracy of Data 
A declaration assuring the accuracy and content of the data recorded on the CRFs must be 
signed by the investigator.  This certification form accompanies each set of CRFs.  The 
signed form will be provided to the designee with the final set of CRFs for each subject. 
14.2 
Retention of Records 
The investigator must retain all essential study documents, including ICFs, source 
documents, investigator copies of CRFs, and drug accountability records for at least 2 years 
following the completion or discontinuation of the study, or longer if a longer period is 
required by relevant regulatory authorities.  The investigator must consult with the designee 
before discarding or destroying any essential study documents following study completion 
or discontinuation. Records must be destroyed in a manner that ensures confidentiality. 
If the investigator's personal situation is such that archiving can no longer be ensured, the 
investigator must inform the designee and the relevant records will be transferred to a 
mutually agreed-upon destination. 
 
 


 
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15.   Appendix 1:  Injection Procedure 
 
Intravitreal aflibercept injection is formulated as a sterile liquid to a final concentration of 
40 mg/mL. The volume of injection will be 50 µl (0.05 mL) for the 2 mg dose of IAI.  
 
• Preparation (please see below regarding the optional use of topical antibiotic agents pre 
and post dose): 
a. Apply topical anesthetic with or without subconjunctival anesthetic  
b. Apply povidone iodine to eyelid margins, eyelashes, and conjunctival surface.  
For patients who have a known sensitivity to povidone iodine, another equally 
effective agent may be used. 
c. Place 1 or 2 drops of povidone-iodine on the ocular surface at the intended 
injection site. 
d. A sterile speculum may be used. 
e. Mark the injection site location with a empty Tb syringe. 
f. Apply additional drop of povidone-iodine to site of injection. 
 
• Study Drug (VEGF Trap-Eye) Administration: 
a. Insert needle at marked injection point.  
b. Gently inject study drug.  
c. As the needle is withdrawn, a sterile cotton tip applicator may be rolled over 
the entry site to minimize the risk of drug reflux.  
 
• Post-Injection Procedures 
Confirm that the patient has at least counting fingers vision.  See guidelines below for 
additional post-injection management procedures.   
 
Guidelines for Pre and Post-injection Management 
• Use of Topical Antibiotic Agents 
No pre or post-injection antibiotics will be used.  
 


 
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• If vision is less than Counting Fingers: 
Visualize the optic nerve to verify reperfusion of the central retinal artery in the 
immediate post-injection period.  
 
Check the IOP while maintaining a clean field.  Monitor the IOP closely until it is 
below 30 mm Hg. If a Tono-pen™ is used to check pressure, a clean Tono-pen™ 
condom should be placed on the tip before taking each measurement. If Goldmann 
applanation tonometry is used, the applanator tip should be swabbed with alcohol and 
let to dry before using it to measure IOP.  IOP may be lowered by pharmaceutical or 
surgical intervention, if required.  Treatment should be initiated whenever IOP is 
increased to the extent that the central retinal artery remains closed or the patient 
remains less than count fingers for more than 1 to 2 minutes with an IOP > 35 mm Hg.   
 
• Discharge 
No special precautions are required before discharge of a patient who has had an 
uneventful recovery from intravitreal injection, but patients and/or caregivers should 
be educated to avoid rubbing the eye and to recognize the signs and symptoms of 
endophthalmitis, retinal detachment, or intraocular hemorrhage; these are eye pain or 
increased discomfort, increased redness of the eye (compared to immediately after 
injection), blurred or decreased vision, and increased ocular sensitivity to light.   
 


 
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16.   Appendix 2:  References 
 
1. Ferrara N, Davis-Smyth T. The biology of vascular endothelial growth factor. 
Endocr Rev. 1997 Feb;18(1):4-25. 
 
2. Ferrara N, Houck KA, Jakeman LB, Winer J, Leung DW. The vascular 
endothelial growth factor family of polypeptides. J Cell Biochem. 1991 
Nov;47(3):211-8. 
 
3. Ferrara N. Vascular endothelial growth factor and the regulation of angiogenesis. 
Recent Prog Horm Res. 2000;55:15-35; discussion 35-6. 
 
4. Rakic JM, Lambert V, Devy L, Luttun A, Carmeliet P, Claes C, Nguyen L, 
Foidart JM, Noël A, Munaut C. Placental growth factor, a member of the VEGF 
family, contributes to the development of choroidal neovascularization. Invest 
Ophthalmol Vis Sci. 2003 Jul;44(7):3186-93. 
 
5. Singer M, Tan CS, Bell D, Sadda SR. Area of peripheral retinal nonperfusion and 
treatment response in branch and central retinal vein occlusion. Retina. 2014 
Sep;34(9):1736-42. 
 
6. Thickett DR, Armstrong L, Millar AB. Vascular endothelial growth factor 
(VEGF) in inflammatory and malignant pleural effusions. Thorax. 1999 
Aug;54(8):707-10. 
 
7. Wessel MM, Nair N, Aaker GD, Ehrlich JR, D'Amico DJ, Kiss S. Peripheral 
retinal ischaemia, as evaluated by ultra-widefield fluorescein angiography, is 
associated with diabetic macular oedema. Br J Ophthalmol. 2012 May;96(5):694-
8.