Conditions: Diabetic Macular Edema
Allocation: NA | Intervention model: SINGLE_GROUP
Enrollment: 30
Healthy volunteers: yes

Brief summary:
This is a phase 4 prospective, nonrandomized, open label, interventional clinical trial. Study eyes will receive 5 required initial monthly Intravitreal Aflibercept (IAI) doses of 2 mg followed by 2q8 IAI for a total of 52 weeks; only one study eye from each patient will be enrolled.

Detailed description:
This is a phase 4 prospective, nonrandomized, open label, interventional clinical trial. Study eyes will receive 5 required initial monthly IAI doses of 2 mg followed by 2q8 IAI for a total of 52 weeks; only one study eye from each patient will be enrolled.

Starting at week 24, patients may be eligible to receive additional 2mg IAI (2q4) treatment if both of the following criteria is met and the investigator feels additional treatment would be beneficial:

* Loss of \>5 letters from baseline or best previously recorded best corrected visual acuity (BCVA)
* Presence of new or recurrent intraretinal fluid or subretinal fluid as assessed by SD OCT

Starting at week 24, rescue therapy with macular laser photocoagulation may be administered if any the following criteria are met

* Loss of \> 15 letters from baseline or best previously recorded BCVA and loss of acuity felt to be secondary to Diabetic Macular Edema (DME) and not from other cause (i.e., cataract, epiretinal membrane, vitreous hemorrhage, etc) and investigator feels patient would benefit from rescue therapy
* Increase in SD OCT CSF \> 100 um from baseline or best previously recorded SD OCT CSF and investigator feels patient would benefit from rescue therapy.

Every 4 week visit will include ETDRS BCVA, IOP measurement, Slit lamp biomicroscopy, Indirect ophthalmoscopy, Heidelberg Spectralis SD-OCT and evaluation for systemic and ocular adverse events. Fundus Photography and Wide field Optos fluorescein angiography will be performed at baseline and at week 20and week 52.

STUDY DURATION: Approximately 52 weeks to the end of the study. Primary endpoint will be evaluated at week 52.

Arms:
arm 1: Evaluating the efficacy of Alflibercept Injections in DME Following Treatment With Bevacizumab and Ranibizumab

Interventions: intervention 1: Alflibercept
Intervention descriptions: intervention 1: Intravitreal Injection

Protocol document:
Prot_SAP_000.pdf: 
1 
 
 
Clinical Study Protocol 
 
Intravitreal aflibercept injection (IAI) for persistent diabetic macular edema (DME) after 
treatment with bevacizumab and/or ranibizumab (ROTATED Trial) 
 
 
 
 
Compound: 
Aflibercept 2 mg 
 
 
Study Name: 
Intravitreal aflibercept injection (IAI) for 
persistent diabetic macular edema (DME) after 
treatment with bevacizumab and/or 
ranibizumab (ROTATED Trial) 
 
Clinical Phase: 
IV 
 
 
Date of Issue 
26 January 2017 
 
Primary Investigator: 
Dennis Marcus, MD 
 
 
 
 
 
 


2 
 
 
CLINICAL STUDY PROTOCOL SYNOPSIS 
 
TITLE: 
Intravitreal aflibercept injection (IAI) for persistent diabetic macular edema (DME) 
after treatment with bevacizumab and/or ranibizumab (ROTATED Trial) 
 
SITE LOCATION(S):  
Southeast Retina Center, PC 
 
PRINCIPAL  
INVESTIGATOR:  
 
Dennis Marcus, MD 
 
OBJECTIVE(S): 
To evaluate treatment effect of IAI in eyes persistent diabetic macular edema  
 
STUDY DESIGN: 
This is a phase 4 prospective, nonrandomized, open label, interventional clinical trial. 
Study eyes will receive 5 required initial monthly IAI doses of 2 mg followed by 2q8 
IAI for a total of 52 weeks; only one study eye from each patient will be enrolled.  
 
 
Starting at week 20 patients may be eligible to receive additional 2mg IAI (2q4) 
treatment if both of the following criteria is met and the investigator feels additional 
treatment would be beneficial: 
 
Loss of >5 letters from baseline or best previously recorded BCVA 
 
Presence of new or recurrent intraretinal fluid or subretinal fluid as assessed 
by SD OCT 
 
Starting at week 24, rescue therapy with macular laser photocoagulation may be 
administered if any the following criteria are met  
 
Loss of > 15 letters from baseline or best previously recorded BCVA and 
loss of acuity felt to be secondary to DME and not from other cause (i.e., 
cataract, epiretinal membrane, vitreous hemorrhage, etc) and investigator 
feels patient would benefit from rescue therapy 
 
Increase in SD OCT CSF > 100 um from baseline or best previously 
recorded SD OCT CSF and investigator feels patient would benefit from 
rescue therapy. 
Every 4 week visit will include ETDRS BCVA, IOP measurement, Slit lamp 
biomicroscopy, Indirect ophthalmoscopy, Heidelberg Spectralis SD-OCT and 
evaluation for systemic and ocular adverse events. Fundus Photography and Wide 
field Optos fluorescein angiography will be performed at baseline and at week 20 
and week 52. For subjects participating in the OCT Angiography sub-study, Optovue 
OCT angiography will be performed at baseline, weeks 12,20,36, and 52.  
 


3 
 
STUDY DURATION: 
Approximately 52 weeks to the end of the study. Primary endpoint will be evaluated 
at week 52. 
 
EST. COMPLETION  
DATE: 
 
2017 
 
POPULATION: 
 
30 patients with persistent DME who have completed and exited the ROTATE trial 
will be enrolled. Amendment 1 (9 May 2016) was made to expand the inclusion 
criteria to include additional patients with persistent DME undergoing treatment with 
bevacizumab and/or ranibizumab beyond those that had been previously enrolled in 
the ROTATE trial.  
 
TREATMENT(S): 
 
Study eyes will receive 5 required initial monthly IAI doses of 2 mg followed by 2q8 
IAI for a total of 52 weeks. 
 
 
This is a phase 4 prospective, nonrandomized, open label, interventional clinical trial. 
Study eyes will receive 5 required initial monthly IAI doses of 2 mg followed by 2q8 
IAI for a total of 52 weeks; only one study eye from each patient will be enrolled.  
 
 
Starting at week 20 patients may be eligible to receive additional 2mg IAI (2q4) 
treatment if both of the following criteria is met and the investigator feels additional 
treatment would be beneficial: 
 
Loss of >5 letters from baseline or best previously recorded BCVA 
 
Presence of new or recurrent intraretinal fluid or subretinal fluid as assessed 
by SD OCT 
 
Starting at week 24, rescue therapy with macular laser photocoagulation may be 
administered if any the following criteria are met  
 
Loss of > 15 letters from baseline or best previously recorded BCVA and loss 
of acuity felt to be secondary to DME and not from other cause (i.e., cataract, 
epiretinal membrane, vitreous hemorrhage, etc) and investigator feels patient 
would benefit from rescue therapy 
 
Increase in SD OCT CSF > 100 um from baseline or best previously recorded 
SD OCT CSF and investigator feels patient would benefit from rescue 
therapy. 
 
ENDPOINT(S): 
        Primary: 
Reduction in macular edema measured as 
 
Proportion of eyes with baseline SD OCT CST >350um demonstrating >15% 
reduction at week 52 from baseline 


4 
 
 
Proportion of eyes that demonstrate SD OCT CST <305um (males) and <290 
um (females) at week 52 from baseline  
 
         Secondary: 
 
Vision: 
o Mean change in BCVA letter score at week 4, week 12, week 20, 
week 24 and week 52 
o Mean BCVA letter score at week 4, week 12, week 20, week 24, and, 
week 52 
o Proportion of eyes with any gain (> 0 letters) at week 52, compared 
to baseline BCVA 
 
 
 
Anatomic 
o Mean change SDOCT CSF thickness and macular volume change 
from baseline at week 4, week 12, week 20, week 24, and, week 52 
o Proportion of eyes with absence of fluorescein angiographic macular 
leakage at week 52 
o Proportion of eyes with unchanged, worsened or improved 
fluorescein angiographic macular leakage from baseline at week 20 
and week 52 
o Proportion of eyes with unchanged, worsened, or improved fundus 
photographic DME grading from baseline at week 20 and week 52 
o For patients in the OCT-A substudy: 
 
Proportion of eyes with unchanged, worsened, or improved 
capillary dropout on Optovue OCT Angiography from 
baseline at week 20 and week 52.  
 
Proportion of eyes with unchanged, increased, or decreased 
macular capillary non-perfusion area of superficial and deep 
capillary plexus. 
 
Mean change in macular capillary non-perfusion area of 
superficial and deep capillary plexus from baseline at week 
12, week 20, week 36, and week 52.  
 
 
 
Treatment 
o Mean number of IAI injections from baseline to Week 52 
o Proportion of eyes not requiring rescue therapy from baseline at 
week 52 
 
 
Safety 
o Incidence and severity of ocular and systemic safety events through 
week 52 including: worsened acuity > 30 letters, retinal detachment, 


5 
 
endophthalmitis, cataract progression, vitreous hemorrhage, new 
PDR or neovascularization of the iris or angle, systemic 
thromboembolic events, deaths, and systemic serious adverse events. 
 
PROCEDURES/ASSESSMENTS: The following assessments will be conducted at each visit – EDTRS BCVA and 
SD-OCT.   Wide field Optos fluorescein angiography and standard fundus 
photos will be performed at screening, week 20, and week 52. Adverse events 
and concomitant medications will be collected at each visit. Subjects 
participating in the OCT angiography sub-study will have Optovue OCT 
angiography performed at baseline, weeks 12,20,36, and 52. 
 
STATSITCAL PLAN: 
 
This is an open-label study with no formal sample size calculation.  Data from 
all enrolled patients will be analyzed. 
 
 
 
 
 


 
TABLE OF CONTENTS  
 
1. 
INTRODUCTION AND RATIONALE 
9 
1.1 
Introduction 
9 
1.2 
Rationale 
12 
1.2.1 Rationale for Study Design 
12 
1.2.2 Rationale for Dose Selection 
13 
2. 
STUDY OBJECTIVES 
12 
2.1 
Primary Objective 
12 
2.2 
Secondary Objectives 
12 
3. 
STUDY DESIGN 
13 
3.1 
Study Description and Duration 
13 
3.2 
Planned Interim Analysis 
14 
4. 
SELECTION, WHIDRAWAL, AND REPLACEMENT OF PATIENTS 
14 
4.1 
Number of Patients Planned 
14 
4.2 
Study Population 
14 
4.2.1 Inclusion Criteria 
14 
4.2.2 Exclusion Criteria 
15 
4.3 
Premature Withdrawal from the Study 
16 
4.4 
Replacement of Patients 
16 
5. 
STUDY TREATMENTS 
17 
5.1 
Investigational Treatment 
17 
5.2 
Dose Modification and Patient Discontinuation 
17 
5.2.1 Dose Modification 
17 
5.2.2 Patient Discontinuation 
17 
5.3 
Study Discontinuation 
18 
5.4 
Treatment Logistics and Accountability 
18 
5.4.1 Packaging, Labeling, and Storage 
18 
5.4.2 Supply and Disposition of Treatments 
19 
5.4.3 Treatment Accountability 
19 
5.5 
Concomitant Medications 
20 
5.5.1 Study Eye 
20 
5.5.2 Fellow eye 
20 
5.5.3 Permitted Medications 
20 


 
6. 
STUDY SCHEDULE OF EVENTS AND VISIT DESCRIPTIONS 
21 
6.1 
Schedule of Events 
21 
6.2 
Study Visit Descriptions 
22 
6.2.1 Screening/Baseline (Day 0) 
22 
6.2.2 Weeks 4, 8, 12, 16 (±1 week) 
22 
6.2.3 Weeks 24, 28, 32, 36, 40, 44, 48 (±1 week) 
23 
6.2.4 Week 52 (±2 weeks) or Early Termination 
23 
6.2.5 Unscheduled Visits 
24 
7. 
SAFETY DEFINITIONS, REPORTING, AND MONITORING 
24 
7.1 
Definitions 
24 
7.1.1 Adverse Event 
24 
7.1.2 Serious Adverse Event 
24 
7.2 
Recording and Reporting Adverse Events 
25 
7.2.1 Deaths 
25 
7.2.2 Pregnancy and Other Events that Require Accelerated Reporting 
25 
7.2.3 Reporting Adverse Events Leading to Withdrawal from the Study 
26 
7.2.4 Abnormal Vital Signs 
26 
7.2.5 Follow-Up 
27 
7.3 
Evaluation of Severity 
27 
7.4 
Evaluation of Causality 
27 
8. 
STUDY VARIABLES 
27 
8.1 
Demographic and Baseline Characteristics 
28 
8.2 
Primary and Secondary Endpoints 
28 
9. 
STATISTICAL PLAN 
28 
9.1 
Statistical Methods 
29 
9.1.1 Demography and Baseline Characteristics 
29 
9.1.2 Efficacy Analysis 
29 
9.1.2.1 Primary Efficacy Analysis 
29 
9.1.2.2 Secondary Efficacy Analysis 
29 
9.1.3 Safety Analysis 
29 
9.1.4 Interim Analysis 
29 
9.2 
Statistical Considerations Surrounding the Premature Termination of a Study 
29 
10. 
STUDY MONITORING 
29 
10.1 
Source Document Requirements 
29 


 
10.2 
Case Report Form Requirements 
30 
10.3 
AUDITS AND INSPECTIONS 
30 
11. 
ETHICAL AND REGULATORY CONSIDERATIONS 
30 
11.1 
Good Clinical Practice Statement 
30 
11.2 
Informed Consent 
31 
11.3 
Patient Confidentiality and Data Protection 
31 
11.4 
Institutional Review Board 
32 
12. 
PROTOCOL AMMENDMENTS 
32 
13. 
PREMATURE TERMINATION OF THE STUDY OR CLOSE-OUT OF A SITE 
32 
13.1 
Premature Termination of the Study 
33 
14. 
STUDY DOCUMENTATION 
33 
14.1 
Certification of Accuracy Data 
33 
14.2 
Retention of Records 
33 
15. 
REFERENCES 
33 
16. 
APPENDIX 1  
35 
 


 
 
1. 
INTRODUCTION AND RATIONALE 
1.1 
Introduction 
For the past 25 years,years, focal/grid laser photocoagulation had been the mainstay of treatment 
for DME. In the ETDRS, focal/grid photocoagulation of eyes with DME reduced the risk of 
moderate visual loss by approximately 50% (from 24% to 12%) three years after initiation of 
treatment. The advent of intravitreal pharmacotherapy with intraocular steroids and anti-VEGF 
agents have led to numerous clinical trials investigating new therapy for DME. 
 
A study conducted by DRCR.net, A Randomized Trial Comparing Intravitreal Triamcinolone 
Acetonide and Focal/grid Photocoagulation for DME (DRCR.net Protocol B), showed triamcinolone 
as monotherapy was not superior to use with the ETDRS focal/grid laser technique for central-
involved DME.  Results from a DRCR.net study (“Intravitreal Ranibizumab or Triamcinolone 
Acetonide  in Combination with Laser Photocoagulation for Diabetic Macular Edema”(DRCR.net 
Protocol  I) indicate that treatment for DME with intravitreal anti-vascular endothelial growth factor 
(anti- VEGF) therapy (0.5 mg ranibizumab) plus deferred (>24 weeks) or prompt focal/grid laser 
provides visual acuity outcomes at one year and two years that are superior to prompt focal/grid laser 
alone or intravitreal triamcinolone with prompt focal/grid laser, providing definitive confirmation of 
the important role of VEGF in DME and the role of anti-VEGF drugs in the treatment of DME. 
These results with ranibizumab DME therapy were confirmed with other phase 3 trials, including the 
RISE, RIDE and RESTORE studies. Participants in RISE and RIDE were randomized to continuous 
monthly 0.5 or 0.3 mg ranibizumab versus sham injections as treatment for DME with macular laser 
available to all treatment arms. The percentage of individuals gaining > 15 letters from baseline 
at 24 months was significantly higher in the ranibizumab groups in both studies. In RESTORE, both 
ranibizumab (0.5mg) monotherapy and combination ranibizumab+laser treatment resulted in better 
visual acuity outcomes than laser alone in patients with DME. Ranibizumab therapy was well-
tolerated in these studies although the overall rate of Antiplatelet Trialists’ Collaboration events was 
slightly higher in the 0.3 mg (5.6%) and 0.5 mg (7.2%) groups as compared with the sham group 
(5.2%) in the pooled data from the RISE and RIDE studies. Deaths were also more frequent in the 
ranibizumab groups (0.8% and 1.6% of sham and 2.4-4.8% of ranibizumab treated patients) in these 
trials. The rate of non-fatal cerebrovascular events in this pooled analysis was numerically higher in 
the 0.5mg group (2%) than in the sham (1.2%) or 0.3mg group (0.8%) but the rate of non-fatal 
myocardial infarctions was similar across treatment groups (2.8%, 2.8% and 2.4% in the sham, 


 
0.3mg and 0.5mg groups, respectively.  The results of the RISE and RIDE studies led to the FDA’s 
approval of 0.3 mg ranibizumab for DME and provided anti-vegf therapy as a new standard of care 
for DME. 
 
Aflibercept is composed of key domains from human VEGF receptors 1 and 2 fused to the Fc 
domain of human IgG1 and has approximately 100-fold greater binding affinity to VEGF-A than 
either bevacizumab or ranibizumab.  Intravitreal aflibercept injection (IAI; also known in the 
scientific literature as VEGF Trap-Eye or IVT-AFL) was recently demonstrated to have clinically 
equivalent efficacy to monthly ranibizumab in neovascular age-related macular degeneration 
(AMD), whether it was administered monthly or by a more convenient every two months regimen 
following three initial monthly doses. 
 
The VISTA and VIVID studies are the first phase 3 studies directly comparing VEGF-blockade 
alone with laser alone in DME. The studies demonstrated mean BCVA gains from baseline to week 
52 in the IAI 2q4 and 2q8 groups vs the laser group were 12.5 and 10.7 vs 0.2 letters (P<0.0001) in 
VISTA, and 10.5 and 10.7 vs 1.2 letters (P<0.0001) in VIVID. The corresponding proportions of 
eyes gaining ≥15 letters were 41.6% and 31.1% vs 7.8% (P<0.0001) in VISTA, and 32.4% and 
33.3% vs 9.1% (P<0.0001) in VIVID. Similarly, mean reductions in central retinal thickness were 
185.9 and 183.1 vs 73.3 µm (P<0.0001) in VISTA, and 195.0 and 192.4 vs 66.2 µm (P<0.0001) in 
VIVID. Overall incidences of ocular and non-ocular adverse events and serious adverse events, 
including the Anti-Platelet Trialists’ Collaboration-defined arterial thromboembolic events and 
vascular deaths, were similar across treatment groups. IAI demonstrated significant superiority in 
functional and anatomic endpoints over laser at week 52 and these results have led to the recent FDA 
approval of IAI for DME with 2q8 week dosing after 5 consecutive monthly doses. Thus, IAI dosed 
every 8 weeks (after 5 initial monthly doses) could provide a therapeutic option that may reduce the 
total number of injections and necessary office visits, substantially reducing burden on patients, 
physicians, and the health care system. More recently, DRCR protocol T demonstrated IAI has 
superior visual acuity outcomes compared to bevacizumab or ranibizumab and bevacizumab for eyes 
with DME and baseline visual acuity <20/50 at 1 year.  Central OCT thickness at one year decreased 
on average by 169 µm (IAI), 147 µm (ranibizumab), and 101 µm (bevacizumab) (P < .001 for both 
IAI vs. Bevacizumab and Ranibizumab vs. Bevacizumab; P=.036 for IAI vs. Ranbizumab). At 2 
years, among eyes with better baseline VA, DRCR protocol T demonstrated mean VA letter gains of 
12.8, 10, and 12.3 from baseline in the IAI, bevacizumab, and ranibizumab groups, respectively. In 
eyes with poor baseline VA, the mean letter gains at 2 years were 18.3, 13.3, and 16.1 in the IAI, 


 
bevacizumab, and ranibizumab groups, respectively demonstrating IAI superiority over 
bevacizumab, but no longer over ranibizumab as in year 1. Central OCT thickness at two years 
decreased on average by 171 µm (IAI), 149 µm (ranibizumab) and 126 µm (bevacizumab) 
demonstrating superior anatomic improvement via IAI and ranibizumab over bevacizumab (P<.001 
for IAI vs. Bevacizumab and Ranibizumab vs. Bevacizumab; P=.26 for IAI vs. Ranibizumab).  
 
With the above confirmation of the important role and efficacy of anti-VEGF therapy for DME, 
bevacizumab has evolved to be commonly used as an off-label DME therapy by retina physicians. 
Bevacizumab has been shown to potentially be efficacious for DME and is low cost and readily 
available and used by retina physicians.   
With FDA approval and availability of IAI for DME, many eyes with persistent DME after 
bevacizumab and ranibizumab, may be switched to IAI. While previous experience and smaller 
reports exist for comparing and switching from one anti-VEGF agent to another anti-VEGF agent, 
there is limited experience with switching from bevacizumab/ranibizumab to the now approved IAI. 
It is likely that a common clinical scenario for switching from previous bevacizumab/ranibizumab to 
IAI will occur in eyes with persistent DME or in eyes with resolved DME after frequent anti-vegf 
injections in an attempt to reduce frequent dosing when recurrent DME occurs.  In light of the 
DRCR T results, IAI may be optimal therapy for persistent DME after previous anti-VEGF therapy. 
 
The DRCR network protocol U has initiated a trial to assess the short-term effects of 
combination steroid+anti-VEGF therapy on retinal thickness on OCT and visual acuity in 
comparison with that of continued anti-VEGF therapy alone in pseudophakic eyes with persistent 
central-involved DME and visual acuity impairment despite previous anti-VEGF treatment. The trial 
has revised enrollment criteria as recruitment of eligible eyes has been challenging.  Thus, 
prospective and rigorous assessment of alternative therapies in eyes with persistent DME after 
previous anti- VEGF therapy may be more difficult than anticipated. 
 
We fortunately have a potential population of eyes with persistent DME enrolled in the 
ROTATE study evaluating the safety and efficacy of 0.3 mg ranibizumab in eyes with persistent 
DME after recent and frequent bevacizumab (at least 2 bevacizumab injections within 2 months of 
enrollment and at least 6 bevacizumab injections within 8 months of enrollment). In order to 
evaluate potential differences in dosing regimens  of ranibizumab after previous bevacizumab, eyes 
were randomized to 12 monthly required injections of 0.3 mg ranibizumab over 1 year or 6 monthly 
required injections of 0.3 mg ranibizumab for 6 months, followed by PRN dosing (required 


 
ranibizumab if DME persistent on OCT and ETDRS BCVA <20/20) for 6 months.  30 of 30 
anticipated eyes have been enrolled. Eyes allocated to both dosing schemes demonstrated improved 
VA at 1 year, with a mean gain of 6.7 and 6.4 letters in the PRN and Sustained groups, respectively. 
At month 12, the mean overall decrease in CST thickness was 116 m overall, with a 92 m and a 
127 m decrease in the Sustained and PRN groups, respectively. The ocular and systemic safety 
signals observed were consistent with other anti-VEGF trials in the DME population.  These eyes 
represent a unique cohort for evaluation of IAI in eyes with persistent DME after chronic, recent and 
frequent anti- VEGF therapy. In addition, the larger, prospective anti-VEGF DME studies such as 
RISE/RIDE, DRCR protocol T comparing aflibercept, bevacizumab and ranibizumab, and 
VIVID/VISTA have required a washout period of at least 3 months without anti-VEGF therapy. Our 
cohort is unique in that eyes with more recent anti-VEGF therapy can prospectively be evaluated 
when switched to another anti-VEGF agent.   
 
This cohort provided to opportunity to evaluate if IAI can improve anatomic and visual 
outcomes in eyes with persistent DME despite previous long-term bevacizumab and/or 0.3 mg or 0.5 
mg ranibizumab. In addition, improvement or maintenance of anatomic and visual outcomes will be 
evaluated with q8weeks dosing with IAI. Given the favorable IAI DRCR protocol T results at 1 year, 
as well as trends at year two especially of IAI compared to bevacizumab, evaluation of switching 
chronic DME eyes to IAI remains important. Amendment I (9 May 2016) was created to expand the 
inclusion criteria to include additional patients with persistent DME undergoing treatment with 
bevacizumab and/or ranibizumab beyond those that had been previously enrolled in the ROTATE 
trial.  
 
1.2 
Rationale 
1.2.1 
Rationale for Study Design 
There is limited prospective data evaluating visual and anatomic outcomes in eyes with 
persistent DME after recent and frequent anti-VEGF therapy.  The major DME trials have 
required lengthy washout periods and may not represent the frequent clinical scenario where 
switching to a different anti-VEGF agent is considered.  Switching to IAI will and is often 
considered given the results of DRCR protocol T as well as the less frequent recommended IAI 
dosing with q8 weeks.  The proposed study will provide important data in a prospective manner 
regarding outcomes when switching to IAI for eyes with recalcitrant DME after frequent and 
recent bevacizumab and/or ranibizumab.  


 
1.2.2 
Rationale for Dose Selection 
Phase 3 clinical trials evaluated 2 mg IAI administered every 4 weeks or every 8 weeks for 3 
years. Additionally, 2mg IAI has been approved for the treatment of choroidal 
neovascularization due to age-related macular degeneration, retinal vein occlusion and diabetic 
macular edema.  
 
2. 
STUDY OBJECTIVES 
2.1 
Primary Objective 
The primary objective is to evaluate the reduction in macular edema measured as: 
 
Proportion of eyes with baseline SD OCT CST > 350 um demonstrating >15% reduction 
at week 52 from baseline 
 
Proportion of eyes with baseline SD OCT CST < 305 um (males) and <290 um 
(females) at week 52 from baseline.  
 
2.2 
Secondary Objectives 
The secondary objectives of the study are to evaluate additional efficacy and safety outcomes listed 
below: 
 
Vision: 
o Mean change in BCVA letter score at week 4, week 12, week 20, week 24, and week 52 
o Mean BCVA letter score at week 4, week 12, week 20, week 24, and, week 52 
o Proportion of eyes with any gain (> 0 letters) at week 52, compared to baseline BCVA 
 
 
Anatomic 
o Mean change SDOCT CSF thickness and macular volume change from baseline at week 
4, week 12, week 20, week 24, and, week 52 
o Proportion of eyes with absence of fluorescein angiographic macular leakage at week 52 
o Proportion of eyes with unchanged, worsened or improved fluorescein angiographic 
macular leakage from baseline at week 20 and week 52 
o Proportion of eyes with unchanged, worsened, or improved fundus photographic DME 
grading from baseline at week 20 and week 52 
o For patients in the OCT-A substudy: 


 
 
Proportion of eyes with unchanged, worsened, or improved capillary dropout on 
Optovue OCT Angiography from baseline at week 20 and week 52.  
 
Proportion of eyes with unchanged, increased, or decreased macular capillary 
non-perfusion area of superficial and deep capillary plexus. 
 
Mean change in macular capillary non-perfusion area of superficial and deep 
capillary plexus from baseline at  week 12, week 20, week 36, and week 52.  
 
 
Treatment 
o Mean number of IAI injections from baseline to Week 52 
o Proportion of eyes not requiring rescue therapy from baseline at week 52 
 
 
Safety 
o Incidence and severity of ocular and systemic safety events through week 52 including: 
worsened acuity > 30 letters, retinal detachment, endophthalmitis, cataract progression, 
vitreous hemorrhage, new PDR or neovascularization of the iris or angle, systemic 
thromboembolic events, deaths, and systemic serious adverse events. 
 
 
3. 
STUDY DESIGN  
3.1 
Study Description and Duration  
This is a phase 4 prospective, nonrandomized, open label, interventional clinical trial. Study eyes 
will receive 5 required initial monthly IAI doses of 2 mg followed by 2q8 IAI for a total of 52 
weeks; only one study eye from each patient will be enrolled.  
 
Starting at week 20, patients may be eligible to receive additional 2mg IAI (2q4) treatment if both of 
the following criteria is met and the investigator feels additional treatment would be beneficial: 
 
Loss of >5 letters from baseline or best previously recorded BCVA 
 
Presence of new or recurrent intraretinal fluid or subretinal fluid as assessed by SD OCT 
 
Starting at week 24, rescue therapy with macular laser photocoagulation may be administered if any 
the following criteria are met  
 
Loss of > 15 letters from baseline or best previously recorded BCVA and loss of acuity felt to be 
secondary to DME and not from other cause (i.e., cataract, epiretinal membrane, vitreous 
hemorrhage, etc) and investigator feels patient would benefit from rescue therapy 


 
 
Increase in SD OCT CSF > 100 um from baseline or best previously recorded SD OCT CSF and 
investigator feels patient would benefit from rescue therapy.  
 
Panretinal photocoagulation is allowed only for the purpose of treating any new/active proliferative 
diabetic retinopathy and iris neovascularization. 
 
3.2 
Planned Interim Analysis 
No interim analysis is planned.  
 
4. 
SELECTION, WHIDRAWAL, AND REPLACEMENT OF PATIENTS 
4.1 
Number of Patients Planned 
A maximum of 30 patients will be enrolled.  
 
4.2 
Study Population 
4.2.1 
Inclusion Criteria 
A patient must meet the following criteria to be eligible for inclusion in the study: 
1. Adults > 18 years old with Type 1 or Type 2 Diabetes Mellitus 
2. Visual acuity letter score in study eye ≤ 80 and ≥ 20 (approximate Snellen equivalent  20/25  
to 20/400) 
3. Central-involved DME in study eye (OCT CSF ≥ 305 μm (males) and 290 um (females ) on 
Heidelberg Spectralis spectral domain OCT with evidence of intraretinal or subretinal fluid 
or cysts).  
4. History of at least 6 intravitreal bevacizumab and/or ranibizumab injections within the past 9 
months and 2 intravitreal bevacizumab and/or ranibizumab injections within the past 3 
months. 
5. At least 28 days, but less than 45 days since prior bevacizumab and/or ranibizumab injection 
6. No other treatment for DME, other than bevacizumab and/or ranbizumab, in the study eye at 
any time in the past 3 months (such as focal/grid macular photocoagulation, intravitreal or 
peribulbar corticosteroids or other anti-vegf agents such as macugen) 
7. No anticipated major ocular surgery within the next 6 months following randomization.  
8. Willing and able to comply with study visits and study-related procedures. 


 
9. Provide signed HIPAA statement and informed consent prior to any study procedures 
 
4.2.2 
Exclusion Criteria 
 
A patient who meets any of the following criteria will be excluded from the study: 
1. Macular edema considered to be due to a cause other than DME (ERM, Vein Occlusion, 
Postop CME, uveitis) 
2. History of PRP within 3 months prior to enrollment or anticipated need for PRP 
3. History of idiopathic or autoimmune uveitis in the study eye 
4. Cataract surgery in the study eye within 90 days of baseline 
5. Any intraocular surgery within 90 days of baseline 
6. Vitreomacular traction or epiretinal membrane in the study eye that is thought to affect 
vision 
7. Clinically significant pre-retinal fibrosis involving the macula in the study eye per 
investigator judgment 
8. Intraocular inflammation of trace or above in the study eye 
9. Evidence of active infection in either eye 
10. Uncontrolled glaucoma in the study eye defined as a pressure of > 25 on maximal medical 
therapy. 
11. Concurrent disease in the study eye, other than DME, that could compromise VA, require 
medical or surgical intervention during the study or could confound interpretation of the 
results 
12. Ocular media of insufficient quality to obtain fundus and OCT images 
13. Current treatment for a serious systemic infection 
14. Administration of systemic anti-angiogenic agents within 180 days of screen 
15. History of yag capsulotomy within 1 month prior to enrollment 
16. Receipt of any treatment for DME, other than ranibizumab and/or bevacizumab, in the study 
eye at any time in the past 3 months, (such as focal/grid macular photocoagulation, 
intravitreal or peribulbar corticosteroids or other anti-VEGF agents such as Macugen, any 
history of 2 mg IAI in the study eye is exclusionary) 
17. Any women who are pregnant, breast-feeding, or attempting to become pregnant 
18. Sexually active men* or 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) 
*Contraception is not required for men with documented vasectomy. 
**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. 
 
4.3 
Premature Withdrawal from the Study 
A patient 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 patient from the study in the event of an intercurrent 
illness, adverse event, 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 patients will be avoided. 
 
Should a patient (or a patient’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 will be followed. 
 
4.4 
Replacement of Patients 
Patients prematurely discontinued from the study will not be replaced. 
 
5. 
STUDY TREATMENTS 
5.1 
Investigational Treatment 
The study treatment is 2.0 mg IAI, which will be supplied at a concentration of 40 mg/mL solution 
for intravitreal injection in a single-use vial. The injection volume will be 50 μL (0.05 mL) and will 
be administered to the patients by intravitreal injection.   
 
Study eyes will receive 5 required initial monthly IAI doses of 2 mg followed by 2q8 IAI for a total 
of 52 weeks.  


 
 
Starting at week 20 patients may be eligible to receive additional 2mg IAI (2q4) treatment if both of 
the following criteria is met and the investigator feels additional treatment would be beneficial: 
 
Loss of >5 letters from baseline or previously best recorded BCVA 
 
Presence of new or recurrent intraretinal fluid or subretinal fluid as assessed by SD OCT 
 
Starting at week 24, rescue therapy with macular laser photocoagulation may be administered if any 
the following criteria are met  
 
Loss of > 15 letters from baseline or best previously recorded BCVA and loss of acuity felt to be 
secondary to DME and not from other cause (i.e., cataract, epiretinal membrane, vitreous 
hemorrhage, etc) and investigator feels patient would benefit from rescue therapy 
 
Increase in SD OCT CSF > 100 um from baseline or best previously recorded SD OCT CSF and 
investigator feels patient would benefit from rescue therapy.  
 
5.2 
Dose Modification and Patient Discontinuation 
5.2.1 
Dose Modification 
Dose modification for an individual patient is not allowed. 
 
5.2.2 
Patient Discontinuation 
Patients have the right to withdraw from the study at any time for any reason. 
 
The patient may be withdrawn from the study for any of the following reasons: if it is in the best 
interest of the patient, intercurrent illness, adverse events, or worsening condition. Southeast 
Retina Center of Dr. Dennis Marcus may request the withdrawal of a patient due to protocol 
violations, administrative reasons, or any other valid or ethical reason. 
 
If a patient discontinues from the study, they will not be allowed to re-enter the study. 
Reasons for patient discontinuation may include, but are not limited to: 
 
Investigator determination that it is not in the best interest of the patient to 
continue participation for any reason 
 
Pregnancy 
 
Need for alternative therapy in the study eye 


 
 
Any serious adverse event 
 
Safety concerns 
 
5.3 
Study Discontinuation 
Southeast Retina Center or Regeneron may terminate this study at any time. Reasons for 
terminating the study include, but are not limited to: 
 The incidence or severity of adverse events in this or other studies using intravitreal 
aflibercept indicating that there is a potential health hazard to patients 
 Patient enrollment is unsatisfactory 
 Data recording is inaccurate or incomplete 
 
5.4 
Treatment Logistics and Accountability 
5.4.1 
Packaging, Labeling, and Storage 
2.0 mg intravitreal aflibercept injection is formulated as a sterile liquid to a final concentration 
of 40 mg/mL intravitreal aflibercept injection in 5% sucrose, 10 mM sodium phosphate pH 6.3, 
0.03% polysorbate 20, and 40 mM NaCl. Intravitreal aflibercept 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. 
 
5.4.2 
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 used and unused vials will be returned or disposed of 
according to Regeneron IST standard operating procedures. 
 
5.4.3 
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 inspector’s 
treatment compliance. 
 
5.5 
Concomitant Medications 
5.5.1 
Study Eye 
Patients may not receive any medications (approved or investigational) for DME in the study 
eye other than the assigned study treatment (2 mg IAI) until they have completed the end of the 
study (week 52) or early termination visit.  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 eye and/or fellow eye. 
 
5.5.2 
Fellow eye 
If a patient requires anti-VEGF therapy in the fellow eye, IAI will be utilized per investigator 
discretion (IAI provided by Regeneron). Follow-up visits for study eye occur every 4 weeks for 
52 weeks. The fellow eye may receive treatment on the same day as the study eye or at an 


 
unscheduled visit but it will not be considered an additional study eye. Safety of the fellow eye 
will be monitored and all AEs will be collected. 
 
5.5.3 
Permitted Medications 
Any other medication that are considered necessary for the patient’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. 
 


 
 
6. 
STUDY SCHEDULE OF EVENTS AND VISIT DESCRIPTIONS 
Study assessments and procedures are presented below: 
 
Study Procedure 
Screening/ 
Baseline  
(Day 0) 
Weeks 4, 8, 12, 
16  
(±1 week) 
Weeks 20, 24, 28, 
32, 36, 40, 48  
(±1 week) 
Week 52  
(±2 weeks) or 
Early 
Termination 
Review Eligibility 
Criteria 
 
X 
 
 
 
Review/Sign ICF 
X 
 
 
 
Medical 
History/Demographics 
X 
 
 
 
Urine Pregnancy Test  
(if needed) 
X 
 
 
 
HbA1c 
X 
 
 
 
Vitalsa 
X 
X 
X 
X 
ETDRS BCVA 
X 
X 
X 
X 
Ophthalmic Exam 
X 
X 
X 
X 
SD-OCT and Optovue 
OCT Angiographyd 
X 
X 
X 
X 
OPTOS FA and Standard 
FP 
X 
 
Xb 
X 
Intravitreal Aflibercept 
Injection 
X 
X 
Xc 
 
Adverse Events/ 
Con Meds 
X 
X 
X 
X 
aBlood pressure, pulse, and respiration rate will be measured after the patient has been sitting for 5 minutes 
bOPTOS (Wide-Field) FA and Standard FP to be performed only at baseline, week 20, and week 52 cIAI will 
be given every 8 weeks at weeks 24, 32, 40, and 48, following administration of the 5 mandatory IAI at 
screening, weeks 4,8,12, and 16. Additional IAI can be given every 4 weeks beginning at week 20 if protocol 
defined criteria are met. dOptovue OCT Angiography to be performed at baseline, week 12, week 20, week 36, 
and week 52  only for those subjects participating in the sub-study.   
 
 
 


 
 
6.1 
Study Visit Descriptions 
6.1.1 
Screening/Baseline (Day 0) 
After the patient has provided informed consent, the following information will be collected: 
o Inclusion/exclusion criteria 
o Demographics 
o Medical and ophthalmic history and concurrent illnesses 
o Concomitant medications 
The following procedures and assessments will be conducted: 
 
HbA1c (HbA1c does not need to be repeated if available in the prior 3 
months) 
 
Urine Pregnancy Test (for women of child bearing potential) 
 
ETDRS Refraction/BCVA 
 
Ophthalmic Examination 
 
Indirect ophthalmoscopy  
 
SDOCT 
 
OPTOS (Wide-Field) FA and Standard FP  
 
Vital signs 
 
Mandatory Intravitreal Aflibercept Injection 
 
Optovue OCT Angiography (for sub-study participants only) 
 
6.1.2 
Weeks 4, 8, 12, 16 (±1 week) 
The following information will be collected: 
o Concomitant medications 
o AEs 
The following procedures and assessments will be conducted: 
o Ophthalmic evaluation 
 
ETDRS Refraction/BCVA 
 
Ophthalmic examination 
 
Indirect ophthalmoscopy 
 
SDOCT 
 
Optovue OCT Angiography at week 12 (for sub-study participants only) 
 
Vital signs 


 
 
Mandatory Intravitreal Aflibercept Injection 
 
6.1.3 
Weeks 20, 24, 28, 32, 36, 40, 44, 48 (±1 week) 
The following information will be collected: 
o Concomitant medications 
o AEs 
The following procedures and assessments will be conducted: 
o Ophthalmic evaluation 
 
ETDRS Refraction/BCVA 
 
Ophthalmic examination 
 
Indirect ophthalmoscopy  
 
SDOCT  
 
Optovue OCT Angiography at weeks 12, 20, and 36(for sub-study 
participants only) 
 
OPTOS (Wide-Field) FA and Standard FP (week 20) 
 
Vital signs 
 
Intravitreal Aflibercept Injection: 
 
Mandatory IAI will be administered at weeks 24, 32, 40, and 48 
 
*Starting at week 20 patients may be eligible to receive 
additional 2 mg IAI if predefined criteria are met and the 
investigator feels additional treatment would be beneficial 
 
6.1.4 
Week 52 (±2 weeks) or Early Termination  
The following Information will be collected 
o Concomitant medications 
o AEs 
The following procedures and assessments will be conducted: 
o Vital signs (Temperature, blood pressure, pulse, and respiration rate will be 
measured after the patient has been sitting for 5 minutes) 
o Ophthalmic evaluation 
 
ETDRS Refraction/BCVA 
 
Ophthalmic examination 
 
Indirect ophthalmoscopy 


 
 
SDOCT 
 
OPTOS (Wide-Field) FA and Standard FP 
 
Optovue OCT Angiography (for sub-study participants only)  
 
6.1.5 
Unscheduled Visits 
All attempts should be made to keep patients on the study schedule. Unscheduled visits may be 
necessary at investigator discretion. 
 
7. 
SAFETY DEFINITIONS, REPORTING, AND MONITORING 
7.1 
Definitions 
7.1.1 
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. 
 
7.1.2 
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 malignancy (other than basal cell skin cancers) would 
be considered a medically important event. 
7.2 
Recording and Reporting Adverse Events 
All AEs and SAEs will be recorded on the CRF and in the patient’s source documents. 
 
Vital sign abnormalities 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 
patients. 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.  
 
7.2.1 
Deaths 
Any AE that results in death is considered an SAE. Deaths that occur from the time the patietns 
signs the ICF until 30 days after dosing will be reported to the appropriate IRB and to Regeneron 
Pharmacovigilance and Risk Manaagement (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 
 
7.2.2 
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: 
1. Overdose: Accidental or intentional overdose of the study drug or concomitant medication, 
whether or not it is considered an AE. 
2. 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. 
 
These AEs will be reported to: 
Medical.safety@regeneron.com 
 
Fax: (914) 345-7476 
 
SAE hotline: (914) 593-1504 
 
7.2.3 
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 
 
7.2.4 
Abnormal Vital Signs 
The criteria for determining whether an abnormal objective test finding will be reported as an 
AE are as follows: 
 
the test result is associated with accompanying symptoms, and/or 


 
 
the test result requires additional diagnostic testing or medical/surgical intervention, and/or 
 
the test result leads to a change in dosing (outside of protocol-stipulated dose adjustments), 
discontinuation from the study, significant additional concomitant drug treatment, or other 
therapy. 
 
Repeating an abnormal test, in the absence of any of the above conditions, does not constitute an 
AE.  Any abnormal test result that is determined to be an error does not require reporting as an 
AE. 
 
7.2.5 
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. 
 
7.3 
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. 
If a laboratory value is considered an AE, its severity will be based on the degree of physiological 
impairment the value indicates.   
 
7.4 
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. 
 
 
8. 
STUDY VARIABLES 
8.1 
Demographic and Baseline Characteristics 
Baseline characteristics will include standard demography (age, race), disease characteristics 
including medical history and medication history for each patient. 
 
8.2 
Primary and Secondary Endpoints 
The primary endpoint is the reduction in macular edema as measured by:  
 
Proportion of eyes with baseline SD OCT CST > 350 um demonstrating > 15% 
reduction at week 52 from baseline 
 
Proportion of eyes that demonstrate SD OCT CST < 305 um (males) and <290 um 
(females) at week 52 from baseline.  
The secondary endpoints of the study are listed below: 
 
Vision: 
o Mean change in BCVA letter score at week 4, week 12, week 20,week 24, and week 52 
o Mean BCVA letter score at week 4, week 12, week 24, and, week 52 
o Proportion of eyes with any gain (> 0 letters) at week 52, compared to baseline BCVA 
 
 
Anatomic 
o Mean change SDOCT CSF thickness and macular volume change from baseline at week 
4, week 12, week 20, and, week 52 
o Proportion of eyes with absence of fluorescein angiographic macular leakage at week 52 
o Proportion of eyes with unchanged, worsened or improved fluorescein angiographic 
macular leakage from baseline at week 20 and week 52 
o Proportion of eyes with unchanged, worsened, or improved fundus photographic DME 
appearance from baseline at week 20 and week 52 
o For patients in the OCT-A substudy: 
 
Proportion of eyes with unchanged, worsened, or improved capillary dropout on 
Optovue OCT Angiography from baseline at week 20 and week 52.  


 
 
Proportion of eyes with unchanged, increased, or decreased macular capillary 
non-perfusion area of superficial and deep capillary plexus. 
 
Mean change in macular capillary non-perfusion area of superficial and deep 
capillary plexus from baseline at week 12, week 20, week 36, and week 52.  
 
 
Treatment 
o Mean number of IAI injections from baseline to Week 52 
o Proportion of eyes not requiring rescue therapy from baseline at week 52 
 
 
Safety 
 
Incidence and severity of ocular and systemic safety events through week 52 including: 
worsened acuity > 30 letters, retinal detachment, endophthalmitis, cataract progression, 
vitreous hemorrhage, new PDR or neovascularization of the iris or angle, systemic 
thromboembolic events, deaths, and systemic serious adverse events. 
 
9. 
STATISTICAL PLAN 
This is an open-label study with no formal sample size calculation.  Data from all enrolled patients 
will be analyzed.  Reports of adverse events from this  study  may  be reviewed and summarized 
periodically (anticipated every 24 weeks) while the study is ongoing to ensure the safety of patients. 
 
9.1 
Statistical Methods 
9.1.1 
Demography and Baseline Characteristics 
Age, gender, race, HbA1c, number of previous injections, BCVA, OCT thickness, presence 
or absence of OCT evidence of epiretinal membrane or vitreomacular traction will be 
collected.  OCT thickness and acuity outcomes will be reviewed with ANOVA to assess for 
any influencing baseline factors.   
 
9.1.2 
Efficacy Analysis 
9.1.2.1 
Primary Efficacy Analysis- 
Proportions will be determined.  Baseline factors and their influences will be evaluated by 
ANOVA 


 
 
Proportion of eyes with baseline SD OCT CST >350 um demonstrating >15% reduction 
at week 52 from baseline 
 
Proportion of eyes that demonstrate SD OCT CST <305um (males) and <290 um 
(females) at week 52 from baseline  
 
9.1.2.2 
Secondary Efficacy Analysis 
Proportions, mean change in ETDRS letters and OCT thickness changes will be 
determined.  Baseline factors and their influences will be evaluated by ANOVA. 
 
 Vision: 
o Mean change in BCVA letter score at week 4, week 12,week 20, week 24, and week 52 
o Mean BCVA letter score at week 4, week 12, week 20, and, week 52 
o Proportion of eyes with any gain (> 0 letters) at week 52, compared to baseline BCVA 
 
 
Anatomic: Qualitative analysis/grading will be reviewed by one observer(Principal Investigator) 
who will compare fundus photos and f/a leakage from baseline to timepoint.   
o Mean change SDOCT CSF thickness and macular volume change from baseline at week 
4, week 12, week 20, and, week 52 
o Proportion of eyes with absence of fluorescein angiographic macular leakage at week 52 
o Proportion of eyes with unchanged, worsened or improved fluorescein angiographic 
macular leakage from baseline at week 20 and week 52 
o Proportion of eyes with unchanged, worsened, or improved fundus photographic DME 
appearance from baseline at week 20 and week 52 
o For patients in the OCT-A substudy: 
 
Proportion of eyes with unchanged, worsened, or improved capillary dropout on 
Optovue OCT Angiography from baseline at week 20 and week 52.  
 
Proportion of eyes with unchanged, increased, or decreased macular capillary 
non-perfusion area of superficial and deep capillary plexus. 
 
Mean change in macular capillary non-perfusion area of superficial and deep 
capillary plexus from baseline at week 12, week 20, week 36, and week 52.  
 
 Treatment 
o Mean number of IAI injections from baseline to Week 52 
o Proportion of eyes not requiring rescue therapy from baseline at week 52 
 


 
9.1.3 
Safety Analysis 
o Incidence and severity of ocular and systemic safety events through week 52 
including: worsened acuity > 30 letters, retinal detachment, endophthalmitis, 
cataract progression, vitreous hemorrhage, new PDR or neovascularization of 
the iris or angle, systemic thromboembolic events, deaths, and systemic serious 
adverse events. 
 
9.1.4 
Interim Analysis 
An interim analysis of the data is not planned. 
 
9.2 
Statistical Considerations Surrounding the Premature Termination of a Study 
If the study is terminated prematurely, outcome measures and safety parameters will be summarized.  
  
 
10. 
STUDY MONITORING 
10.1 
Source Document Requirements 
Investigator will prepare and maintain adequate and accurate patient records (source documents). 
The investigator will keep all source documents on file with the CRF.  Case report forms and source 
documents will be available at all times for inspection by authorized representatives of the regulatory 
authorities. 
 
10.2 
Case Report Form Requirements 
A CRF for each patient enrolled in the study will be completed and signed by the study investigator 
or authorized designee. The CRF will be typed or filled out using indelible ink.  The writing will be 
legible. Errors will be crossed out but not obliterated, the correction inserted, and the change 
initialed and dated by the investigator or authorized designee. The investigator will ensure the 
accuracy, completeness, legibility, and timeliness of the data reported in the CRFs.  Case report 
forms will be available at all times for inspection by authorized representatives of the regulatory 
authorities. 
 


 
10.3 
AUDITS AND INSPECTIONS 
This study may be patient to a quality assurance audit or inspection by the regulatory authorities.  
Should this occur, the investigator will be responsible for: 
 
Informing Regeneron of a planned inspection by the authorities as soon as notification is 
received 
 
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 
Regeneron immediately 
 
Taking all appropriate measures requested by the regulatory authorities to resolve the 
problems found during the audit or inspection 
 
Documents patient 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 patient to inspection.   
In all instances, the confidentiality of the data will be respected. 
 
11. 
ETHICAL AND REGULATORY CONSIDERATIONS 
11.1 
Good Clinical Practice Statement 
It is the responsibility of 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 patient 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 patient in 


 
language that he/she can understand.  The ICF will be signed and dated by the patient and by the 
investigator or authorized designee who reviewed the ICF with the patient.   
 
Patients who can write but cannot read will have the ICF read to them before signing and dating the 
ICF. 
 
Patients 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 will be retained by the investigator as part of the patient's study record, and a copy 
of the signed ICF will be given to the patient. 
 
If new safety information results in significant changes in the risk/benefit assessment, the ICF will 
be reviewed and updated appropriately.  All study patients will be informed of the new information 
and provide their written consent if they wish to continue in the study.  The original signed revised 
ICF will be maintained in the patient’s study record and a copy will be given to the patient. 
 
11.3 
Patient Confidentiality and Data Protection 
The investigator will take all appropriate measures to ensure that the anonymity of each study patient 
will be maintained.   
 
The patient's and investigator's personal data will be treated in compliance with all applicable laws 
and regulations.   
 
11.4 
Institutional Review Board 
An appropriately constituted IRB, as described in ICH Guidelines for GCP, will review and approve:  
 
The protocol, ICF, and any other materials to be provided to the patients (e.g. advertising) 
before any patient 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 patients, in which case the 
IRB will be informed as soon as possible  
 


 
Ongoing studies will be reviewed by the IRB on an annual basis or at intervals appropriate to the 
degree of risk.  
 
In addition, the IRB will be informed of any event likely to affect the safety of patients or the 
continued conduct of the clinical study. 
 
A copy of the IRB approval letter will be sent to Regeneron prior to shipment of drug supplies to the 
investigator.  The approval letter will 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) will be kept on file by the investigator. 
 
12. 
PROTOCOL AMMENDMENTS 
The investigator will 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 
The investigator will notify Regeneron of a desire to close-out a site in writing, providing 
approximately 30 days’ notice.  The final decision will be made through mutual agreement with 
Regeneron.  Both parties will arrange the close-out procedures after review and consultation. 
 
In all cases, the appropriate IRB and Health Authorities will be informed according to applicable 
regulatory requirements, and adequate consideration will be given to the protection of the 
patients’ interests. 
 
14. 
STUDY DOCUMENTATION 
14.1 
Certification of Accuracy Data 
The investigator will sign a declaration assuring the accuracy and content of the data recorded on 
the CRFs.  This certification form accompanies each set of CRFs.  


 
 
14.2 
Retention of Records 
The investigator will retain all essential study documents, including ICFs, source documents, 
CRFs, and drug accountability records for at least 5 years following the completion or 
discontinuation of the study, or longer if a longer period is required by relevant regulatory 
authorities.  Records will be destroyed in a manner that ensures confidentiality. 
 
 
 
 
 
 
 
 
 
 
 
 
15. 
REFERENCES 
 
Antcliff RJ, Marshall J, The pathogenesis of edema in diabetic maculopathy. Semin 
Ophthalmol.1999;14(4):223-32. 
 
Callanan DG, Gupta S, Boyer DS, et. al. Dexamethasone intravitreal implant in combination 
with laser photocoagulation for the treatment of diffuse diabetic macular edema. 
Ophthalmology. 2013 Sep;120(9):184-51. 
 
Diabetic Retinopathy Clinical Research Network. A randomized trial comparing intravitreal 
triamcinolone acetonide and focal/grid photocoagulation for diabetic macular edema. 
Ophthalmology. 2008;115(9):1447-9, 9 e1-10. 
 
Diabetic Retinopathy Clinical Research Network. Three-year follow up of a randomized trial 
comparing focal/grid photocoagulation and intravitreal triamcinolone for diabetic macular 
edema. Arch Ophthalmol. 2009;127(3):245-51. 
 
Diabetic Retinopathy Clinical Research Network. Randomized trial evaluating ranibizumab 
plus prompt or deferred laser or triamcinolone plus prompt laser for diabetic macular edema. 
Ophthalmology. 2010;117(6):1064-77 e35. 
 
Diabetic Retinopathy Clinical Research Network,Scott IU Edwards A, et al. A phase II 1681 
randomized clinical trial of intravitreal bevacizumab for diabetic macular edema. 
Ophthalmal. 2007;114(10):1860-7. 


 
 
Ferris FL, 3rd, Patz A, Macular edema. A complication of diabetic retinopathy. Surv 
Ophthalmol. 1984;28(suppl)(May):452-61. 
 
Korobelnik J, Do DV, Schmidt-Erfurth U, et al. Intravitreal aflibercept for diabetic macular 
edema. Ophthalmology 2014;2247-2254 
 
Michaelides M, Kaines A, Hamilton RD, et al. A prospective randomized trial of intravitreal 
bevacizumab or laser therapy in the management of diabetic macular edema (BOLT study) 
12-month data: report 2. Ophthalmology. 2010;117(6):1078-86 e2 
 
Nguyen QD, Shah SM, Heier JS, et al. Primary end point (six months) results of the 
ranibizumab for edema of the macula in diabetes (READ-2) study. Ophthalmology. 1679 
2009;116(11):2175-81 e1. 
 
Nguyen QD, Brown DM, Marcus DM, et al. Ranibizumab for Diabetic Macular Edema: 
Results from 2 Phase III Randomized Trials: RISE and RIDE. Ophthalmology. 
2012;119(4):789-801. 
 
Diabetic Retinopathy Clinical Research Network, Wells JA, Glassman AR, Ayala AR, 
Jampol LM, Aiello LP, Antoszyk AN, Arnold-Bush B, Baker CW, Bressler NM, Browning 
DJ, Elman MJ, Ferris FL, Friedman SM, Melia M, Pieramici DJ, Sun JK, Beck RW. 
Aflibercept, Bevacizumab, or Ranibizumab for Diabetic Macular Edema. N Engl J Med. 
2015 Mar 26; 372(13): 1193–1203. DOI: 10.1056/NEJMoa1414264 (Published).  
 
Aflibercept, Bevacizumab, or Ranibizumab for Diabetic Macular Edema: Two-Year Results 
from a Comparative Effectiveness Randomized Clinical Trial. Wells JA, Glassman AR, 
Ayala AR, Jampol LM, Bressler NM, Bressler SB, Brucker AJ, Ferris FL, Hampton GR, 
Jhaveri C, Melia M, Beck RW; Diabetic Retinopathy Clinical Research Network. 
Ophthalmology.2016 Feb27.pii:S0161-6420(16)00206-2.doi: 10.1016/j.ophtha.2016.02.022. 
[Epub ahead of print] 
 
Farooq A, Frazier H, Fechter CM, Marcus WB, Singh H, Marcus DM. Ranibizumab (0.3 
mg) for Persistent Diabetic Macular Edema (DME) After Recent, Frequent, and Chronic 
Bevacizumab (ROTATE Trial). 2016; ARVO E-Abstract 2430329 


 
 
16. 
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 l (0.05 mL) for the 2 mg dose of intravitreal aflibercept injection.  
 
The required sequence of steps must be adhered to for administration of the dose in this clinical trial.  
 
Preparation (please see below regarding the optional use of topical antibiotic agents pre and post 
dose): 
a. Apply topical 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 5% povidone-iodine on the ocular surface at the intended injection site. 
d. Optional:  inject 0.5 mL of 2% xylocaine without epinephrine subjconjunctivally at the 
intended injection site; (the entry site of the needle for the intravitreous injection should be 
3.0-3.5 mm from the limbus in aphakic/pseudophakic patients, and 3.5-4.0 mm in the phakic 
patients).   
e. Single use Proparacaine bottles should be used for all patients. “Fluoracaine” or other 
combination Fluorescein Sodium and Proparacaine HCl mixtures should NOT be used. 
f. Apply additional drop of povidone-iodine to site of injection. 
 
 
Study Drug Administration: 
a. Insert needle at marked injection point.  
b. Gently inject study drug.  
c. As the needle is withdrawn, a sterile cotton tip applicator should be rolled over the entry site 
to minimize the risk of drug reflux. This should be held in place for a full 10 seconds. 
 
 
Post-Injection Procedures 
Measure patient’s IOP before the end of the observation period for each injection.  See guidelines below 
for additional post-injection management procedures.   
 
Guidelines for Pre and Post-injection Management 


 
 
Use of Topical Antibiotic Agents 
At the time of this study, the use of topical antibiotics as prophylaxis in IVT injections, both in the 
preparation and post injection varies considerably between the different practices. There is no consensus 
on the use of topical antibiotics, the agent to be used and the dose to be administered. In this protocol, it 
is recommended that a broad-spectrum topical antibiotic be used as part of the preparation for the 
intravitreal injection procedure, and as prophylaxis in the days immediately following the injection.   
 
Suggested use: 
o Instruct the patient to self-administer 1-2 drops of the antibiotic to the study eye, 3 times a 
day, for 3 days before the injection day. 
o On the injection day, as part of the preparation for injection, instill 1 drop to the eye 1 hour 
before the injection, and another drop 15 minutes before the injection.  
o After the injection, instruct the patient to self-administer 1-2 drops of the topical antibiotic to 
the injected eye, 3 times a day, for additional 3 days. 
 
 
Post-injection reperfusion of the optic nerve 
Visualize the optic nerve to verify reperfusion of the central retinal artery in the immediate post-injection 
period.  Verify intravitreal location of therapeutic agent when possible.  Verify that the retina is attached 
and that there is no new intraocular hemorrhage.  
 
 
Intraocular pressure 
Monitor intraocular pressure (IOP) before the end of the approximate 30-minute observation period post 
each injection.  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 and the patient has no light 
perception for more than 1 to 2 minutes.  Transient graying or obscuration of vision following injection, 
however, is expected and should not be treated. 
 
Paracentesis should be used only in extreme circumstances when the degree of pressure elevation poses 
an imminent and irreversible threat to vision. In the rare situation when a paracentesis is warranted, the 
IOP should be recorded both before and after the procedure. A 0.1 to 0.2 mL paracentesis may be 


 
performed at the temporal limbus using a 27-gauge or 30-gauge needle or surgical knife if judged to be 
necessary by the investigator. Record all IOP measurements in the source document and on the 
appropriate eCRF page, and related treatments in the concomitant medications section of the source 
documents and the eCRF. 
 
 
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.  
Patients should be informed that some blurring of vision is common post-injection, which is often 
described as seeing spots floating in the eye.  The floaters usually resolve after a few days or weeks.  
Patients who experience post-injection adverse events that require additional monitoring should remain 
in the clinic for longer than 30 minutes, and treated according to the investigator’s medical judgment.