Peripheral and Macular Retinal Vascular Perfusion and Leakage in DME and RVO (PERMEATE)

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

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.

Study Overview

• Status: Completed
• Conditions: Central Retinal Vein Occlusion; Diabetic Macular Edema; Retinal Vein Occlusion; Branch Retinal Vein Occlusion
• Intervention / Treatment: Drug: Aflibercept

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.

• Study Type: Interventional
• Enrollment (Actual): 31
• Phase: Phase 4

Contacts and Locations

Study Locations

• United States
  • Ohio
    • Cleveland, Ohio, United States, 44195
      • Cole Eye Institute, Cleveland Clinic

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

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.
4. E-ETDRS best-corrected visual acuity of: 20/25 to 20/400 in the study eye or Hand Motion (HM) 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) 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.
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 Descemet stripping automated endothelial keratoplasty and Descemet membrane endothelial keratoplasty 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.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: N/A
• Interventional Model: Single Group Assignment
• Masking: None (Open Label)

Number of Arms

1

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Other: Aflibercept; Monthly aflibercept for 6 months and then every other month for 6 months.	Drug: Aflibercept; Intravitreal aflibercept will be given q4 wks for 6 treatments and then q 8 weeks through month 12.; Other Names: Eylea

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Change in Panretinal Leakage Index at Month 12 From Baseline	Change in panretinal leakage index (defined as the proportion of retinal area involved in angiographic leakage) at month 12 from baseline as measured by ultra-widefield angiography (UWFA).	12 months

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Mean Change in Total Leakage Index	Mean change in total leakage index from baseline to month 6	6 months
Change in Panretinal Ischemic Index	Change in panretinal ischemic index from baseline to postoperative month 12	12 months
Change in Panretinal Ischemic Index From Baseline at 6 Months	Change in panretinal ischemic index (defined as the proportion of retinal area with nonperfusion) from baseline at 6 months	6 months
Mean Change From Baseline Central Subfield Thickness	OCT central subfield thickness change from baseline to 6 months	6 months
Mean Change From Baseline in Best-corrected Visual Acuity (BCVA) Score Based on ETDRS	Mean change from baseline in best-corrected visual acuity (BCVA) score from baseline to month 12	12 months
Number of Participants Who Gained 15 ETDRS Letters or More of Vision		12 months
Number of Patients Who Gained 15 ETDRS Letters or More of Vision		6 months
Number of Patients That Showed Visual Acuity 20/40 or Better		6 months
Number of Patients That Showed Visual Acuity 20/200 or Worse		6 months
Ocular Serious Adverse Events		12 months
Number of Participants Who Lost 15 ETDRS Letters or More of Vision		12 months
Number of Participants Who Lost 15 ETDRS Letters or More of Vision		6 months
Number of Patients That Showed Visual Acuity 20/40 or Better		12 months
Number of Patients That Showed Visual Acuity 20/200 or Worse		12 months
Mean Change From Baseline Central Subfield Thickness		12 months
Systemic Serious Adverse Events	Incidence of systemic SAEs	12 Months

Collaborators and Investigators

• Sponsor: Justis Ehlers
• Collaborators: Regeneron Pharmaceuticals
• Investigators: Principal Investigator: Justis P Ehlers, MD, Cole Eye Institute, Cleveland Clinic, OH 44195

Publications and helpful links

General Publications

• Ferrara N, Davis-Smyth T. The biology of vascular endothelial growth factor. Endocr Rev. 1997 Feb;18(1):4-25. doi: 10.1210/edrv.18.1.0287. No abstract available.
• Rakic JM, Lambert V, Devy L, Luttun A, Carmeliet P, Claes C, Nguyen L, Foidart JM, Noel 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. doi: 10.1167/iovs.02-1092.
• 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. doi: 10.1136/bjophthalmol-2011-300774. Epub 2012 Mar 15.
• 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. doi: 10.1002/jcb.240470305.
• Ferrara N. Vascular endothelial growth factor and the regulation of angiogenesis. Recent Prog Horm Res. 2000;55:15-35; discussion 35-6.
• Thickett DR, Armstrong L, Millar AB. Vascular endothelial growth factor (VEGF) in inflammatory and malignant pleural effusions. Thorax. 1999 Aug;54(8):707-10. doi: 10.1136/thx.54.8.707.
• 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. doi: 10.1097/IAE.0000000000000148.
• Figueiredo N, Srivastava SK, Singh RP, Babiuch A, Sharma S, Rachitskaya A, Talcott K, Reese J, Hu M, Ehlers JP. Longitudinal Panretinal Leakage and Ischemic Indices in Retinal Vascular Disease after Aflibercept Therapy: The PERMEATE Study. Ophthalmol Retina. 2020 Feb;4(2):154-163. doi: 10.1016/j.oret.2019.09.001. Epub 2019 Sep 10.

Study record dates

Study Major Dates

• Study Start (Actual): August 18, 2015
• Primary Completion (Actual): February 6, 2018
• Study Completion (Actual): February 6, 2018

Study Registration Dates

• First Submitted: July 17, 2015
• First Submitted That Met QC Criteria: July 20, 2015
• First Posted (Estimate): July 21, 2015

Study Record Updates

• Last Update Posted (Actual): May 12, 2021
• Last Update Submitted That Met QC Criteria: May 10, 2021
• Last Verified: May 1, 2021

More Information

Terms related to this study

• Keywords: diabetic macular edema; macular edema; rvo
• Additional Relevant MeSH Terms: Cardiovascular Diseases; Vascular Diseases; Eye Diseases; Retinal Degeneration; Retinal Diseases; Embolism and Thrombosis; Venous Thrombosis; Thrombosis; Macular Degeneration; Macular Edema; Retinal Vein Occlusion; Edema; Physiological Effects of Drugs; Antineoplastic Agents; Angiogenesis Inhibitors; Angiogenesis Modulating Agents; Growth Substances; Growth Inhibitors; Aflibercept
• Other Study ID Numbers: 15-442

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO