The Diabetic Retinopathy Clinical Research Network Intravitreous Anti-VEGF Treatment for Prevention of Vision Threatening Diabetic Retinopathy in Eyes at High Risk Investigator Training Slides 1.0 [Protocol version 1.0] 11

Background  Eyes with severe NPDR are at high risk for DR worsening and subsequent VA loss 52% develop PDR over 1 year 60% develop PDR with HRC over next 5 years 2

5% 10% 0% Years P=0.43 P= P (Interaction) = No clear treatment mandate for severe NPDR although some eyes may benefit from early PRP Deferred Scatter Early Scatter Type 1 Type 2 Background Risk of Severe Visual Loss or Vx Ferris F. Early photocoagulation in patients with either type I or type II diabetes. Trans Am Ophthalmol Soc. 1996;94:

More Recent Data: DRCR.net Trial Laser Groups (DME at baseline) 4

DRCR.net Protocol I: Comparison to Anti-VEGF Treated Eyes 5

3 fold higher risk in sham group Cumulative probabilities calculated using the Kaplan-Meier method. Progression was defined by (1) progression from NPDR (DR severity level 0 at a later time point, (4) cases identified by ophthalmoscopy, (5) vitrectomy, (6) iris neovascularization AE, or (7) retinal neovascularization AE. 1 month = 30 days. AE, adverse event; PRP, panretinal photocoagulation. RISE/RIDE: Risk of PDR Outcomes in Sham vs Ranibizumab Groups Time to First Progression to PDR Outcome Months

PRP: Panretinal Photocoagulation IAI: Intravitreal Aflibercept Injection Proportion of Patients Requiring PRP From Baseline to Week 100 VIVIDVISTA Proportion of patients

DME Development  Eyes with severe NPDR and no CI-DME at baseline are also at risk for developing DME requiring anti-VEGF treatment 15% in ETDRS developed CI-DME on photos by 2 years  DRCR.net Protocol R included eyes with non-CI DME and any level of retinopathy and 14% developed CI-DME on OCT or required treatment by 1 year 8

Primary Objective Observation (sham injections) 9 To determine safety and efficacy of prompt anti-VEGF versus observation in eyes presenting with severe NPDR and no CI-DME for prevention of vision threatening outcomes Intravitreous anti-VEGF Primary outcome: Proportion of eyes that develop PDR/PDR-related outcomes or center-involved DME causing visual acuity loss at 2 years

Follow-Up and Treatment Overview  Total duration: 4 years Primary outcome: 2 years for anatomic outcome – if anatomic benefit through 2 years, continue follow-up through 4 years to determine if VA benefit too  Visits at 1, 2, and 4 months; every 4 months thereafter  Injections (intravitreous or sham) required at each of the above visits through 2 years  Thereafter, evaluate at each visit for retreatment: If eye is “Mild NPDR” or better, defer injection If “Moderate NPDR” or worse, injection is required 10

Composite Primary Outcome: Part 1 – PDR  Development of NV within the 7 modified ETDRS fields on fundus photography or FA, confirmed by Reading Center  NVI, NVA, or NVG on clinical exam  Traction retinal detachment, vitreous hemorrhage, or pre-retinal hemorrhage presumed to be from PDR, documented on fundus photography or FA  PRP, anti-VEGF, or vitrectomy for PDR, images should be obtained prior to treatment 11

Composite Primary Outcome: Part 2 – DME  Center-involved DME on clinical exam with ≥10% increase in central subfield thickness from baseline and visual acuity loss, defined as: 1) at least 10 letter VA loss at a single visit, or 2) 5 to 9 letter VA loss at 2-consecutive visits, presumed to be from DME  Treatment for DME performed without meeting above criteria (protocol deviation) Note: An eye will be considered to have met the primary outcome if any one of the above PDR or DME criteria are met 12

Outcome Estimates  Anti-VEGF group Based on Protocol I and RIDE/RISE data, we estimate ~ 15% of eyes in this study that receive the study anti-VEGF regimen will develop PDR/DME outcome.  Observation (Sham) group Based on available data from Protocols A, B, I, we estimate ~ 30% of eyes in this study that receive no treatment will develop PDR/DME outcome. SAMPLE SIZE  386 eyes (193 per group) 13

Long-Term Objectives  If there is a clinically important difference identified among the treatment groups for the primary outcome at 2 years, the study will also evaluate whether increased chance of prevention of PDR/DME with anti-VEGF at 2 years results in long-term beneficial visual outcomes at 4 years. 14

Rationale  The application of anti-VEGF therapy earlier in the course of disease could help to reduce future potential treatment burden in patients, at the same time resulting in similar or better long- term visual acuity outcomes.  If this study demonstrates that anti-VEGF treatment is effective and safe in the setting of severe NPDR, a new strategy to prevent vision- threatening complications will be available for patients. 15

Major Inclusion/Exclusion Criteria in Study Eye  Severe NPDR (ETDRS level 53) according to investigator rule oSevere hemorrhages in at least 4 quadrants, or oDefinite venous beading in at least 2 quadrants, or oModerate IRMA in at least 1 quadrant  VA letter score 20/25 or better  No CI-DME using standard OCT thresholds  No history of DME/DR treatment in prior 12 months and <4 prior injections at any time  No prior PRP 16

Determining Eligibility Using Standard Photos  “All 4 midperipheral quadrants show severe hemorrhages or microaneurysms (at least as great as Standard photograph 2a, approximately 20 dot and blot hemorrhages” 17 Link to “Standard photograph 2a” will be available on website

Standard Photos  OR “At least 2 fields of definite venous beading in the midperipheral quadrants, at least as severe as Standard photograph 6A” 18 Link to “Standard photograph 6a” will be available on website

Standard Photos  OR “At least 1 field of moderate intraretinal microvascular abnormalities (IRMA) in the midperipheral quadrants, at least as severe as Standard photograph 8A” 19 Link to “Standard photograph 8a” will be available on website

DR Level Confirmation  At Screening Visit, investigator must confirm eye has severe NPDR on photos and no PDR within the 7-modified ETDRS fields on FA or clinical exam  The FA and photos must be uploaded immediately for Reading Center grading  The Reading Center will confirm eligibility prior to randomization Expected turnaround within 1 week  If eligible, the Randomization Visit must occur within 35 days of Screening Visit 20

Use of Wide-Field Imaging  Sites should use OPTOS if available at baseline Presence of NV outside of the 7-modified ETDRS fields will NOT be an exclusion.  If a new OPTOS machine is obtained during follow-up, images should then be taken for ALL participants enrolled at that site using the widest approach now available Peripheral NV outside the 7 modified ETDRS fields will not meet the primary outcome and generally should not be treated unless high risk–will be evaluated in secondary outcomes  Note: Heidelberg UWF device not permitted at this time 21

Randomization Reminder  Before submitting the Randomization Visit, the investigator MUST Confirm eligibility Confirm patient’s willingness to accept either assignment and to complete all treatment/follow-up Be available to perform the injection (intravitreous or sham) THAT DAY  Educate patient with a thorough ICF process so that they understand: Time commitment Treatment requirements 22

Assessment Visits 23 First 2 Years: Injections given at every visit Baseline (0) Month 1 Month 2 Month 4 Month 8 Month 12 Month 16 Month 20 Month 24 Month 28 Month 32 Month 36 Month 40 Month 44 Final Visit (48M) ≥2 Years: Injections given if worse than mild NPDR

When are photos/FA required?  At 4-month visit and annually Reading Center will perform a masked assessment of whether primary endpoint has been met  If initiating PDR or DME treatment and primary endpoint not previously confirmed by RC at one of the time points above Note: Images will not be sent as soon as early NV detected There is concern with unmasked investigators detecting NV earlier in the sham group than in the anti-VEGF group, this approach is intended to minimize such potential bias  To document TRD, VH, or PRH for primary endpoint 24

Intravitreous Injection Procedure 25  Two individuals must confirm the study eye and drug number against the printout or website  Mark the eye for injection  Apply topical anesthetic Subconjunctival anesthetic may only be given if topical anesthetic is not sufficient to minimize discomfort  Place the lid speculum  Apply povidone iodine directly over and surrounding the injection site DRCR.net injections must NOT be given without the use of povidone iodine in any circumstance  Pre- and post-injection topical antibiotics should NOT be used (prior discussion with Protocol Chair or her designate will be required prior to use)

Endophthalmitis Rates by Antibiotic Use 26 24,052* Intravitreal Injections (2,596 eyes) 24,052* Intravitreal Injections (2,596 eyes) 9 Cases of Endophthalmitis 9 Cases of Endophthalmitis 3 (0.02%) Without Topical Antibiotics 3 (0.02%) Without Topical Antibiotics 6 (0.06%) With Topical Antibiotics 6 (0.06%) With Topical Antibiotics *Excluding injections given without povidone iodine (13 injections in 2 eyes) P = 0.19

Evolution of Antibiotic Use in DRCR.net Over Time 27 If you are in the 34% and are planning to participate in this protocol and still are uncomfortable omitting antibiotics, please discuss with Network leadership

Povidone-Iodine Use 28 24,065 Intravitreal Injections (2,598 eyes) 24,065 Intravitreal Injections (2,598 eyes) 13 injections (2 eyes) without Povidone-Iodine (protocol violation) 13 injections (2 eyes) without Povidone-Iodine (protocol violation) 100% of eyes developed endophthalmitis 100% of eyes developed endophthalmitis

Sham Injection Procedure  Same procedure as intravitreous injection, including: Confirming/marking the study eye Apply topical anesthetic (subconj should not be used) Place the lid speculum Apply povidone iodine directly over and surrounding the injection site (allowing sufficient time for the povidone iodine to dry) oSham injections must NOT be given without the use of povidone iodine in any circumstance  A syringe without a needle will be used, with the hub pressed against the conjunctival surface to simulate the force of an actual injection 29

Successful Sham Masking  In DRCR.net Protocol I, participants with 1 study eye (N = 423)  The majority receiving sham thought they were receiving real injections 30 Participant Response to type of injections Sham Group Ranibizumab Groups IVT Group Always Real 72%88-90%55% Sometimes real /sometimes sham 18%7-12%44% Always Sham 10%0-4%1%

Bilateral Injections  2 study injections Perform all required injection procedures on the right eye first before initiating any pre-injection prep of the left eye. Study drug for the left eye should not be in the room before completing all right eye injection procedures.  One non-study injection Perform all required injection procedures on the study eye before initiating any pre-injection prep of the non-study eye. Study drug for the non-study eye should not be in the room before completing all study eye injection procedures. 31

PDR/DME Treatment During Follow-Up  It is expected that many eyes will require PDR or DME treatment at some point during follow-up ~15% to 30% in the first 2 years are estimated to meet PDR/DME endpoint  Standardizing the criteria to treat and the treatment itself will allow us to better evaluate long-term visual acuity outcomes for the two treatment strategies (prevention vs. observe and treat) 32

 Treatment for PDR must not be given unless: 1.The eye has high-risk characteristics: oNVD greater than standard photograph 10A (1/4 to 1/3 disc area) or oAny NVD with pre-retinal or vitreous hemorrhage or oNVE greater than ½ disc area with pre-retinal or vitreous hemorrhage 2.The eye has VH requiring treatment that is presumed to be from PDR PDR Treatment Criteria 33

PDR Treatment Criteria  If high-risk criteria not met, RC confirmation of the primary endpoint (NV within 7-modified fields) should be obtained prior to initiating treatment whenever possible.  Treatment for NVE outside of the 7 modified fields without the presence of pre-retinal or vitreous hemorrhage is discouraged. If the investigator believes treatment for peripheral NV is necessary, protocol chair review is required. 34

Treatment for PDR  PDR treatment will include intravitreous anti- VEGF using DRCR.net Protocol S algorithm 3 q4-week injections Then each eye will be categorized into one of the following 5 scenarios: 35 CategoryInjectionPRP ResolvedAt investigator discretionNo Improved from last injection RequiredNo Stable Required 1 st 2 times stable; then at investigator discretion No Not fully treated (worsening) RequiredNo Failure/FutilityAt investigator discretionYes

DME Criteria and Treatment  Treatment for CI-DME must not be given until the primary endpoint for DME has been met:  CI-DME on clinical exam with ≥10% increase in central subfield thickness from baseline and: 1) at least 10 letter VA loss at a single visit, or 2) 5 to 9 letter VA loss at 2 consecutive visits.  Once the above endpoint has been met, must use DRCR.net Anti-VEGF Regimen for DME: Continue q4w injections as long as there is improvement or worsening No injection if stable after 2 consecutive injections and either “success” or >24w from initial injection Resume injection if worsen after withholding injection 36

PDR/DME Treatment Visits 37 Baseline (0) Month 1 Month 2 Month 4 Month 8 Month 12 Month 16 Month 20  Once PDR or DME treatment is initiated, visits are every 4 weeks for first 6 months and then follow-up can be extended if injections no longer needed  Assessment Visits must still be completed on schedule 1 st PDR Injection Month 21 Month 22 Month 23 Month 24 Month 25 Month 26 Month 27 Month 28 Month 32

DRCR.net Website  Like all DRCR.net trials, the website will help guide you through follow-up, including: Assessing eligibility (standard photos provided) Assessing primary outcome (reminders when imaging is needed) Criteria to initiate treatment PDR or DME Retreatment criteria once initiated Visit schedule 38

The Diabetic Retinopathy Clinical Research Network Only YOU can prevent vision loss! 3939