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Ophthalmology Volume 119, Number 9, September 2012

from the previous best-corrected visual acuity mea-surement with any increase in CRT on OCT. Webelieve that it would have been more appropriate ifboth groups had similar criteria for retreatment.

2. Another point was that Figure 3 shows that the 34%gain in visual acuity by �15 letters at 6 months wasseen only in the groups receiving 0.5 mg every 4weeks and 0.2 mg every 4 weeks, whereas it was17% in the groups receiving 0.2 mg every 8 weeksand 27% in the groups receiving 2 mg for 3 initialdoses then as needed as compared with 21% in themacular laser arm. VEGF Trap-Eye is reported tohave a longer duration of action compared with otheranti VEGF agents.2 However, it appears that itsefficacy is maintained only if the injections are givenat 4 weekly intervals.

Thus, while we agree with the authors regarding thebeneficial effects of VEGF Trap-Eye in DME, we have ourdoubts regarding the duration of its action.

MUDIT TYAGI, MSANNIE MATHAI, MSHyderabad, India

References

1. Do DV, Schmidt-Erfurth U, Gonzalez VH, et al. The DAVINCI study: phase 2 primary results of VEGF trap-eye inpatients with diabetic macular edema. Ophthalmology 2011;118:1819–26.

2. Gaudreault J, Fei D, Rusit J, et al. Preclinical pharmacokinet-ics of ranibizumab (rhuFabV2) after a single intravitreal ad-ministration. Invest Ophthalmol Vis Sci 2005;46:726–33.

Author reply

Dear Editor:We appreciate the interest in our recent publication re-garding the primary endpoint results of the DA VINCIStudy, which evaluated VEGF Trap-Eye (aflibercept) fordiabetic macular edema (DME). As Drs. Tyagi andMathai have noted, the retreatment criteria was differentfor those eyes randomized to macular laser comparedwith VEGF Trap-Eye. The intention of the retreatmentcriteria was to allow investigators ample opportunity toretreat eyes that still had DME. For those eyes assignedto macular laser, allowing retreatment according to theEarly Treatment Diabetic Retinopathy Study (ETDRS)tried to encourage investigators to apply the maximumamount of laser to those study eyes, rather than just applylaser for center-involved DME.

Regarding Figure 3, which illustrated the proportionof eyes that gained �15 letters at month 6, we agree thatin this study population, the every 4 weeks (q4week)dosing was more likely to produce �15 letters improve-ment compared with the every 8 weeks dosing (q8week).However, we would like to point out a few key points: (1)the DA VINCI study was a phase II clinical trial, and itwas not powered to evaluate a difference between thedifferent doses and dosing regimens of VEGF Trap-Eye;and (2) there may have been some baseline differences

among those randomized to the q4week dosing vs the l

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8week dosing because these groups behaved differentlyn the number of ETDRS letters gained from baselinehrough week 8 although they received a similar dose andosing frequency of VEGF Trap Eye (Fig 2). Because ofhese important 2 points, we cannot conclude yet whetherr not the q8week dosing is inferior to the q4week dosingf VEGF Trap-Eye.

We eagerly await the results of phase III clinical trials ofEGF Trap-Eye to further evaluate the efficacy and safetyf VEGF Trap-Eye for DME.

DIANA V. DO, MDON BEHALF OF THE DA VINCI STUDY INVESTIGATORS

Baltimore, Maryland

ersistent Fetal Vasculature

ear Editor:e note with interest the article by Lambert et al1 “Con-

enital fibrovascular pupillary membranes.” We have seen aimilar case with vascular anomalies of the iris, retina, andrbit in a 2-year-old white girl. Her previous medical historyas unremarkable, and she had a normal delivery to non-

onsanguineous parents. There was no strabismus and vi-ual acuities were 20/40 in each eye. Cycloplegic refractionas �5.00 diopters (D) right eye (OD) and left eye (OS)8.00D/�3.00D � 90. There was no proptosis, anterior

rbital mass, pulsatility, iris heterochromia, or scleral di-ated vessels. Examination under general anesthesia re-ealed normal intraocular pressures, left microcornea (hor-zontal corneal diameters 12 mm OD and 9 mm OS), theeft pupil did not dilate as well; and the iris had arominent vessel at the 9 o’clock position with otherrominent vessels circumnavigating the pupil (Fig 1,vailable at http://aaojournal.org). Fluorescein angio-ram highlighted the prominent iris vessels, traversinghe pupil (Fig 2, available at http://aaojournal.org). Theeft fundus revealed markedly tortuous retinal arterial andenous vessels (Fig 3, available at http://aaojournal.org)ncluding the peripheral minor branches. The macula andetina were otherwise normal, without leakage on fluo-escein angiography, and B mode ultrasound showed nother structural abnormality and the axial lengths were 21m OD and 22.2 mm OS. Although interestingly, the left

ye had microcornea. There was no other systemic ab-ormality on examination.

A magnetic resonance angiogram (MRA) demonstratedormal intracranial appearance, with no evidence of vascu-ar malformations. There were abnormal, enlarged vesselsithin the left orbit. At the intraconal superomedial corner,

here was a serpiginous cystic mass, with evidence of flown MRA sequences. This was closely related to the opticerve, but did not involve it. There was a second, similar,xtraconal abnormality in the inferomedial orbit (Fig 4,vailable at http://aaojournal.org), with an abnormalridging vessel communicating with the more superioresion. The left superior and inferior ophthalmic veinsere enlarged. The lesions had the features of a lymphatic-

rteriovenous malformation. The presence of flow within the

esion suggests that it is the vascular component that predom-