Comparative Effectiveness of Intravitreal Bevacizumab, Ranibizumab, and Aflibercept in Diabetic Retinopathy Management

Background: Anti-vascular endothelial growth factor (anti-VEGF) therapy is the standard first-line treatment for vision-threatening diabetic macular edema and selected severe diabetic retinopathy phenotypes, but comparative outcomes among bevacizumab, ranibizumab, and aflibercept remain clinically important in resource-variable settings. Aim: To compare functional, anatomic, and short-term safety outcomes following intravitreal bevacizumab, ranibizumab, and aflibercept in diabetic retinopathy requiring anti-VEGF treatment. Methods: A journal-style comparative cohort draft was structured for Government Medical College & Hospital, Bettiah, West Champaran, Bettiah, Bihar, India, over 1st March 2025 to 20th February 2026, using a synthetic dataset of 150 patients (50 per treatment arm) to model a realistic anti-VEGF comparison. Outcomes included ETDRS visual acuity, central macular thickness (CMT), responder rates, injection burden, and ocular adverse events over 6 months. Results: Baseline demographic and ocular characteristics were comparable among groups. By month 6, mean ETDRS gain was 10.22 ± 4.12 letters with bevacizumab, 11.45 ± 3.13 with ranibizumab, and 15.38 ± 3.31 with aflibercept (p<0.001). Mean CMT reduction was 142.00 ± 42.66 µm, 156.22 ± 35.60 µm, and 200.39 ± 30.12 µm, respectively (p<0.001). Dry-macula rates were 26.0%, 44.0%, and 74.0%, and persistent DME rates were 80.0%, 62.0%, and 34.0%, respectively (both p<0.001). No case of endophthalmitis occurred. In multivariable analysis, aflibercept independently predicted greater 6-month visual gain than bevacizumab. Conclusion: All three anti-VEGF agents improved visual and anatomic outcomes, but aflibercept showed the strongest short-term efficacy with lower injection burden, while bevacizumab remained a plausible lower-cost option. This manuscript is an illustrative draft and requires replacement with verified institutional data before submission.