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To compare the efficacy and safety of three first-line anti-vascular endothelial growth factor (anti-VEGF) agents: ranibizumab, aflibercept, and conbercept in the treatment of diabetic macular edema (DME). This retrospective, non-randomized comparative study included DME patients treated at the Sanmenxia Eye Hospital between December 2019 and November 2024. Patients were divided into three groups based on the intravitreal agent received. All patients received an initial series of monthly intravitreal anti-VEGF injections for the first three months, followed by a pro re nata (PRN) regimen. Primary outcomes were the change in best-corrected visual acuity (BCVA) and central subfield macular thickness (CSMT) at 1 week, and 1, 3, 6, and 12 months. Secondary outcomes included DME recurrence rates and injection frequency. All three groups showed significant improvements in BCVA at 3 months (p < 0.05). By 6 months, the improvement in BCVA in the aflibercept and conbercept groups was significantly greater than in the ranibizumab group (p < 0.05). The conbercept group was associated with a significant reduction in CSMT compared to the ranibizumab group as early as 1 month (p < 0.05). At 6 months, CSMT reduction was significantly greater in both the aflibercept and conbercept groups compared to the ranibizumab group (p < 0.01). All regimens demonstrated a favorable safety profile. In this retrospective cohort, aflibercept and conbercept were associated with greater improvements in visual and anatomical outcomes compared to ranibizumab. Aflibercept was associated with greater visual acuity improvement at 6 months, while conbercept was associated with an earlier reduction in macular thickness. These findings support individualized treatment strategies for DME.