Anti-VEGF Therapy

CNV lesions do not recede or disappear with anti-VEGF therapy, however they do demonstrate less leakage on fluorescein angiography [78]. In general, the size of these lesions is stabilized with continued treatment. Treated eyes also demonstrate less fibrosis and decreased retinal thickness on OCT. Such improvements in anatomical outcomes have been demonstrated in CNV lesions of various clinical phenotypes and reflect the functional outcomes achieved in the pivotal MARINA and ANCHOR trials [78]. Currently, monthly intravitreal anti-VEGF injections remain the gold standard for neovascular AMD. Yet, due to the relatively invasive nature of fluorescein angiography and its potential adverse effects, it is generally not performed on a frequent basis by most treating physicians. Instead, OCT is commonly used to monitor the status of a patient (Fig. 4.10).

Not surprisingly, the treatment burden imposed by monthly injections has prompted a myriad of investigations into the efficacy of various alternative dosing regimens. The current norm in clinical practice with ranibizumab or bevacizumab is to implement an initiation/induction phase followed by an individualized maintenance phase that is modeled after one of two basic approaches: PRN [79–81] or treat and extend [82], which involves treating a patient at every visit, but extending the follow-up duration in the absence of exudation on OCT. However, the ideal evi- dence-based alternative treatment strategy remains elusive. This topic and other treatment approaches will be discussed in more detail in subsequent chapters.

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