Polypoidal Choroidal Vasculopathy in Asians

One-year real-world outcomes of ranibizumab 0.5 mg treatment in Taiwanese patients with polypoidal choroidal vasculopathy: a subgroup analysis of the REAL study

AIM

To assess the effectiveness and safety of ranibizumab 0.5 mg in Taiwanese patients with polypoidal choroidal vasculopathy (PCV) by performing a retrospective exploratory subgroup analysis of the REAL study.

METHODS

REAL was a 12-month, observational, prospective, non-interventional phase IV post-marketing surveillance study conducted at 9 centers in Taiwan. The study collected data as part of the routine patient visits from the medical records of patients with neovascular age-related macular degeneration treated with ranibizumab 0.5 mg according to local standard medical practice and local label and/or reimbursement guidelines. The presence of PCV at baseline was determined using indocyanine green angiography.

RESULTS

At baseline, PCV was diagnosed in 64 of the 303 enrolled patients (21.1%). Of these, 41 patients (64.1%) had received prior treatment; 15 (23.4%) patients had received ranibizumab. The intent-to-treat population included 58 patients; 47 (80%) who received ranibizumab and 11 (20%) who received ranibizumab plus photodynamic therapy (PDT; 9 patients received once, 2 patients received twice). Bevacizumab was used as a concomitant medication in a similar percentage of patients who received ranibizumab (43%, n=20) or ranibizumab plus PDT (45%, n=5). In patients who received ranibizumab, visual acuity (VA) at baseline was 50.1±12.9 Early Treatment Diabetic Retinopathy Study letters, and the gain at month 12 was 1.1±17.8 letters. In patients who received ranibizumab plus PDT, VA at baseline was 51.4±15.9 letters, and there was a marked gain in VA at month 12 (14.0±9.2 letters, P=0.0009). In the intent-to-treat population, the reduction in central retinal subfield thickness from baseline at month 12 was 69.6±122.6 µm (baseline: 310.8±109.8 µm, P=0.0004). The safety results were consistent with the well-characterized safety profile of ranibizumab.

CONCLUSION

In real-world settings, ranibizumab 0.5 mg treatment for 12mo results in maintenance of VA and reduction in central retinal subfield thickness in Taiwanese patients with PCV. Improvements in VA are observed in patients who received ranibizumab plus PDT. There are no new safety findings.

The Use of Vascular Endothelial Growth Factor Inhibitors and Complementary Treatment Options in Polypoidal Choroidal Vasculopathy: A Subtype of Neovascular Age-Related Macular Degeneration

Polypoidal choroidal vasculopathy (PCV) is a subtype of neovascular age-related macular degeneration (AMD; nAMD) which occurs more commonly in Asian populations as compared to Caucasians. PCV and nAMD share pathological mechanisms, including pathological expression of vascular endothelial growth factor (VEGF). The advent of anti-vascular endothelial growth factor (VEGF) revolutionized the treatment of nAMD. Despite being a subtype of nAMD, PCV responds less well to VEGF inhibitors; thus, photodynamic therapy (PDT) in combination with anti-VEGF treatment may be considered. This review aims to summarize the current evidence for the treatment of PCV, especially whether VEGF inhibitors should be used alone or in combination with PDT.

Etiologies and Characteristics of Choroidal Neovascularization in Young Chinese Patients

PURPOSE

To investigate the etiologies and characteristics of choroidal neovascularization (CNV) in young Chinese patients.

METHODS

A retrospective review of young Chinese patients (< 50 years of age) with CNV from January 2010 to June 2016 was performed.

RESULTS

Of the 501 patients (537 eyes) with CNV, 58.7% were female, and 7.2% had bilateral CNV. The mean age was 35 years. The etiologies were idiopathic CNV (ICNV, 43.9%), pathologic myopia (PM, 21.9%), punctate inner choroidopathy (PIC, 17.4%), polypoidal choroidal vasculopathy (4.4%), multifocal choroiditis with panuveitis (3.6%), and other disorders (8.8%). Five hundred and six CNVs (94.2%) showed a predominantly classic CNV composition on fundus fluorescein angiography (FFA) and 316 CNVs (96.6%) were type 2 CNV on optical coherence tomography (OCT).

CONCLUSION

The etiologies of CNV in young Chinese patients were diverse, and ICNV, PM, and PIC were the three most common etiologies. Most CNVs were classic on FFA and type 2 on OCT.

Presenting characteristics and prevalence of polypoidal choroidal vasculopathy in Scandinavian patients with treatment-naïve exudative age-related macular degeneration

PURPOSE

To study presenting characteristics and prevalence of polypoidal choroidal vasculopathy (PCV) in Scandinavian Caucasians with treatment-naïve exudative age-related macular degeneration (AMD).

METHODS

We reviewed all patients referred in year 2014 and diagnosed using fundus examination, optical coherence tomography, and fluorescein and indocyanine green angiography (ICGA). Details of found PCVs and its subtypes (clinical and angiographical) were correlated to the baseline best-corrected visual acuity (BCVA).

RESULTS

Of 299 Caucasian patients with a tentative diagnosis of exudative AMD, 18 eyes of 17 patients (5.7%, CI 95%: 3.5-9.1%) had PCV. Patients with PCV were 75.8 (SD: 7.5) years old and 11 (65%) were females. Lesions were predominantly extramacular. Most eyes (56%) had subretinal haemorrhage, 39% had the exudative type and one (6%) eye had the quiescent type. Larger lesion area and disruption of the foveal inner-segment/outer-segment layer correlated with worse baseline BCVA. Polypoidal choroidal vasculopathy (PCV) type 1 was present in 50% and PCV type 2 in the other 50%. Polypoidal choroidal vasculopathy (PCV) type 1 was associated with a worse baseline BCVA and greater lesion size.

CONCLUSION

Polypoidal choroidal vasculopathy (PCV) is not a rare condition in Danes with exudative AMD and presents often extramacular and with haemorrhage. This study underscores the importance of ICGA as a part of the diagnostic repertoire in AMD and suggests its routine use in Scandinavian populations.

Time trends, disease patterns and gender imbalance in the top 100 most cited articles in ophthalmology

We analysed the 100 top cited articles in ophthalmology to identify and characterise the most influential articles of the past four decades. Two independent investigators searched the Scopus database to determine the 100 most frequently cited articles in ophthalmology (T100-Eye) and general non-ophthalmology journals (T100-Gen) published from 1975 to December 2017. The T100-Eye list consisted of 83 original articles and 17 reviews, and the number of citations ranged from 582 to 2833. Seventy-eight of these articles were published in three journals alone (impact factor (IF): 5.05-8.2), led by the Archives of Ophthalmology The T100-Gen list consisted of 84 original articles and 16 reviews and the number of citations ranged from 358 to 3272. Forty-five of these articles were published in four journals alone (IF: 9.66-72.41). In both lists, majority of the first authors were from the USA (T100-Eye, n=80; T100-Gen, n=66), and were men (n=76 in T100-Eye; n=72 in T100-Gen). With regard to the article type, in the T100-Eye, among the 83 original research articles, most were randomised controlled trials (n=26) or clinical observational studies related to description of a new condition or new management (n=26). In the T100-Gen, of the 84 original research articles, many were clinical observational studies (n=27) or basic science research (n=26). In both lists, the most frequently examined diseases were age-related macular degeneration, diabetic retinopathy and glaucoma. Our analysis reveals landmark articles, trends and medical advancements in ophthalmology over the past four decades. It also highlights gender disparity and influence of the USA in seminal ophthalmic research.

IMPROVING THE AGE-RELATED MACULAR DEGENERATION CONSTRUCT: A New Classification System

Previous models of disease in age-related macular degeneration (AMD) were incomplete in that they did not encompass subretinal drusenoid deposits (pseudodrusen), subtypes of neovascularization, and polypoidal choroidal vasculopathy. In addition, Type 3 neovascularization starts in the retina and may not necessarily involve the choroid. As such, the term choroidal neovascularization is not appropriate for these eyes. The new aspects in the AMD construct are to include specific lipoprotein extracellular accumulations, namely drusen and subretinal drusenoid deposits, as early AMD. The deposition of specific types of deposit seems to be highly correlated with choroidal thickness and topographical location in the macula. Late AMD includes macular neovascularization or atrophy. The particular type of extracellular deposit is predictive of the future course of the patient. For example, eyes with subretinal drusenoid deposits have a propensity to develop outer retinal atrophy, complete outer retinal and retinal pigment epithelial atrophy, or Type 3 neovascularization as specific forms of late AMD. Given Type 3 neovascularization may never involve the choroid, the term macular neovascularization is suggested for the entire spectrum of neovascular disease in AMD. In contrast to older classification systems, the proposed system encompasses the relevant presentations of disease and more precisely predicts the future course of the patient. In doing so, the concept was developed that there may be genetic risk alleles, which are not necessarily the same alleles that influence disease expression.

Comparison of the effects of photodynamic therapy, intravitreal ranibizumab and combination for polypoidal choroidal vasculopathy under 1 + PRN regimen

Background

The optimal treatment for polypoidal choroidal vasculopathy (PCV) is still under debate. Little knowledge is known about the treatment effect of “1+pro re nata(PRN)” treatment regimen for PCV. The aim of this study was to compare the outcomes of photodynamic therapy (PDT), intravitreal ranibizumab injection (IVR) and combination therapy under the “1 + PRN” treatment regimen for PCV.

Methods

Fifty-seven eyes of 57 patients completed the 12 months’ follow-up in this prospective study. The patients in the PDT arm(n = 23), ranibizumab arm(n = 18), or combination arm(n = 16) underwent a session of PDT, IVR or combination of both at baseline followed by additional IVR as needed. Mean change of logarithm of the minimal angle of resolution (logMAR) visual acuity (VA), central foveal thickness (CFT) and the regression rate of polyps were evaluated. Cost-benefit analysis was also performed.

Results

At Month 12, the mean logMAR VA improved from 0.90 ± 0.52 to 0.75 ± 0.57 in the PDT group (P < 0.05), from 0.96 ± 0.58 to 0.77 ± 0.41 in the IVR group (P < 0.05), and from 0.94 ± 0.55 to 0.72 ± 0.44 in the combination group (P < 0.05), respectively. The CFT decreased from 478.04 ± 156.70 μm, 527.5 ± 195.90 μm, and 522.63 ± 288.40 μm at the baseline to 366.43 ± 148.28 μm, 373.17 ± 134.88 μm and 328.44 ± 103.25 in the PDT group (P < 0.05), IVR group (P < 0.01), and the combination group (P < 0.05), respectively. However, no statistical difference was found between groups (P > 0.05). PDT treatment (60.87%) was superior to the IVR therapy (22.22%) in achieving complete regression of polyps (P < 0.05). Cost-benefit analysis showed that IVR treatment cost the least money for improving per 0.1logMAR units and the combination therapy demanded the least money for reducing per 100 μm of CFT.

Conclusions

PDT, IVR and the combination therapy have similar efficacy in the VA improvement as well as the reduction of CFT under the “1 + PRN” treatment regimen.

Trial registration

Current Controlled Trials NCT03459144. Registered retrospectively on March 2, 2018.

Homocysteine and risk of age-related macular degeneration: a systematic review and meta-analysis

There is still no agreement on total plasma homocysteine (tHcy) role in age-related macular degeneration (AMD), the leading cause of new blindness in industrialized countries. We performed a systematic review and meta-analysis of the published data on the correlation between tHcy and AMD. MEDLINE/PubMed and ISI Web of Sciences searches were performed according to MOOSE guidelines. Case-control studies were eligible for inclusion. Participants and controls were AMD patients and subjects without AMD. The main outcome measure was wet AMD. Homocysteine level was the main exposure variable. Data were pooled using a random-effects model. Twelve case-control studies were identified: 10 assessed wet AMD, four dry AMD, one early AMD, one late AMD, and one any AMD. As for wet AMD, there was a total of 453 cases and 514 controls. Mean tHcy was on average 1.1 μmol/l (95% confidence interval [CI] = 0.96-1.25) greater in wet AMD cases, but there was evidence of extreme between-study heterogeneity (p < 0.001, I²  = 91.8%). In a model homogenous for age, including six wet AMD studies (214 cases, 274 controls), mean tHcy was on average 0.58 μmol/l (95% CI = 0.35-0.73) greater in the case group, a not statistically significant result (p = 0.144) associated with moderate heterogeneity (I²  = 39.2%). Our meta-analysis indicates that there is some weak evidence that increased tHcy might be associated with wet AMD; however, this result should be interpreted cautiously, because of a marked between-study heterogeneity and the possible effect of publication bias. Future studies, preferably of cohort design, are necessary before any firm conclusions on the putative role of increased tHcy on AMD can be drawn.

Treat and Extend Dosing Regimen with Anti-vascular Endothelial Growth Factor Agents for Neovascular Age-related Macular Degeneration

Anti-vascular endothelial growth factor (anti-VEGF) agents are the mainstay of therapy for treatment of neovascular age-related macular degeneration (nvAMD), one of the leading causes of blindness in the developed world. There have been a variety of different treatment regimens that have been examined for the administration of anti-VEGF therapies, including continuous fixed dosing, pro re nata administration, and treat and extend (TAE) protocols. There is no clear consensus on which dosing regimen optimizes visual and anatomical outcomes while accounting for factors such as cost and patient burden. Based on recent surveys in 2014 and 2017 by the American Society of Retina Specialists (ASRS), the majority of ophthalmology providers are utilizing TAE protocol for anti-VEGF dosing for the management of nvAMD. Although there are a number of clinical trials that have examined TAE dosing, the ALTAIR study is the first, large, prospective randomized controlled trial to compare two different TAE protocols utilizing the anti-VEGF agent aflibercept for nvAMD. The ALTAIR study, in conjunction with other previous clinical trials, suggests that TAE protocol with aflibercept is an effective anti-VEGF dosing regimen for patients with nvAMD as it produces good visual gains and minimizes cost and burden for the patient.

Prevalence and treatment patterns of ranibizumab and photodynamic therapy in a tertiary care setting in Malaysia

AIM

To describe the prevalence and changes in treatment patterns of ranibizumab and photodynamic therapy (PDT) among retinal disease patients who attended the Ophthalmology Clinic in the tertiary care Hospital Selayang from 2010 to 2014.

METHODS

Study subjects were recruited retrospectively using the Electronic Medical Record (EMR) database software in Hospital Selayang. Demographic data, medical history, diagnostic procedure, treatments and diagnosis of patients were recorded.

RESULTS

The five-year analysis included 821 patients with a mean age of 65.9±11.73y. Overall, there were a higher number of males (63.1%) and a higher number of Chinese (47.4%) patients. Among the 821 patients, 62.9% received ranibizumab injection followed by 19.2% PDT therapy and 17.9% had ranibizumab combined with PDT therapy. Age-related macular degeneration (AMD) and polypoidal choroidal vasculopathy (PCV) were the most common retinal eye diseases reported, recording prevalence of 25.0% and 45.6%, respectively. The trend in ranibizumab treatment was reported to increase while PDT showed a decrease in trend from year 2010 to 2014. In terms of treatment, following multiple logistic regression, AMD was associated with the subjects being more likely to have received ranibizumab monotherapy (P<0.001) while PCV was associated with more likely to have received PDT (P<0.001) and PDT combined with ranibizumab therapy (P<0.001).

CONCLUSION

The tertiary care setting in Malaysia is consistent with management of patients from other countries whereby ranibizumab is the most common treatment given to patients with AMD, while PCV patients most commonly receive PDT and ranibizumab combined with PDT therapy.

Valsalva-Related Subretinal Hemorrhage as a Presenting Symptom of Polypoidal Choroidal Vasculopathy

Purpose

To describe a case of Valsalva-related subretinal hemorrhage as a presenting symptom of polypoidal choroidal vasculopathy (PCV). The patient refrained from treatment against our best advice, and thus this is also a rare case of the natural course of an untreated PCV.

Methods

Case report.

Results

A 66-year-old female with a respiratory infection coughed intensely until exhaustion, after which she developed visual symptoms on the right eye. Primary care ophthalmologist examined the patient on the same day of the onset of symptoms and referred her to our tertiary medical retinal service for detailed retinal diagnosis including fluorescein and indocyanine green angiography. The right eye had a large subretinal hemorrhage and pigment epithelium detachment in the lower temporal arcade with foveal involvement. Against our best advice, the patient refused treatment. In the following 9 months, the BCVA decreased from 68 to 55 ETDRS letters, the subretinal hemorrhage almost regressed, pigment epithelium detachments persisted, and macular edema, intraretinal cysts, and subretinal fibrosis developed.

Conclusions

Although classic Valsalva retinopathy with preretinal hemorrhage in most cases can be managed by careful observation and no treatment, this case demonstrates that Valsalva-related subretinal hemorrhage needs different attention and approach.

Updates on the Epidemiology of Age-Related Macular Degeneration

This meta-analysis reports on current estimates of the prevalence of age-related macular degeneration (AMD) based on a review of recent meta-analyses and literature research. Within an age of 45-85 years, global prevalences of any AMD, early AMD, and late AMD were 8.7% [95% credible interval (CrI), 4.3‒17.4], 8.0% (95% CrI, 4.0‒15.5), and 0.4% (95% CrI, 0.2-0.8). Early AMD was more common in individuals of European ancestry (11.2%) than in Asians (6.8%), whereas prevalence of late AMD did not differ significantly. AMD of any type was less common in individuals of African ancestry. The number of individuals with AMD was estimated to be 196 million (95% CrI, 140‒261) in 2020 and 288 million (95% CrI, 205‒399) in 2040. The worldwide number of persons blind (presenting visual acuity < 3/60) or with moderate to severe vision impairment (MSVI; presenting visual acuity < 6/18 to 3/60 inclusive) due to macular disease in 2010 was 2.1 million [95% uncertainty interval (UI), 1.9‒2.7] individuals out of 32.4 million individuals blind and 6.0 million (95% UI, 5.2‒8.1) persons out of 191 million people with MSVI. Age-standardized prevalence of macular diseases as cause of blindness in adults aged 50+ years worldwide decreased from 0.2% (95% UI, 0.2‒0.2) in 1990 to 0.1% (95% UI, 0.1‒0.2) in 2010; as cause for MSVI, it remained mostly unchanged (1990: 0.4%; 95% UI, 0.3‒0.5; 2010: 0.4%; 95% UI, 0.4‒0.6), with no significant sex difference. In 2015, AMD was the fourth most common cause of blindness globally (in approximately 5.8% of blind individuals) and third most common cause for MSVI (3.9%). These data show the globally increasing importance of AMD.

Dual-stage deep learning framework for pigment epithelium detachment segmentation in polypoidal choroidal vasculopathy

Worldwide, polypoidal choroidal vasculopathy (PCV) is a common vision-threatening exudative maculopathy, and pigment epithelium detachment (PED) is an important clinical characteristic. Thus, precise and efficient PED segmentation is necessary for PCV clinical diagnosis and treatment. We propose a dual-stage learning framework via deep neural networks (DNN) for automated PED segmentation in PCV patients to avoid issues associated with manual PED segmentation (subjectivity, manual segmentation errors, and high time consumption).The optical coherence tomography scans of fifty patients were quantitatively evaluated with different algorithms and clinicians. Dual-stage DNN outperformed existing PED segmentation methods for all segmentation accuracy parameters, including true positive volume fraction (85.74 ± 8.69%), dice similarity coefficient (85.69 ± 8.08%), positive predictive value (86.02 ± 8.99%) and false positive volume fraction (0.38 ± 0.18%). Dual-stage DNN achieves accurate PED quantitative information, works with multiple types of PEDs and agrees well with manual delineation, suggesting that it is a potential automated assistant for PCV management.

Aflibercept for recurrent or recalcitrant polypoidal choroidal vasculopathy in Indian eyes: Early experience

Treatment guidelines for symptomatic polypoidal choroidal vasculopathy (PCV) have been described, but the management of recurrent or recalcitrant PCV is a challenge. The newer anti-vascular endothelial growth factor: aflibercept has shown promise in the treatment of both treatment naive and recalcitrant PCV in studies outside India. We present the minimum 6 months results of intravitreal aflibercept in recurrent and recalcitrant PCV in Indian eyes after multiple injections of bevacizumab/ranibizumab with or without photodynamic therapy. Of 10 eyes, 7 resolved of which 4 recurred needing continued aflibercept. Three of the ten eyes did not show a response. To the best of our knowledge, this is the first report from India in this challenging situation.

The impact of typical neovascular age-related macular degeneration and polypoidal choroidal vasculopathy on vision-related quality of life in Asian patients

AIMS

To determine the impact of neovascular age-related macular degeneration (nAMD) on vision-related quality of life (VRQoL) in an Asian population.

METHODS

In this cross-sectional study, 162 subjects with nAMD from the Asian AMD Phenotyping Study and 105 randomly sampled age-matched and gender-matched controls from the population-based Singapore Chinese Eye Study were recruited. nAMD was categorised as either polypoidal choroidal vasculopathy (PCV) or 'typical' AMD (tAMD). The reading, mobility and emotional well-being subscales of the impact of vision impairment (IVI) scale were validated using Rasch analysis and used as the main outcome measures and collectively referred to as VRQoL. Multivariate linear regression analyses were performed to assess the impact of nAMD overall, and PCV and tAMD subtypes, on the three IVI domains.

RESULTS

Of the 162 with nAMD, 103 (63.6%) had PCV and 59 (36.4%) had tAMD. In multivariate models, nAMD overall was independently associated with a 21% reduction in reading (β=-1.08; CI -1.58 to -0.57); 16% reduction in mobility (β=-0.74; -1.14 to -0.33) and 44% reduction in emotional well-being (β=-2.15; -2.83 to -1.47) compared with controls. There were significant VRQoL deficits (p<0.05) associated with both PCV and tAMD; these deficits were similar and not statistically different between the two nAMD subtypes (p>0.05).

CONCLUSIONS

Neovascular AMD, including both PCV and tAMD subtypes, has a detrimental impact on VRQoL in Asian subjects independent of level of vision impairment. Interventions to increase reading capacity, enhance mobility and independence and improve mental health outcomes for subjects with neovascular AMD further address the impact of the condition on VRQoL in addition to pharmacological therapies.

Resistance to anti-VEGF therapy in neovascular age-related macular degeneration: a comprehensive review

As a progressive chronic disease, age-related macular degeneration (AMD) is the leading cause of irreversible vision impairment worldwide. Experimental and clinical evidence has demonstrated that vascular endothelial growth factor (VEGF) plays a vital role in the formation of choroidal neovascularization. Intravitreal injections of anti-VEGF agents have been recommended as a first-line treatment for neovascular AMD. However, persistent fluid or recurrent exudation still occurs despite standardized anti-VEGF therapy. Patients suffering from refractory or recurrent neovascular AMD may develop mechanisms of resistance to anti-VEGF therapy, which results in a diminished therapeutic effect. Until now, there has been no consensus on the definitions of refractory neovascular AMD and recurrent neovascular AMD. This article aims at clarifying these concepts to evaluate the efficacy of switching drugs, which contributes to making clinical decision more scientifically. Furthermore, insight into the causes of resistance to anti-VEGF therapy would be helpful for developing possible therapeutic approaches, such as combination therapy and multi-target treatment that can overcome this resistance.

A New Variant of Polypoidal Choroidal Vasculopathy With Annular Pigmentary Changes in Haitian Males

The authors report a new variant of idiopathic polypoidal choroidal vasculopathy (IPCV) in middle-aged Haitian men characterized by extramacular polypoidal lesions and bilateral extensive pigmentary alterations in the posterior pole in an annular wreath-like pattern surrounding the optic nerve and macular area. Two patients were seen at Massachusetts Eye and Ear Infirmary and one at Boston University Medical Center between 2010 and 2015. All three patients were middle-aged Haitian men who exhibited bilateral features of IPCV, including subretinal hemorrhages and serosanguinous pigment epithelial detachments. Indocyanine green angiography revealed extramacular polypoidal lesions located mostly along the major vascular arcades. Extensive pigmentary alterations were evident in the posterior pole surrounding the macula and optic nerve in an annular wreath-like pattern. These cases further expand the clinical spectrum of IPCV.

Treatment of Exudative Age-related Macular Degeneration: Focus on Aflibercept

A formulation of aflibercept for intravitreal injection (Eylea) is approved for the treatment of patients with exudative age-related macular degeneration (AMD). Aflibercept has a significantly higher affinity for Vascular endothelial growth factor (VEGF)-A compared with other monoclonal anti-VEGF antibodies. In addition to binding all VEGF-A isoforms, aflibercept also blocks other proangiogenic factors such as VEGF-B and placental growth factor. The VIEW 1 and 2 trials showed this drug achieves improved results in patients with exudative AMD similar to those obtained with monthly ranibizumab, using a bimonthly treatment regimen after a loading dose of three intravitreal injections, which translates to less use of healthcare resources. There is a subgroup of patients that present with persistent fluid after the loading dose that could benefit from monthly injections or personalized proactive treatment after the first year. In the second year of treatment, the Treat and Extend patterns can permit even more lengthening of the time between injections. More data are needed to confirm the optimal monitoring and retreatment dosing, to maintain long-term efficacy. Other preliminary data suggest that patients that do not respond to other anti-angiogenics and patients with special pathologies such as polypoidal choroidopathy or retinal angiomatous proliferation can improve upon switching to aflibercept. To date, the safety profile of aflibercept is excellent and is comparable to other anti-angiogenic treatments.