Studies have demonstrated that OCT-guided pro re nata dosing strategies seem to be as beneficial as fixed monthly regimens. This treatment approach allows for patient-specific dosing for maintenance of visual acuity while using the fewest doses possible. In real-world clinical practice, however, the impact of this OCT approach and visual acuity changes on physicians’ retreatment decisions with anti-VEGF is still unclear. To address this, a recent study evaluated the association between OCT markers of lesion activity and visual acuity changes in patients receiving anti-VEGF therapy for nAMD and how both factored into retreatment decisions.

The retrospective, noncomparative, nonrandomized cohort study included EHR data from 1,190 patient eyes with nAMD at two sites in the United Kingdom. The researchers selected two subcohorts of 321 (Group A) and 301 (Group B) eyes for analysis.

In Group A, an absence of intraretinal or subretinal fluid at two or more clinical visits led to a gain of five ETDRS letters from baseline, while this same finding in eyes with fewer than two visits resulted in a gain of only two letters.

The researchers noted that anti-VEGF treatment was administered at 421 clinic visits, while 308 visits included no treatment. Comparing treatment and nontreatment clinic visits, they found that the maximum difference in frequency of OCT markers of lesion activity were for intraretinal fluid (24% vs. 5%) and subretinal fluid (32% vs. 5%). In 58% of treatment visits, pigment epithelial detachment was reported, compared with 36% of nontreatment visits.

Additionally, visual acuity loss represented the lowest difference between injection and non-injection visits, as it was present in 63% of treatment vs. 49% of nontreatment visits; the researchers concluded that visual acuity loss was not a consistent trigger for retreatment.

“These findings are in agreement with previous studies reporting that the presence of intraretinal fluid at baseline and during treatment is detrimental to vision,” the researchers wrote in their paper. “Furthermore, EURETINA guidelines highlight that baseline presence of intraretinal fluid is a predictor of poor visual acuity outcomes following anti-VEGF treatment.”

They concluded that retreatment decision was most strongly influenced by the presence of intraretinal and subretinal fluid and less by pigment epithelial detachment or visual acuity loss. “In this context, we observed that a record of presence of retinal fluid was at least fourfold more likely to be present at an injection visit compared with a non-injection visit, indicating that these two OCT markers of lesion activity are key drivers for physicians to order anti-VEGF retreatment. This means that physicians base their decision to inject not only on VA decline, but also on the presence of fluid, as suggested by many clinical guidelines.”

Chakravarthy U, Pillai N, Syntosi A, et al. Association between visual acuity, lesion activity markers and retreatment decisions in neovascular age-related macular degeneration. Eye (Lond). 2020;34(12):2249-56.