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Clinical Case Report: Treatment of Neovascular Age-Related Macular Degeneration
A 72-year-old male patient presented in January 2024 to our ophthalmology clinic complaining of progressive central vision distortion and diminished visual acuity in his right eye over the past two months. The patient’s medical history was unremarkable except for systemic hypertension, which was well-controlled with therapy. Upon examination of his ocular history, it was noted that the patient had previously undergone treatment for neovascular age-related macular degeneration (nAMD) in his left eye, though the lesion was currently quiescent. Importantly, the right eye was treatment-naive at the time of presentation.
15/01/24: Baseline
At baseline, the patient’s visual acuity was 60 ETDRS letters in the right eye. Comprehensive imaging studies were performed on both eyes. The retinal photography of the right eye revealed the presence of drusen and pigmentary alterations in the macular region, together with signs of subretinal fluid suggestive for MNV type 1 (figure 1). The presence of MNV was confirmed by the angio-oct scan (figure 2). The left eye showed evidence of previous treatment with some residual pigmentary changes but no active exudation (figure 3).
Fluorescein angiography (FA) of the right eye demonstrated an active subfoveal choroidal neovascular membrane with characteristic early hyperfluorescence and progressive leakage in the late phases, confirming the diagnosis of neovascular AMD (figure 4). The left eye showed staining of the previous neovascular lesion without evidence of active leakage, confirming its quiescent state (figure 5).
Optical coherence tomography (OCT) of the right eye revealed significant subretinal fluid accumulation and fibrovascular PEDs. A well-defined hyperreflective lesion corresponding to the choroidal neovascular membrane was clearly visible beneath the retinal pigment epithelium. Central retinal thickness was markedly increased at 425 μm. In contrast, OCT imaging of the left eye showed hyperreflective lesion consistent with neovascular complex without signs of active exudation, with a central retinal thickness of 275 μm, reflecting the quiescent nature of the previously treated lesion.
Based on the clinical and imaging findings, a diagnosis of treatment-naive neovascular AMD in the right eye was established. The patient was treated with intravitreal anti-VEGF therapy with Aflibercept 2 mg following a treat-and-extend regimen. Initially, a loading dose consisting of three consecutive monthly injections was administered to the right eye (January 15, February 12, and March 12, 2024).
07/05/2024: First IVT after loading phase (8 weeks interval)
Following completion of the loading dose and adhering to the treat-and-extend protocol, the first post-loading injection was administered 8 weeks after the last loading injection. The patient showed remarkable functional and anatomical improvement. Visual acuity in the right eye improved to 68 ETDRS letters. OCT imaging revealed significant reduction in subretinal fluid, with central retinal thickness decreasing to 320 μm. The hyperreflective choroidal neovascular lesion remained visible but demonstrated substantially reduced activity (figure 6). Based on the excellent response with no signs of disease activity, the treatment interval was extended to 10 weeks for the next injection.
16/07/2024: IVT at 10-week interval
After 10 weeks, further improvement was noted. Visual acuity in the right eye increased to 76 ETDRS letters. OCT showed continued significant reduction in subretinal fluid with progressive resolution of the fluid accumulation. Central retinal thickness further decreased to 295 μm (figure 7). Given the sustained good therapeutic response with no recurrence of fluid, the treatment interval was extended to 12 weeks.
08/10/2024: IVT at 12-week interval
After 12 weeks, the patient maintained stable visual acuity at 78 ETDRS letters. OCT imaging revealed almost complete resolution of subretinal fluid, with central retinal thickness stabilized at 285 μm. Given this favorable anatomical response with continued disease quiescence, the treatment interval was extended to 14 weeks as per the treat-and-extend protocol (figure 8).
14/01/2025: IVT at 14-week interval
After 14 weeks, the patient’s vision remained stable at 78 ETDRS letters. OCT showed a dry macula with no recurrence of fluid and stable central retinal thickness at 280 μm. Based on the sustained anatomical improvement and disease stability, the treatment interval was extended to 16 weeks (figure 9)
20/05/2025: Final follow-up visit (15 weeks after last injection)
At this follow-up visit, 15 weeks after the last injection, the patient maintained excellent visual acuity at 80 ETDRS letters. OCT continued to show a dry macula with stable central retinal thickness at 278 μm and no signs of disease recurrence. The patient was scheduled for the next injection at 16 weeks from the previous treatment (28/05/2025).
Discussion
This case exemplifies the efficacy of the treat-and-extend regimen in managing neovascular AMD in a treatment-naive eye. The patient demonstrated significant anatomical improvement as evidenced by OCT imaging, accompanied by substantial visual gain from baseline (60 to 80 ETDRS letters). The progressive extension of treatment intervals from the initial 8 weeks post-loading to a planned 16-week interval, without disease recurrence, illustrates successful disease control while minimizing treatment burden. The protocol was correctly implemented by starting with 8-week intervals after the loading phase, rather than shorter intervals, which allows for proper evaluation of disease stability and optimal extension of treatment intervals. Close monitoring with regular OCT imaging proved instrumental in guiding treatment decisions and optimizing visual outcomes in this patient. At the final follow-up in May 2025, the patient maintained excellent disease control with stable vision and dry macula, demonstrating the long-term efficacy of the treat-and-extend approach (figure 10).