Recommended Treatment Plan for Polypoidal Choroidal Vasculopathy Responding to Aflibercept
Continue aflibercept therapy with regular monitoring, as this patient has demonstrated clear clinical benefit with functional vision improvement from 20/60 to 20/30 after failing bevacizumab, and aflibercept has proven efficacy in treating polypoidal choroidal vasculopathy with 67-91% of patients achieving polyp regression and fluid resolution. 1, 2
Treatment Continuation Strategy
Maintain aflibercept injections using a treat-and-extend or pro re nata (PRN) protocol after the initial loading phase, as this patient has already demonstrated excellent response. 3
Initial maintenance approach: Continue monthly injections for 4-6 months total (including the loading doses already given), then transition to an as-needed regimen with monthly OCT monitoring. 4, 5
Treatment intervals: Once disease stability is achieved (no fluid on OCT, stable vision), extend intervals gradually by 2-week increments up to a maximum of 8-12 weeks between injections. 3, 1
Retreatment criteria: Resume injections if there is worsening vision, increased central macular thickness on OCT, or recurrence of subretinal fluid. 4, 5
Monitoring Protocol
Monthly follow-up visits are essential during the maintenance phase to detect early recurrence and optimize injection frequency. 5, 1
At each visit assess: Best-corrected visual acuity, OCT for subretinal fluid and retinal thickness, and clinical examination for hemorrhage. 1, 2
Indocyanine green angiography: Consider repeat imaging at 6-12 months to document polyp regression, which occurs in 67% of aflibercept-treated eyes. 1, 2
OCT-guided decision making: The presence or absence of fluid on spectral-domain OCT should guide treatment decisions rather than fixed intervals. 3
Evidence Supporting Aflibercept in PCV
The clinical evidence strongly supports continuing aflibercept in this patient:
Vision stabilization: In the EPIC study, 91% of PCV patients maintained or improved vision with aflibercept, with mean gain of 2.76 ETDRS letters at 6 months. 1
Anatomic improvement: Subretinal fluid resolved in 72% of eyes, subretinal hemorrhage in 75%, and retinal pigment epithelial detachment improved in 87% of cases. 1
Polyp regression: A Caucasian population study demonstrated 62% polyp disappearance with significant +13 letter BCVA gain at 28 weeks using aflibercept monotherapy. 2
Response after other anti-VEGF failure: Aflibercept produces marked improvement in persistent polyps and retinal pigment epithelial detachments even in eyes previously treated with ranibizumab and bevacizumab. 1
Rationale for Not Switching Agents
Do not switch to another anti-VEGF agent when aflibercept is working effectively. This patient's excellent response (20/60 to 20/30 vision improvement with fluid resolution) indicates aflibercept is the appropriate medication. 1, 2
Switching from a successful therapy risks losing disease control, as demonstrated by cases requiring return to aflibercept after attempting other agents. 6
Aflibercept has superior binding affinity for VEGF compared to bevacizumab and may be more effective in PCV, which is why this patient responded after bevacizumab failure. 7
Long-Term Expectations
Expect to continue treatment indefinitely, as PCV is a chronic condition requiring ongoing anti-VEGF therapy to maintain disease control. 3, 1
Injection burden: Most patients require bimonthly (every 8 weeks) maintenance after the loading phase, with 71% achieving this interval in clinical trials. 1
Recurrence risk: Even with complete fluid resolution, 87.7% of eyes experience at least one recurrence requiring retreatment during long-term follow-up. 3
Vision prognosis: The functional improvement from legally impaired (20/60) to near-normal (20/30) vision can be maintained with continued therapy, but permanent vision loss may occur if treatment is discontinued. 1, 2
Common Pitfalls to Avoid
Do not discontinue therapy prematurely when the retina appears dry on OCT, as PCV has high recurrence rates and requires ongoing surveillance. 3, 6
Avoid fixed dosing intervals: Rigid every-8-week dosing without OCT assessment may result in either overtreatment or missed recurrences. Use OCT-guided individualized intervals instead. 3
Monitor for treatment fatigue: If fluid recurs despite monthly aflibercept, consider more frequent monitoring rather than switching agents, as 59.4% of apparent non-responders to aflibercept simply require continuous therapy. 7
Document medical necessity: Maintain detailed records of OCT findings, visual acuity measurements, and clinical response to support ongoing treatment authorization, particularly given the off-label use in PCV. 5