Anti-VEGF Agents for Visual Acuity and Choroidal Thickness
Aflibercept has demonstrated the ability to both improve visual acuity and reduce choroidal thickness in patients with neovascular age-related macular degeneration, with specific evidence showing significant reduction in central macular thickness while maintaining vision gains.
Visual Acuity Outcomes
Both aflibercept and ranibizumab demonstrate comparable visual acuity improvements in neovascular AMD:
Aflibercept produces mean visual acuity gains of approximately 4-5 letters at 12 months, with vision maintained at baseline levels through 4 years of treatment 1, 2.
Ranibizumab achieves similar visual acuity improvements of approximately 7 letters at 12 months in treat-and-extend regimens, though the difference between the two agents is not statistically significant (P = 0.06) 3.
In direct comparative studies, the difference in visual acuity outcomes between ranibizumab and aflibercept is negligible (0.6 letters; P = 0.76), with both agents requiring similar injection frequencies 2.
Choroidal Thickness Reduction
Aflibercept specifically demonstrates significant anatomic benefits with measurable reduction in choroidal thickness:
Aflibercept produces an average decrease in central macular thickness of 65 μm after just 3 monthly injections (P = 2.9 × 10⁻⁶), even in eyes previously resistant to bevacizumab or ranibizumab 4.
Thicker baseline choroid is a positive predictive factor for better long-term visual outcomes with aflibercept treatment 1.
Aflibercept reduces subretinal or intraretinal fluid in 50% of treatment-resistant cases, with fluid remaining stable in an additional 41.7% of eyes 4.
Clinical Algorithm
For patients requiring both visual acuity improvement AND choroidal thickness reduction:
Initiate aflibercept as first-line therapy, given its demonstrated dual benefit on both visual acuity and anatomic outcomes 1, 4.
Begin with 3 monthly loading doses, then transition to treat-and-extend regimen 3.
For treatment-resistant cases previously managed with ranibizumab or bevacizumab, switching to aflibercept provides anatomic benefit in approximately 92% of cases (either improvement or stabilization) 4.
Important Caveats
Baseline predictive factors matter significantly:
The presence of intact external limiting membrane, absence of vitreoretinal adhesion, and thicker baseline choroid predict better 4-year outcomes with aflibercept 1.
Both agents require ongoing treatment to maintain gains, as switching to as-needed regimens results in incremental visual acuity loss 5.
The mean injection burden is similar between agents (approximately 7-9 injections in year one, with 8 additional injections over the subsequent 3 years) 3, 1, 2.