Ten‐Year Incidence, Risk Factors and Progression Rate of Macular Atrophy in Neovascular Age‐Related Macular Degeneration

Background To evaluate the 10‐year cumulative incidence, progression rates, and risk factors for macular atrophy (MA) in neovascular age‐related macular degeneration (nAMD) patients receiving long‐term anti‐vascular endothelial growth factor (VEGF) therapy. Methods Retrospective, multicenter, cohort study including 148 eyes from 140 nAMD patients treated with a pro‐re‐nata (PRN) anti‐VEGF regimen and followed for ≥ 10 years. Annual multimodal imaging—including blue autofluorescence [BAF], spectral‐domain optical coherence tomography [SD‐OCT] and near‐infrared reflectance—was reviewed to detect and quantify MA using RegionFinder. Kaplan–Meier analysis estimated cumulative MA incidence, while mixed‐effects Cox and linear regressions identified risk factors and progression rates. Results Baseline MA prevalence was 23.0%, increasing to 64.9% at 5 years and 79.8% at 10 years. Foveal involvement occurred in 47.4% of cases. Significant predictors for MA included baseline BCVA < 20/40 (HR = 1.50, p = 0.02), greater central subfield thickness (CST) fluctuations (HR = 1.04, p = 0.01), and more frequent submacular haemorrhages (HR = 1.34, p = 0.04). Type 3 macular neovascularization was associated with fovea‐involving MA (HR = 2.03, p = 0.02). Mean MA size increased from 0.34 to 2.27 mm at 10 years, progressing at 0.20 mm/year ( β = 0.15, p < 0.001). Eyes with incident MA exhibited faster progression ( β = 0.03, p = 0.01) and worse BCVA decline compared to those with baseline MA (−1.96 vs. −1.42 letters/year, p < 0.001). Conclusions nAMD patients treated with PRN anti‐VEGF therapy demonstrated a high 10‐year cumulative incidence of MA (79.8%), with poor baseline BCVA and CST fluctuations as key risk factors. Eyes with incident MA progressed faster and were associated with greater visual decline, suggesting a more visually impactful atrophy.