Aflibercept, ranibizumab, and bevacizumab for macular neovascularization secondary to age-related macular degeneration: a retrospective OCT-angiography study

Intravitreal aflibercept, ranibizumab, and bevacizumab represent the three most widely used anti-VEGF agents for the treatment of neovascular age-related macular degeneration (AMD). The objective of this study is to compare the loading phase effects of these three agents on the macular neovascularization (MNV) area and flow in treatment-naïve eyes affected by neovascular AMD, utilizing optical coherence tomography angiography (OCTA). Eighty-four neovascular AMD eyes from eighty-four patients were included in this retrospective study. Twenty-five patients were treated with aflibercept, thirty-four with ranibizumab, and twenty-five with bevacizumab within the initial loading phase preceding a treat-and-extend regimen. All patients underwent a three-monthly injection loading phase and were evaluated at baseline and one month after the loading phase. Best-corrected visual acuity (BCVA), central retinal thickness (CRT), MNV area, and MNV flow area were assessed. MNV parameters were measured using the device-integrated "Flow Area" tool and ImageJ software. Average baseline BCVA and CRT were 0.60 ± 0.22 logMAR and 343 ± 46 μm, respectively, and did not differ between groups. All three anti-VEGF agents improved anatomical and functional parameters, with no statistically significant differences between treatment groups (p > 0.05). Aflibercept showed the most significant CRT reduction (88 μm; p < 0.01), while bevacizumab led to the highest BCVA gain (0.15 logMAR; p < 0.01). MNV area significantly decreased only in the bevacizumab group (0.26 mm2; p < 0.01), and flow area only in the ranibizumab group (0.23 mm2; p < 0.05). A strong positive correlation between MNV areas and flow areas was found at baseline (r > 0.8) and follow-up (r > 0.9). Aflibercept, ranibizumab, and bevacizumab demonstrated similar efficacy in reducing MNV area and flow and improving visual and anatomical outcomes after a three-injection loading phase. OCTA-derived flow area measurement may be a valuable and easily accessible tool in monitoring early treatment response.