Challenging the Treatment Threshold: Early Faricimab Prevents Vision Loss in nAMD – A Real-World Welsh Experience

Purpose: To compare real-world outcomes in treatment-naïve neovascular age-related macular degeneration (nAMD) patients initiated on Faricimab at early (< 0.3 logMAR) versus late (0.6– 0.7 logMAR) visual thresholds. Methods: Retrospective, single-centre cohort study of 97 patients (53 early, 44 late) treated at a UK centre, with three monthly loading doses followed by treat-and-extend. Outcomes: BCVA change, vision loss (≥ 5 letters), stable vision at 6/12/18 months, injection intervals, extension > 8 weeks, dry macula. Results: Baseline VA was 74 ± 3.5 letters (early) vs 54 ± 2.0 letters (late), p< 0.001. No early patient experienced sustained vision loss at 6, 12, or 18 months compared with 76.7%, 73.3%, and 75.0% of late patients, respectively (p< 0.05 for all). At the 7th injection, 67.6% of late patients lost ≥ 5 letters vs 14.9% of early patients (ARR 52.7%, p< 0.001). Cumulatively, 81.8% of late patients experienced ≥ 5-letter loss vs 41.5% of early patients (ARR 40.3%, NNT 3, p< 0.001). Mean injection intervals were similar, but the early cohort sustained extension beyond 8 weeks in > 50% of eyes from the 4th– 5th interval onward. In contrast, the late cohort exhibited a biphasic collapse, with extension rates declining from 62.2% at 6th– 7th to only 35.0% by 9th– 10th. Despite a significant baseline anatomical disadvantage (18.9% vs 50.0% dry macula, p=0.001), the early cohort achieved 100% dryness by 18 months compared with 96.7% in the late cohort, with crossover occurring by 12 months (95.8% vs 89.7%, p=0.269). Conclusion: In this retrospective, single-centre study, early faricimab initiation was associated with preservation of high-function vision, a lower risk of clinically significant vision loss, and high rates of anatomical quiescence and durable treatment extension. These findings suggest that proactive early intervention may offer advantages over reactive treatment paradigms, although confirmation in larger, prospective, and multi-centre studies is needed. Plain Language Summary: Why was this study done? Wet AMD is a leading cause of sight loss in older people. In the UK, treatment usually starts after visions reaches 6/12 or below. In Wales, doctors have been starting treatment earlier, while vision is still good, to try to preserve sight rather than just slow further loss. This study compared these two approaches. What did the researchers find? Of 97 patients starting the drug Faricimab, 53 started early (good vision) and 44 started later (usual UK threshold). Key findings :All Early patients kept stable vision at 6, 12, and 18 months. In contrast, about one in four Late patients lost vision.By the 7th injection, two out of three Late patients had lost vision, compared to only one in seven Early patients.Four out of five Late patients experienced vision loss, versus two out of five Early patients.Early patients achieved completely dry retinas by 18 months, even though they began with more fluid.Early patients were also better able to maintain longer gaps between injections over time. What do these results mean? Starting treatment early preserves high-quality vision and prevents the decline that current pathways accept. Early patients were more likely to keep their driving vision, vital for independence and quality of life. Our findings suggest that waiting for vision to drop misses a critical window. With modern anti-VEGF drugs, a proactive approach can help people with wet AMD retain useful vision longer and maintain the lifestyle they value.