Rapid Vascular Pruning and Remodeling in Refractory Type 1 Macular Neovascularization: A Quantitative Swept-source OCT Angiography Study of Faricimab

PURPOSE: To evaluate the structural impact of intravitreal faricimab on the neovascular network in treatment-resistant Type 1 macular neovascularization (MNV) using quantitative swept-source optical coherence tomography angiography (SS-OCTA). METHODS: A retrospective, single-center cohort study was conducted on 21 eyes with Type 1 MNV (including polypoidal choroidal vasculopathy) that were unresponsive to intensive intravitreal anti-VEGF therapy. Patients underwent switching therapy with a single faricimab injection and were evaluated at baseline and Day 14. Quantitative SS-OCTA analysis included perfusion indices, vascular component segmentation (trunk vs. capillary), and fractal analysis (fractal dimension [FD] and lacunarity) to quantify lesion complexity and pruning. RESULTS: Despite a heavy prior treatment burden (mean 11.8 ± 6.5 injections), significant functional and anatomical improvements were observed. BCVA improved (P = 0.0088), and maximum pigment epithelial detachment height decreased (P = 0.0008) with reductions in CFT and SFCT. Crucially, SS-OCTA revealed profound network regression with reduced perfusion area (P = 0.0002) and vessel density (P = 0.0019). Component analysis demonstrated the regression of both recalcitrant trunk and capillary vessels. This vascular remodeling was confirmed by decreased branching complexity (intersection points, P = 0.0017; FD, P = 0.001) and increase in lacunarity (P = 0.0102), quantitatively indicating the "pruning" of the neovascular tree. CONCLUSIONS: Intravitreal faricimab demonstrated rapid regression of neovascular architecture in refractory MNV. Quantitative SS-OCTA findings suggest that dual Ang-2/VEGF-A inhibition may contribute to vascular pruning of both trunk and capillary vessels, supporting a potential benefit in structural remodeling compared with anti-VEGF therapy.