We read with great interest the article “Long-Term Results of Pro Re Nata Regimen of Aflibercept Treatment in Persistent Neovascular Age-Related Macular Degeneration,” by Muftuoglu and associates. In their recent retrospective study, the authors have clearly demonstrated the usefulness and efficacy of intravitreal aflibercept injections on a pro re nata basis for the management of neovascular age-related macular degeneration. However, we do have a few comments to make in view of the conclusions made in the study.

In the current study, close to 50% of the eyes showed no improvement in terms of resolution of fluid with as-needed injections of aflibercept. These eyes were treated with 3 consecutive monthly injections of aflibercept and significant reduction in central macular thickness, maximal retinal thickness, maximal pigment epithelial detachment height, and maximal subretinal fluid height were achieved, thus suggesting the pro re nata regimen showed no superiority to regimens described in the VIEW 1 and 2 trials.

Cho and associates showed only 18% of the eyes were dry with a single intravitreal aflibercept injection. Repeated injections of aflibercept showed no significant visual acuity gain, probably owing to the chronicity of neovascular membrane and macular atrophy.

Baseline optical coherence tomography indicators like increased central subfield thickness, presence of intraretinal cysts, presence of pigment epithelial detachment, and subfoveal thickening indicate poor prognosis to treatment with intravitreal aflibercept.

To conclude, the decision to switch from ranibizumab and/or bevacizumab injections to intravitreal aflibercept injections in patients with multiple recurrences or persistent fluid must also be based on the baseline OCT features, baseline visual acuity, and chances of visual acuity gain.