We thank Călugăru and associates for their interest in our study. We agree that analyzing parameters related to choroidal neovascularization, including retinal hard exudates, subretinal and sub-RPE fibrovascular proliferation, and disciform scar would be interesting, and that knowledge of these parameters may allow for better understanding of the characteristics of the persistent neovascular macular degeneration. We did analyze several established parameters, including maximum retinal thickness, central macular thickness, maximum pigment epithelial detachment height, integrity of ellipsoidal layer, and external limiting membrane in 81 eyes at 5 different follow-up visits. These are widely believed to be important prognosticators of visual acuity and recovery. We have shown that the changes in these parameters over the 2-year follow-up still provide important information regarding the efficacy of aflibercept treatment in persistent neovascular macular degeneration patients. In addition to reporting several anatomic outcomes and visual acuity at multiple time points in our study population, we compared eyes in the multiple recurrence group and eyes in the persistent fluid group to determine if there was any significant difference in response to aflibercept treatment. Although these 2 groups showed different responses while undergoing monthly aflibercept (multiple recurrences were sometimes called transient responders) and resistant eyes, the overall response to aflibercept was similar between the 2 groups. As the manuscript figures illustrate, eyes in the 2 groups had similar baseline maximum retinal thickness, central retinal thickness, maximum pigment epithelial detachment height, and visual acuity that allow for head to head comparison.
We agree that tachyphlaxis may be responsible from the decrease in the response to bevacizumab or ranibizumab; this was discussed in our previous paper reporting the preliminary results of a smaller cohort with a shorter duration of follow-up. There are anecdotal reports of improvement in exudation in the setting of tachyphylaxis with any switch among the 3 available anti-VEGF agents (ie, ranibizumab, bevacizumab, or aflibercept). We thank the authors for their interest and suggestions. However, only a randomized trial of switching among different agents can definitively answer their questions. Our study does show that there does seem to be some benefit of aflibercept in patients who do not completely respond to bevacizumab or ranibizumab.