Effectiveness of bevacizumab step therapy for neovascular age-related macular degeneration

Objective To determine the effectiveness of bevacizumab step therapy for neovascular age-related macular degeneration (nAMD) in routine clinical practice. Methods In this retrospective case series, eyes initiating treatment for nAMD at an academic medical centre from 2011–2019 were included. Exclusion criteria included previous intravitreal anti-VEGF injections, prior non-cataract intraocular surgery, <1 year of treatment, and not starting on monthly bevacizumab therapy. Of 895 eligible eyes, 548 were excluded, yielding 347 eyes in the study population. These eyes were treated for nAMD under the bevacizumab step therapy protocol with an option to switch to another agent in the event of predefined treatment failure. Treatment failure was defined as losing 15 or more Early Treatment Diabetic Retinopathy Study letters or switching to an alternative anti-VEGF agent. Eyes that did not meet these criteria were deemed treatment successes. Annual change in mean VA from baseline (ΔVA) was the primary outcome. Secondary outcomes included treatment success rate, medication switch rate, and post-switch ΔVA. Results After 1 year, mean ΔVA was +8.4 letters (95% CI: +6.1 to +10.6 letters). 86% had treatment success, and 6% of eyes had switched to aflibercept. In years 2–7, ΔVA ranged from +7.0 to −0.7 letters, and treatment success rates ranged from 68 to 82%. 11% ( n = 38) of eyes were switched to aflibercept. The post-switch ΔVA in these eyes was −7.1 letters (95% CI: −13.3 to −0.1) after a mean of 17.7 ± 12.6 injections over an average of 2.7 ± 2.0 years. Conclusion A bevacizumab step therapy protocol in routine clinical practice is effective for long-term treatment of nAMD.