Real-world treatment outcomes of aflibercept versus bevacizumab for neovascular age-related macular degeneration

PURPOSE: Dutch guidelines recommend bevacizumab as first-line treatment for neovascular age-related macular degeneration (nAMD) due to its lower cost and comparable outcomes to other anti-VEGF agents. However, Dutch clinics report higher injection frequencies than international counterparts, raising concerns about treatment burden. This pilot study compares 24-month real-world outcomes of initiating aflibercept versus bevacizumab in Dutch community ophthalmology clinics. METHODS: We conducted an observational study using prospective data from three Dutch FRB registry clinics. Two clinics used bevacizumab with two-weekly T&E interval adjustments. A third clinic initiated aflibercept with a four-week initial extension, followed by two-weekly adjustments. Primary outcomes were total injections and injections to CNV inactivity. Secondary outcomes included time to CNV inactivity, VA change, and final injection interval. RESULTS: We included 43 eyes (38 patients) in the aflibercept group and 129 eyes (119 patients) in the bevacizumab group, matched 1:3 on age and baseline VA. At 24 months, mean VA was 65.6 (aflibercept) vs. 68.8 (bevacizumab) letters (p = 0.182), and mean letter gains were + 0.8 vs. + 4.2 (p = 0.113). Aflibercept-treated eyes received 5.5 fewer injections (p < 0.001), required 5.6 fewer injections to achieve CNV inactivity (p < 0.001), and reached inactivity 20.6 weeks earlier (p = 0.001). Final injection intervals were 3.3 weeks longer with aflibercept (p < 0.001); 41.9% reached intervals ≥ 12 weeks compared to 14.7% in the bevacizumab group (p < 0.001). CONCLUSION: Aflibercept under a modified T&E regimen resulted in fewer injections, faster disease control and longer treatment intervals, while VA was not significantly different. KEY MESSAGES: WHAT IS KNOWN : Aflibercept and bevacizumab are both widely used anti-VEGF injections for age-related macular degeneration with similar visual outcomes. Real-world studies in the Netherlands report a high injection burden with bevacizumab, but direct comparisons between agents in routine care are limited. WHAT IS NEW : Aflibercept, initiated with a modified treat-and-extend regimen, achieved visual outcomes comparable to bevacizumab while requiring fewer injections. These findings highlight aflibercept’s potential to reduce treatment burden and optimize healthcare resources, warranting confirmation in larger, long-term real-world studies, as well as cost-effectiveness studies.