Undertreatment of Neovascular Age-Related Macular Degeneration after 10 Years of Anti-Vascular Endothelial Growth Factor Therapy in the Real World: The Need for A Change of Mindset

Ophthalmologica. 2020;243(1):1-8. doi: 10.1159/000502747. Epub 2019 Nov 19.


Purpose: To assess the gap between visual acuity (VA) outcomes with anti-vascular endothelial growth factor (anti-VEGF) therapies in clinical trials and real-world practice, and explore the reasons for this gap.

Methods: The literature was searched from January 1, 2013, to June 30, 2018, for studies reporting VA gains and injection frequencies in clinical trials and real-world practice.

Results: Clinical trials of anti-VEGF agents and their extension studies demonstrated initial VA gains maintained at 4 years and beyond (up to 7 years) with continuous proactive treatment. Visual outcomes correlated with injection frequency. In real-world practice, patients are usually undertreated, accounting for the VA decline over time. Reasons for undertreatment include the burden of injections and monitoring visits imposed on patients/caregivers. However, another primary reason is the general mindset in the ophthalmological community that sustained benefits with treatment are not possible, leading to poor compliance and creating a vicious circle.

Conclusions: Initial VA gains can be maintained with more intensive/proactive approaches. Promising new treatments requiring less frequent injections/monitoring will help in the near future; meanwhile, better results could be achieved by changing the community mindset that contributes to undertreatment.

Keywords: Anti-VEGF; Neovascular age-related macular degeneration; Treatment burden; Undertreatment.

Publication types

  • Review

MeSH terms

  • Angiogenesis Inhibitors / administration & dosage
  • Humans
  • Intravitreal Injections
  • Ranibizumab / administration & dosage*
  • Treatment Outcome
  • Vascular Endothelial Growth Factor A / antagonists & inhibitors
  • Visual Acuity*
  • Wet Macular Degeneration / diagnosis
  • Wet Macular Degeneration / drug therapy*


  • Angiogenesis Inhibitors
  • Vascular Endothelial Growth Factor A
  • Ranibizumab