Machine Learning Can Predict Anti-VEGF Treatment Demand in a Treat-and-Extend Regimen for Patients with Neovascular AMD, DME, and RVO Associated Macular Edema

Ophthalmol Retina. 2021 Jul;5(7):604-624. doi: 10.1016/j.oret.2021.05.002. Epub 2021 May 8.


Purpose: To assess the potential of machine learning to predict low and high treatment demand in real life in patients with neovascular age-related macular degeneration (nAMD), retinal vein occlusion (RVO), and diabetic macular edema (DME) treated according to a treat-and-extend regimen (TER).

Design: Retrospective cohort study.

Participants: Three hundred seventy-seven eyes (340 patients) with nAMD and 333 eyes (285 patients) with RVO or DME treated with anti-vascular endothelial growth factor agents (VEGF) according to a predefined TER from 2014 through 2018.

Methods: Eyes were grouped by disease into low, moderate, and high treatment demands, defined by the average treatment interval (low, ≥10 weeks; high, ≤5 weeks; moderate, remaining eyes). Two random forest models were trained to predict the probability of the long-term treatment demand of a new patient. Both models use morphological features automatically extracted from the OCT volumes at baseline and after 2 consecutive visits, as well as patient demographic information. Evaluation of the models included a 10-fold cross-validation ensuring that no patient was present in both the training set (nAMD, approximately 339; RVO and DME, approximately 300) and test set (nAMD, approximately 38; RVO and DME, approximately 33).

Main outcome measures: Mean area under the receiver operating characteristic curve (AUC) of both models; contribution to the prediction and statistical significance of the input features.

Results: Based on the first 3 visits, it was possible to predict low and high treatment demand in nAMD eyes and in RVO and DME eyes with similar accuracy. The distribution of low, high, and moderate demanders was 127, 42, and 208, respectively, for nAMD and 61, 50, and 222, respectively, for RVO and DME. The nAMD-trained models yielded mean AUCs of 0.79 and 0.79 over the 10-fold crossovers for low and high demand, respectively. Models for RVO and DME showed similar results, with a mean AUC of 0.76 and 0.78 for low and high demand, respectively. Even more importantly, this study revealed that it is possible to predict low demand reasonably well at the first visit, before the first injection.

Conclusions: Machine learning classifiers can predict treatment demand and may assist in establishing patient-specific treatment plans in the near future.

Keywords: Anti-VEGF therapy; Machine learning; OCT; Treatment demand.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Aged
  • Aged, 80 and over
  • Angiogenesis Inhibitors / administration & dosage
  • Diabetic Retinopathy / complications
  • Diabetic Retinopathy / drug therapy*
  • Female
  • Follow-Up Studies
  • Humans
  • Intravitreal Injections
  • Machine Learning*
  • Macular Edema / drug therapy*
  • Macular Edema / etiology
  • Male
  • Middle Aged
  • Prognosis
  • Ranibizumab / administration & dosage*
  • Retinal Vein Occlusion / drug therapy*
  • Retrospective Studies
  • Vascular Endothelial Growth Factor A
  • Wet Macular Degeneration / drug therapy*


  • Angiogenesis Inhibitors
  • Vascular Endothelial Growth Factor A
  • Ranibizumab