Notion of tolerating subretinal fluid in neovascular AMD: understanding the fine print before the injection pause

The last decade has seen a paradigm shift in the management of neovascular age-related macular degeneration (nAMD) with the introduction of biologicals that inhibit vascular endothelial growth factor (VEGF). These agents, similar to biologicals have imposed a major burden on all healthcare systems. Patients are not only financially strained by the cost of intravitreal injections that require repeated administrations but multiple visits to the hospital compromise quality of life. The recognition of this burden has to some extent led to a shift in the dosing strategy from fixed monthly (of ranibizumab) or 8-weekly dosing (of aflibercept) to pro-re-nata and treat-and-extend (T&E) protocols.1 After the three initial loading doses, re-injection decisions are made based on the presence of fluid on optical coherence tomography (OCT). The OCT is a tool that demonstrates structural changes in the macular retina arising from leakage in the nAMD lesion or occurring as part of the sequelae of chronicity of the pathology. Leakage of fluid and blood constituents representing lesion activity is interpreted by detecting signs (biomarkers) seen on OCT. The presence of clear hypo-reflective regions within the intraretinal layers is considered to represent fluid accumulation. Depending on the location of these regions of hypo-reflectivity, they can be compartmentalised into intraretinal fluid (IRF), subretinal fluid (SRF) and subretinal pigment epithelial fluid. Multiple post hoc analyses of major trials such as the Comparison of AMD Treatments Trials (CATT) and VIEW 2 have shown that presence of IRF, either foveal or extra-foveal during the …