Comparison of one-year outcomes between aflibercept and brolucizumab for treatment-naïve pachychoroid neovasculopathy

Pachychoroid neovasculopathy (PNV) is characterized by increased choroidal thickness, choroidal hyperpermeability, and fluid accumulation. Given its distinct pathophysiology, PNV requires management with anti-VEGF therapy, as its treatment response differs from typical neovascular age-related macular degeneration (nAMD). This study aimed to compare the one-year visual and anatomic outcomes between aflibercept and brolucizumab for treatment-naive PNV. A retrospective medical chart review was performed for consecutive 45 eyes from 45 patients with treatment-naive PNV initially treated with thee monthly intravitreal aflibercept (n = 28, 2.0 mg/0.05 ml) or brolucizumab (n = 17, 6.0 mg/0.05 ml) followed by as-needed regimen, followed up for at least 12 months. Best corrected visual acuity (BCVA) and OCT parameters including central macular thickness (CMT), subfoveal choroidal thickness (SFCT), changes in thickness of choriocapillaris (CC)/Sattler and Haller layer, choroidal vascularity index (CVI) were evaluated at baseline, 3-month, 6-months, and 12-month visits. At the 12-month visit, BCVA improved and CMT decreased significantly in both brolucizumab-treated group and in the aflibercept-treated group, suggesting comparable visual improvement in both groups (p < 0.05 for all). Mean SFCT were significantly reduced through 12 months of treatment in both aflibercept and brolucizumab groups (p = 0.001 for both). Decrease in CMT from the baseline for the brolucizumab-treated group was significantly greater than for the aflibercept group at month 12 (p = 0.038). Decrease in the mean SFCT and Haller layer thickness were significantly greater for the brolucizumab-treated group than that for the aflibercept-treated group at month 3 and 6 (p = 0.013 and p = 0.035). An increase of the CVI from baseline was observed only in the brolucizumab group at month 12 (p = 0.041). CC flow density did not change after 12 months in both groups. The rate of dry macula at month 12 did not differ significantly between the two groups (78.6% in aflibercept group vs. 82.4% in brolucizumab group, p = 0.104). These findings suggested that as-needed administration of brolucizumab demonstrated comparable visual outcomes to aflibercept in treatment-naïve PNV eyes. Additionally, over 12 months, brolucizumab showed a greater effect in reducing CMT, SFCT, and Haller layer thickness, as well as increasing CVI, suggesting potential choroidal morphology remodeling.