Are We Overusing Anti-vascular Endothelial Growth Factor? – Reflections on Treatment Burden and Real-World Outcomes

Since the advent of anti-vascular endothelial growth factor (VEGF) therapy nearly two decades ago, ophthalmology has witnessed one of its most dramatic transformations. Conditions once deemed untreatable and progressive such as neovascular Age related macular degeneration (AMD), diabetic macular edema (DME), and retinal vein occlusion – have become treatable and visual loss due to these pathologies have come down dramatically. However, amidst the triumph of these sight-saving molecules lies a growing concern: are we overusing anti-VEGF injections? Ranibizumab, aflibercept, and more recently, faricimab and biosimilars, have redefined retinal care. The initial enthusiasm was well-justified. The landmark trials such as MARINA, ANCHOR, and RISE/RIDE demonstrated unprecedented visual gains. However, what began as a revolutionary intervention has, in many clinics, evolved into a regular routine. The ease of access, patient demand, and the measurable “optical coherence tomography (OCT)-driven” endpoint have perhaps led us to inject first and think later. While trial data promised sustained visual improvement, real-world studies have shown varied results. Despite frequent injections, outcomes rarely match those seen in pivotal trials. Adherence, socioeconomic barriers, and clinic capacity all play roles, but there is also growing recognition that repeated anti-VEGF therapy may not always yield proportionate benefit. In chronic disease states such as DME, some eyes enter a “treatment plateau” with poor prognostic OCT features and diminishing functional gain. Moreover, the financial and logistical burden is immense. Monthly inject and visits challenge both patients and healthcare systems. For elderly individuals or those from underserved regions, the repeated hospital visits, costs of imaging, and anxiety associated with injections contribute to what has been termed “treatment fatigue.” The overreliance on anti-VEGF therapy risks narrowing our therapeutic vision. Adjunctive modalities such as laser for selected DME cases, corticosteroids, and systemic metabolic control often gets ignored. The success of anti-VEGF agents should not be the part of comprehensive patient care or individualized decision-making. Not every thick retina or macular edema warrants an injection; not every OCT change needs intervention. It is time to re-evaluate what constitutes “success” in retinal therapy. Should it be an anatomical perfection on OCT, or a meaningful, sustainable improvement in visual function and quality of life? Real-world care must balance efficacy with burden. The “treat-and-extend” paradigm was a step forward, yet even that requires personalization rather than rigid adherence. Future research should focus not only on better drugs but on better strategies but also on predictive biomarkers for responders, set management protocols, and combination therapies that target inflammation and vascular stability alongside VEGF. Patient education and shared decision-making should become integral to therapy. Anti-VEGF therapy remains one of ophthalmology’s greatest achievements, but even great tools can be overused. As clinicians, our responsibility extends beyond injection counts to thoughtful utilization of therapy. The goal is not to abandon anti-VEGF, but to restore balance – to use it wisely, selectively, and ensuring that the pursuit of vision preservation does not over treat and financially burden the patients.