Prognosis and Treatment Approach for Stage 1 Retinal Angiomatous Proliferation Lesions: A Case Series With Long-Term Follow-Up

Retinal angiomatous proliferation (RAP) accounts for approximately 10%-20% of all neovascular (wet) age-related macular degeneration and is classically classified into three stages, with stage 1 representing the earliest form of disease. Despite its clinical relevance, limited evidence exists on the long-term prognosis of treatment-naïve stage 1 RAP, particularly regarding recurrence patterns and the development of macular atrophy or fibrosis over extended follow-up. This retrospective case series evaluates outcomes in four patients diagnosed with stage 1 RAP using optical coherence tomography (OCT) and fluorescein angiography. All patients were planned to receive a loading regimen of three monthly intravitreal aflibercept injections, followed by monthly review for at least 24 months. The loading phase was modified according to findings at each visit. At every appointment, best-corrected visual acuity (BCVA), slit-lamp examination, and OCT assessment of macular anatomy were performed, with recurrence defined as clinical and/or OCT evidence of exudative activity warranting re-treatment. Over the follow-up period, all four patients demonstrated stable or improved BCVA after anti-vascular endothelial growth factor (VEGF) therapy. Two patients had no recurrences across 24 months, while two patients each experienced a single recurrence, occurring at seven months and 24 months, respectively. Importantly, no eyes developed macular atrophy or fibrotic scarring during the observation period, and visual acuity remained stable or improved in all cases. These findings support the concept that early identification and prompt treatment of stage 1 RAP may be associated with a low recurrence burden and a favourable anatomic course, potentially limiting progression to atrophy or fibrosis and preserving long-term vision. They also suggest that a personalised management strategy, combining an initial loading phase with close surveillance and re-treatment only upon recurrence, may be effective in carefully selected early-stage RAP patients and could reduce overall injection burden. Larger studies with longer follow-up are required to confirm these preliminary observations and to better define stage-specific treatment strategies for RAP.