Outcomes of As-Needed Aflibercept Treatment After Complete Regression in Polypoidal Choroidal Vasculopathy

Importance: Complete polypoidal regression (termed regression) is a treatment goal in polypoidal choroidal vasculopathy (PCV), a common cause of vision loss globally. However, outcomes are controversial when treatments continue as fixed-dosing, treat-and-extend, or as-needed (PRN) regimens once regression is achieved. Objective: To determine outcomes using PRN regimens after achieving complete polypoidal regression following an initial treatment of 3 or 6 monthly intravitreal anti-vascular endothelial growth factor injections in eyes with PCV. Design, Setting, and Participants: This prospective cohort study took place at 4 university hospitals in Thailand. Eighty-one treatment-naive participants with PCV received 3 monthly aflibercept 2.0-mg injections. At week 12, eyes with regression underwent PRN treatment and follow-up monthly during year 1 and bimonthly during year 2. Eyes without regression at week 12 received 3 additional monthly injections and if regressed at week 24, also underwent PRN treatment and follow-up monthly through year 1 and bimonthly follow-up through year 2. Eyes without regression through week 24 received treat-and-extend regimens. These data were analyzed from August 2020 to September 2025. Main Outcomes and Measures: Fluid-free interval between first visit with regression and first exudative recurrence on optical coherence tomography (OCT) by life-table analyses. Results: Of 81 study eyes, mean [SD] age was 64 [8] years; 54% were female and 46% were male; 32 (40%) achieved regression at week 12 or 24. Of 26 eyes with regression, 13 (50%; 95% CI, 30%-70%) recurred within 2 years. Fluid-free probability after regression was 57% (95% CI, 37%-77%) at week 24 and 53% (95% CI, 33%-73%) at week 84. Among 14 eyes with recurrence, median best-corrected visual acuity change from the prior visit was -3.5 letters (IQR, -5.0 to -0.25); 3 (21%; 95% CI, 5%-51%) lost 10 or more letters, and 5 (36%; 95% CI, 13%-65%) had new hemorrhage. Post hoc exploratory analyses of eyes with complete polypoidal regression showed baseline massive subretinal hemorrhage had lower recurrence (hazard ratio [HR], 0.18; 95% CI, 0.04-0.80; P = .01). In contrast, leakage without subretinal hemorrhage may have had a higher hazard of recurrence (HR, 2.65; 95% CI, 0.89-7.94; P = .07). Conclusions and Relevance: In this study, half of the eyes with PCV achieved complete polypoidal regression remained quiescent after treatment deferral, whereas the remainder recurred. Posttreatment OCT biomarkers may help identify eyes that could benefit from continued treatment instead of PRN management.