Comparison of Aflibercept and Brolucizumab in Treatment-Naïve Neovascular Age-related Macular Degeneration with Thick Pigment Epithelial Detachments

Purpose: To compare short-term anatomical and functional outcomes of intravitreal brolucizumab versus aflibercept in treatment-naïve neovascular age-related macular degeneration (nAMD) with thick pigment epithelial detachments (PEDs). Methods: This retrospective comparative study included treatment-naïve nAMD eyes with thick PEDs (maximum PED height ≥250 μm) treated with intravitreal aflibercept or brolucizumab between January 2022 and June 2025, with a minimum 6-month follow-up. The primary outcome was anatomical response at Month 6, defined as ≥50% reduction in maximum PED height. Secondary outcomes included changes in best-corrected visual acuity (BCVA), central foveal thickness (CFT), subfoveal choroidal thickness (SFCT), qualitative OCT features, injection burden, and safety. Longitudinal changes were analyzed using linear mixed-effects models. Results: Forty-one eyes (aflibercept, n=21; brolucizumab, n=20) were included. Baseline BCVA, CFT, and PED height did not differ significantly between the groups, although SFCT was thicker in the brolucizumab group (P=0.034). Over 6 months, the mean number of injections was significantly lower with brolucizumab (3.05 ± 0.40 vs. 3.86 ± 0.65, P<0.001). Brolucizumab achieved greater reduction in PED height at Month 3 (P=0.014) and Month 6 (P=0.044). In mixed-effects analysis, all anatomical parameters and BCVA improved over time (Ptime<0.001). SFCT demonstrated significant group and interaction effects (Pgroup=0.031; Pint=0.006), whereas PED height and CFT did not. Residual subretinal hyperreflective material was less frequent at Month 3 with brolucizumab (0.0% vs. 23.8%, P=0.048). No intraocular inflammation occurred. Conclusions: In treatment-naïve nAMD eyes with thick PEDs, brolucizumab was associated with greater short-term anatomical improvement and a lower injection burden compared with aflibercept, whereas no statistically significant between-group difference was observed in BCVA change. Further studies with larger cohorts and longer follow-up are warranted to confirm these findings.