Case Study: Patient Resistant to Anti-VEGF
A 77-year-old male presented to my clinic complaining of distortion in his right eye. He was found to have exudative macular degeneration in his right eye and dry macular degeneration in his left. He was treated with injections of Anti-VEGF and was doing quite well with monthly injections for nine months with vision of 20/25 and normal eye pressure, at which point his response dwindled and the CNV enlarged in size despite monthly injections (Figure 1). The first image shows his PED/CNV on monthly injections; the second scan is one month later. Despite one of the stronger anti-VEGF drugs, his vision dropped to 20/40 in his right eye. The patient felt his vision improved immediately after injections and got worse again sooner than one month. Due to his lack of response to the standard treatment, we attempted to increase injection frequency to every two weeks instead of four. He finally improved once injections were given every two weeks as shown in the fourth scan.
OCT and OCT Angiography were performed using the Optovue Solix by Visionix to evaluate the structural abnormalities and better characterize this patient’s neovascularization. OCT Angiography confirmed a choroidal neovascular complex under the enlarging pigment epithelial detachment (Figure 1). Figure 2 shows the CNV within this PED, and Figure 3 shows the en face OCT demonstrating worsening and resolution. The comparison tool on the Optovue Solix machine was instrumental in assessing treatment response and assuaging the patient’s concerns that he would continue to worsen. Once he saw improvement, he felt more comfortable, and we continued the treatment course. His PED continues to improve, and his vision is back to his baseline of 20/25.
Macular degeneration is a common disease in the retina clinic. This case was unique in that most patients respond to monthly injections (if not less frequently with newer medications). This patient was treatment resistant to the usual management course. As the patient let us know his treatment effect faded more quickly, we were able to manage his disease and improve his vision with a treatment plan tailored to him.
Figure 1 - OCT Angiography confirmed a choroidal neovascular (CNV) complex under the enlarging pigment epithelial detachment. The images show the patient’s CNV enlarging in size despite monthly Anti-VEGF injections.
Figure 2 shows the Choroidal Neovascular (CNV) network within the Pigment Epithelial Detachment (PED).
Figure 3 shows the en face OCT demonstrating worsening and resolution.
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This article originally appeared in Ophthalmology Management in March 2026.
Dr. Alexander Barash is a vitreoretinal surgeon and retinal specialist. He graduated magna cum laude from Cornell University and earned his MD from Icahn School of Medicine at Mount Sinai. He completed his ophthalmology residency at Stony Brook University Hospital and a vitreoretinal fellowship at New York Eye and Ear Infirmary of Mount Sinai. He also teaches ophthalmology residents and retina fellows at New York Eye and Ear, Elmhurst Hospital Center, and Mount Sinai Hospital.
Dr. Barash has participated in ophthalmic missions in Uganda, Peru, and Mongolia and is an active researcher with numerous publications and presentations, including work supported by a Doris Duke Clinical Research Fellowship. Outside of medicine, he enjoys photography, biking, and playing guitar.
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