ASRS 2026: initiating aflibercept 8 mg or faricimab earlier improves durability and anatomic outcomes in real-world practice

Study background and rationale

Modern Retina spoke with Sundeep Dev, MD, FASRS, president of Retina Consultants of Minnesota in Minneapolis–Saint Paul, at the 44th Annual Meeting of the American Society of Retina Specialists (ASRS), held July 15–18, 2026, at the Palais des congrès de Montréal in Montréal, Canada. Dev presented findings from a multicenter retrospective analysis examining whether the timing of initiation of aflibercept 8 mg (Eylea HD; Regeneron) and faricimab (Vabysmo; Genentech), as a first-line agent versus after prior anti-VEGF exposure, affects long-term treatment durability and anatomic outcomes in patients with neovascular age-related macular degeneration (nAMD), diabetic macular edema (DME), or retinal vein occlusion (RVO). The premise of the study, Dev explained, arose from a clinical observation that patients were not achieving real-world outcomes comparable to those seen in clinical trials, particularly with later-generation agents, and that insurance-mandated step-therapy protocols may be contributing to that gap.

Methods and key findings

The analysis included 12,501 eyes across 10,247 patients, categorized as initiators (n=1,396 eyes) who began treatment directly with aflibercept 8 mg or faricimab, or switchers (n=11,105 eyes) who transitioned from older anti-VEGF agents. Switchers were further stratified by timing: early switchers (5 or fewer prior injections, n=2,098 eyes) and late switchers (more than 5 prior injections, n=9,007 eyes). Dev noted that the threshold of 5 injections was selected because step-therapy requirements typically mandate three completed treatments before a prior authorization is required on the fourth injection, meaning patients effectively receive 4 injections before access to newer agents is considered—making 5 injections the practical early-versus-late boundary. Initiators achieved a mean treatment interval of 10 weeks compared with 9 weeks in switchers after transition (P <.01). Early switchers demonstrated greater durability (9.5 weeks) and substantially greater central subfield thickness (CST) reduction (−66 µm) than late switchers (9 weeks; −19 µm; P <.01). Initiators achieved a net CST reduction of −71 µm compared with −24 µm in switchers (P <.01). Best-corrected visual acuity remained stable across both groups.¹

Insurance barriers and the role of step therapy

Dev described insurance-mandated step therapy as a major barrier to optimal outcomes, noting that it shapes clinical decision-making in ways that may be detrimental to patients. Medicare coverage was independently associated with longer treatment durability and better anatomic results compared with Medicare Advantage, which Dev attributed to the step-therapy access barriers common in Medicare Advantage plans. In some cases, he noted, patients are required to fail two older agents before accessing newer therapies—a practice he described as double step therapy. Dev told Modern Retina that ideally Congress should eliminate step-therapy requirements entirely, and that at minimum, the requirement for multiple monthly treatments before access to newer agents is granted should be removed, as it delays meaningful treatment.

The role of artificial intelligence

When asked about the future of retinal disease management, Dev identified artificial intelligence as a meaningful near-term tool, citing its potential to improve clinical record accuracy, assist with imaging interpretation, and advance research. "AI will help us greatly with imaging interpretation and help us greatly with research as well," Dev told Modern Retina, "as we can identify patterns and these types of observations that we make clinically that we can go study."

Reference

1. Dev S, Sather R, Belin P, Chiang T, Moon J. Real-world durability of aflibercept 8 mg and faricimab in initiators vs switchers: a multicenter retrospective analysis. Presented at: 44th Annual Meeting of the American Society of Retina Specialists; July 15–18, 2026; Montréal, Canada.