Anti-VEGF switches for persistent fluid: A review of 3 clinical cases

How should clinicians respond when macular fluid persists despite repeated anti-VEGF injections? During a Modern Retina Clinical Forum at the American Academy of Ophthalmology 2026 Annual Meeting in New Orleans, Louisiana, Dilsher S. Dhoot, MD, FASRS, a retina specialist with California Retina Consultants, presented 3 of his own patient cases: branch retinal vein occlusion (BRVO), neovascular age-related macular degeneration (nAMD), and diabetic macular edema (DME).

Branch retinal vein occlusion across 4 agents

Dhoot presented a patient with hypertension and hyperlipidemia who came in during January 2022 with blurred vision in the left eye and visual acuity (VA) of 20/40-1. He characterized the findings as a macular BRVO with macular edema.

Treatment began with 2 injections of bevacizumab, but the fluid did not move. Dhoot switched to aflibercept 2 mg (Eylea; Regeneron Pharmaceuticals), which was given from April 2022 through November 2023 at intervals of about 4 to 6 weeks. Fluid decreased after the first few injections and then returned, and the response to an intravitreal dexamethasone implant (Ozurdex; AbbVie) “is not a wow,” he said.

Serial dosing with faricimab (Vabysmo; Genentech) followed from December 2023 to January 2026. Fluid continued, VA stayed at 20/25 to 20/30 for much of 2024, and VA dropped to 20/60 in April 2025.

After a switch to aflibercept 8 mg (Eylea HD; Regeneron Pharmaceuticals) in March 2026, Dhoot saw a reduction in fluid by April. By September 2026, VA was 20/25. “Some patients, you just kind of go through the process and find the right agent,” he said. He described the September scan as showing “the least amount of fluid I’ve ever seen in this patient.”

Neovascular AMD with fluid at 10-week intervals

The second case involved a woman aged 89 years who was referred for nAMD in the left eye. She had VA of 20/100 in both eyes and was pseudophakic. Dhoot said the right eye also showed intraretinal fluid and pigment epithelial detachment, so she had nAMD in both eyes.

He focused on the right eye. After starting aflibercept 2 mg in July 2025, VA improved to 20/70, but fluid persisted. The interval went from 5 weeks to 10 weeks with a little fluid remaining, and the patient kept returning at 10-week intervals.

In May 2026, after 5 injections of aflibercept 2 mg, Dhoot switched her to aflibercept 8 mg. Asked whether he gives a loading dose when switching, he said, “I never load.” Ten weeks after the switch, fluid was much improved, and the interval held at 10 weeks, with VA of 20/60 in September. Dhoot said it was the first time no fluid had been seen in this eye.

Diabetic macular edema after 23 aflibercept injections

The third patient was a man aged 67 years with severe nonproliferative diabetic retinopathy and DME in both eyes. Dhoot first saw him in June 2022, when VA was 20/40 in both eyes. He had ocular hypertension and cataracts in both eyes.

After about 3 years of treatment with aflibercept 2 mg, the patient reached his 20th injection in December 2025. Fluid fluctuated, with dosing intervals of about 6 to 8 weeks, and VA ranged from 20/25 to 20/30 through the 23rd injection in April 2026.

Dhoot switched to faricimab in June 2026, after continued fluid. More fluid was present at the second dose in July, but by the August visit, he described a “very nice response,” with no fluid for the first time. VA was 20/40.

Dhoot noted that the follow-up was short and that “sometimes the response happens after this second dose.”