The 180-day problem: How treatment non-adherence affects vision in nAMD

Anti-VEGF therapy remains the cornerstone of treatment for neovascular (wet) age-related macular degeneration (AMD), yet its real-world effectiveness hinges on a factor that trial data often obscure: whether patients actually stay on treatment. New real-world evidence presented at the 2026 American Society of Retina Specialists (ASRS) Annual Meeting held in Montreal quantifies just how quickly adherence erodes and what it costs patients in vision—findings that carry particular weight as a pipeline of longer-acting agents approaches the clinic.

In this interview, Andrew A. Moshfeghi, MD, MBA, FASRS, discusses an analysis of the Vestrum Health database spanning 7 years and multiple U.S. practice types, in which a treatment gap was defined as more than 180 days without anti-VEGF exposure. He reviews the study's central findings—that as many as 40% of treatment-naive patients had already experienced a 180-day gap by the end of year 1, climbing to roughly 80% by year 7—and connects those patterns to declining injection frequency, worsening visual outcomes, and the practical barriers that keep elderly patients from the clinic.

The conversation

Editor's note: This interview has been lightly edited for length and clarity.

Can you summarize the data you presented at ASRS and share what prompted the analysis?

Andrew A. Moshfeghi, MD, MBA, FASRS: We looked at real-world outcomes of patients undergoing intravitreal anti-VEGF therapy for neovascular AMD, focusing on the impact of treatment gaps and treatment non-adherence. We defined a treatment gap as a patient going more than 180 days without exposure to anti-VEGF therapy, and we drew on the Vestrum Health database, which is shared by retina physicians across the United States in multiple cities and practice types. This was over a 7-year period.

What we found was that as many as 40% of these treatment-naive patients were already experiencing a 180-day gap by the end of the first year of therapy, and that figure climbed in a linear fashion over the ensuing years, such that by year 7 as many as 80% of patients had a treatment gap of at least 180 days.

How did injection frequency and vision track alongside those gaps?

Moshfeghi: Not surprisingly, the mean number of injections per year started off around 8 and trailed down to about 6 by year 7. These patients also had a drop in vision over time. When we compared those who were not having a treatment gap with those who were, the patients without the gap had more favorable visual outcomes.

Staying on therapy results in better visual outcomes. One implication is that if we have newer drugs that last as long as 180 days, in a real world where so many patients already have such a gap, we may feel much more comfortable that those patients aren't losing vision and may hold on to better visual outcomes in the long term.

How can clinicians help patients adhere to treatment?

Moshfeghi: We've had anti-VEGF therapy for about 20 years, and this is not a new problem. Despite multiple studies like this one showing that more frequent injections produce more favorable outcomes, these treatment patterns persist. It's not that doctors aren't recommending more frequent treatment—there are many barriers to patients executing on the recommended follow-up.

These are elderly patients; a lot of them can't drive anymore due to their vision or other health problems, so they rely on a family member, loved one, or caretaker to bring them in. That's costly and time-consuming. Each appointment can be two or three hours. You need someone who can bring you there, stay with you the whole time, and leave with you. So even though we have good data, and doctors and patients know it, it's still difficult to execute because it's not a quick process.

Is there concern that if treatment intervals get longer, patients simply won't come back, whether they forget to schedule or drop off entirely?

Moshfeghi: That's a risk, but we know from our dry AMD population—patients at risk for developing AMD and needing these injections—that those patients are very good at coming in twice a year, sometimes three times a year. And it's not because they're getting a rewarding visual outcome from the visit; they come back just to check on the status of their disease. That adherence to once- or twice-a-year follow-up is pretty good, and that's without the added disincentive of possibly getting a shot, which isn't the most pleasant thing for most patients.

Second, the dosing of some future therapies may be twice a year, and they'll probably last longer than every six months, so even if a patient goes a little longer, it may not necessarily put them at greater risk because the drug may still be having a positive effect on their vision.

For patients who miss appointments or stretch the intervals, is there a point of no return with today's shorter-acting therapies?

Moshfeghi: There is a risk that patients could have not just a slight setback but a catastrophic setback in their vision. Fortunately, that's relatively rare.

Usually, when disease reactivates because of a missed appointment or two, it's more of a gradual onset of the disease returning—but it's hard to know which patients will have the gradual onset and which will have the catastrophic, point-of-no-return onset. So we try to err on the side of not allowing that to happen by recommending quite frequent injections.

But the pipeline is strong with long-lasting drug candidates. We just have to get them in our hands, hopefully in the next 12 to 24 months.

Was there anything in the findings that surprised you?

Moshfeghi: The most surprising thing was in the first year. A year only has 365 days, and we defined a treatment gap as 180 days or more—yet as many as 40% of patients were already experiencing that gap in the first year. We were surprised to see it happen so soon.

Andrew A. Moshfeghi, MD, MBA, FASRS, is a vitreoretinal specialist and professor of ophthalmology at the USC Roski Eye Institute, Keck School of Medicine of the University of Southern California, Los Angeles.