Treating the untreatable patient: current options for the management of treatment-resistant neovascular age-related macular degeneration

Anti-vascular endothelial growth factor (anti-VEGF) agents represent the current standard of care for neovascular age-related macular degeneration (nAMD). Although effective in a majority of cases, a significant proportion of patients have persisting retinal exudation despite regular anti-VEGF therapy. This exudation is considered to produce poorer visual outcomes in these patients. Some of these patients may have misdiagnosed nAMD variants such as polypoidal choroidal vasculopathy; however, the majority of these eyes have what has been termed treatment-resistant nAMD. Currently, the best way to care for these patients is uncertain. Here, we review the evidence for different approaches to the management of treatment-resistant nAMD, including high-dose anti-VEGF therapy, combination regimes and switching of anti-VEGF agents, and discuss possible therapeutic approaches for patients with treatment-resistant nAMD.